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'Lansley is right to say that age trumps poverty'

Favouring younger, deprived communities with funding serves neither of the core principles of the NHS, writes Sheena Asthana.

Andrew Lansley’s announcement that areas with a high proportion of older people but little deprivation should no longer be “penalised” with respect to NHS funding has been met with predictable outrage.

Deprived urban and declining industrial areas have the highest mortality and morbidity rates – in standardised terms. But it does not necessarily follow that their need for healthcare is greatest. Measures such as standardised mortality rates intentionally design out the effects of age to reveal the effects of other factors on health, such as deprivation. This is an excellent way of highlighting areas that suffer from the worst health inequalities. However, standardised mortality rates are poorly equipped to identify areas that have the highest crude burdens of illness.

For most conditions (mental health excluded), age is a far more significant determinant of morbidity and mortality than deprivation. Because more affluent areas tend to have older demographic profiles, those with the highest standardised mortality rates tend to have the lowest crude rates of illness – and vice versa. In this respect, the health secretary is correct. The health communities grappling with some of the highest burdens of chronic illness and disability serve ageing, more affluent areas.

But is Mr Lansley correct in proposing such areas should receive the highest NHS allocations? It depends on whether you believe the goal of the NHS is to promote equal opportunity of access for equal needs (horizontal equity) or to promote an equal opportunity to be healthy (vertical equity).

Many health economists favour the latter. Yet health maximisation is inherently ageist. The “fair innings argument” proposes that younger patients are a higher priority, because older patients are considered to have received their entitlement of healthcare. This overlooks the fact that most people do not need or receive that much healthcare until they reach their seventies.

The more “ethical” objective of achieving health equity has also been used to justify shifting resources to deprived areas. However, it is important to ask what the NHS can realistically do to reduce the gap in outcomes.

The factors giving rise to inequalities are well known. Some lend themselves to preventive interventions, but most have less to do with delivery and distribution of healthcare than to policies resulting in socio-economic polarisation. Focusing on the role of the NHS draws attention away from these socio-structural determinants of health and is unlikely to promote greater health equity.

The health secretary has also been accused of trying to shift resources into Tory areas. This will inevitably be the case. However, flaws in previous NHS allocations mean Mr Lansley can justly claim to be attempting to redress gross inequity.

From 2002-09, there was a shift in resources towards deprived populations – mainly because health needs associated with age were effectively cancelled out by deprivation. This was acknowledged with the introduction of the combining age-related and additional needs formula.

If implemented – without adjustment – CARAN would have redistributed revenue income away from the most deprived PCTs. But it did not, because of an inequalities element set (by ministers) at 15 per cent of overall allocations.

Huge variations in funding remain. Dorset, the area with the highest percentage of the population aged 75-plus, has an all-cause standardised mortality rate of 84.5. In crude terms, its mortality rate is 1,159 per 100,000 people and 2.49 per cent of the population are on the cancer register. For each cancer patient, the PCT spent £4,075 last year. Its overall per capita NHS allocation is £1,560.50.

Only 3.4 per cent of Tower Hamlets’ population is over 75. Reflecting the area’s high level of deprivation, standardised mortality is 109.7. Yet crude mortality is only 441 per 100,000 and cancer registrations 0.77 per cent. Cancer spending per patient is £13,087 and per capita allocation NHS £2,084.35.

This is symptomatic of a pattern in which young, deprived populations with lower crude rates of illness and death receive and spend significantly higher NHS allocations than their older, more affluent counterparts.

This does not promote equal access for equal needs, nor the goal of health equity.

Confusion over standardised and crude rates and a willingness to treat as morally defensible the belief that some are more deserving of healthcare than others, we seem to come up with an approach to funding which serves neither of the core principles of the NHS.

Readers' comments (17)

  • Patrick Keady

    What an interesting article! While the core NHS principles were very relevant in the independent-health-dominated late 1940s - meeting the needs of everyone, free at the point of delivery, based on clinical need not ability to pay - they don't seem to fully describe the impact that the NHS intends to have on patient care and the experience of patients in 2012. This article is a helpful catalyst towards identifying what it is that the NHS is about today - is the NHS vision to increase life expectancy,
    or is it something else?

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  • Martin Rathfelder

    Why are we leaving mental health out of this argument? Mental illness is more prevalent in poorer areas.

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  • Sheena Asthana

    [EDITOR'S NOTE - PLEASE READ BEN BARR'S ORIGINAL COMMENT AT END OF COMMENT STREAM FIRST] I would like to thank Mr Ben Barr for your comments. If I could provide a bit of clarification on your points:

    First, crude mortality is not as bad a measure as you imply – as progressive and fatal illness often requires high intensity care, death rates do reflect demand on health services. It should also be noted that the geographical distribution of e.g. CVD mortality is similar to that of CVD morbidity in crude terms (with the highest rates of both being in areas such as the coastal fringe of East Anglia and Lincolnshire, parts of the south east and south west coasts). Indeed, there is a far stronger association between crude mortality and crude morbidity than between deprivation and crude morbidity.

    You also seem to imply that I cherry pick my statistics to ‘reflect my view’. In fact, my original submission did include stats on circulatory disease which were editorially removed due to word count restrictions.
    However, as your preferred condition is circulatory disease, let’s look at the figures. Crude Mortality Rates (CMRs) for circulatory disease are 245 per 100,000 in the 10% most deprived PCTs. They are 388 per 100,000 in the 10% oldest PCTs (% popn aged 75+). The first group receive an average allocation of £1,942 per capita, the second, £1,584. I think these figures support my point that the highest allocations are not going to the places which have the highest burdens of death and disease.

    Second, you say that the 20% most and least deprived populations have similar crude prevalence rates. How then do you account for the fact that the first group receives on average £1,869 per capita and the second group £1,436 per capita?

    You imply that this gap in funding relative to underlying need can be explained by co-morbidity. I am not aware of an explicit adjustment in the formula for this. Besides, as I am sure you are aware, co-morbidity is also strongly associated with ageing. So, one would presumably expect older populations to similarly benefit from any extra funding to cover additional conditions.

    With regard to the points you make about capacity to benefit, it is important to remember that e.g. QALY maximization does not automatically give preference to the young when the expected benefits of receiving the same treatment are compared – so your ‘simple fact’ needs some qualification. I agree that it is the case that, when treatments are predominantly for older patients, estimates of benefit will be affected by the lower life expectancy of the elderly. However, I’m not sure that this is as defensible as you imply. For example, not everybody would agree with the idea that, on the basis of capacity to benefit, access to e.g. morbid obesity surgery should be increased and access to drugs for Alzheimer’s disease restricted.

    I am intrigued about your comments about bed days and how you seem to interpret this. On the one hand, higher bed day rates in deprived areas may reflect longer length of hospital stays (LoS) and, in turn, a lack of adequate support at home for early discharge; differences in patient behaviour (e.g. with respect to adherence to medication and physical recovery regimes); differences in disease severity (e.g. due to late presentation); and differences in co-morbidity (you should note that the very same factors would be expected to give rise to longer LoS for the frail elderly). On the other, longer LoS is deprived areas may actually reflect the fact that these places have been more generously funded relative to underlying need. Thus, patients do not have to be booted out in the middle of the night as, it would seem is the case, in less generously funded areas!

    Finally, It is fine to raise the ‘capacity to benefit’ argument. However, I think you need to follow this through by explicitly outlining how CCGs and acute hospitals in areas that are grappling with high burdens of chronic disease but receiving relatively low allocations are supposed to deal with this. In too many cases, resource constraints are contributing to the fact that standards of dignity and nutrition for the elderly are falling to unacceptable levels (‘failing’ hospitals don’t tend to be in well-resourced deprived areas). We surely need to recognise that there are many types of inequality and that evidence of poor access to care for older people deserves to be taken equally seriously.

    PS. In response to Martin's point, the relative importance of age and deprivation DOES differ for mental health than for the other main chronic diseases. However, there is a complex geography to this. Having produced case-mixed based synthetic estimates of mental health resource needs for the country, we found high rates in the major cities, from Tyneside through the Liverpool-Manchester and Leeds-Sheffield axes, down to inner city London. However, there was also a notable coastal fringe of 'high-needs' which, by and large, reflected the high proportion of elderly people in retirement hot-spots. Do be aware that socio-economic gradients in mental health are FAR less pronounced in older age. Thus, the prevalence of resource-intensive conditions such as dementia largely reflects the distribution of the very elderly.

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  • I would like to thank Sheena Asthana for responding to my comments. I think this argument could be clearer if we distinguished between need, demand and utilization. It seems your argument is based on the premise that in more affluent parts of the country where a higher proportion of the population are elderly , there is a greater demand for health care and therefore greater resources should be allocated to these areas, than is provided through the current resource allocation formula. It would appear you are not actually arguing that there is a greater need (capacity to benefit) in these areas, or even that there is necessarily greater utilization.

    There are two issues with this argument, firstly whether it is actually true that there is greater demand for health care in these areas and secondly even if this was true, the disastrous consequences of taking deprivation out of the formula, in terms of health equity, social justice and the allocative efficiency of the NHS. Let us leave aside the second point for now, and assume that the purpose of resource allocation is just to meet demand, and that we are not interested in social justice, allocating resources where they have the greatest capacity to benefit, or reducing health inequalities, even though both CCGs and the NCB are required to take these into account under the HSC act.

    Is there evidence that health care demand is greater in more affluent areas where a high proportion of the population are elderly? You suggest differences in crude mortality rates indicate that this is the case. Crude death rates are not a good indicator of demand for healthcare, simply because, dying does not cause one to use or want to use healthcare. You are using this as a proxy for the amount of health care people are assumed to have used leading up to their death. This would be fine if there was no systematic differences in the length of time people are sick or disabled prior to dying. We know this is not the case, people in deprived communities will tend to spend a greater length of time with sickness and disability prior to the end of life. From the age of 65 people from the most deprived 20% of the population on average will spend just over 1 year longer with a limiting illness prior to death, than people from the most affluent parts of the country (

    Using the crude prevalence of single diseases is also not ideal as an indicator of demand, since it does not take into account multiple commodities. Using the combined prevalence of all long term conditions from QOF registers would be better, when you do this the difference is less stark (22% in deprived areas vs 23% in affluent areas). However this doesn’t include common mental disorders and using diagnosed prevalence from GP registers is likely to underestimate prevalence in deprived areas where there is poor access to primary care. A better estimate would be from survey data. The crude prevalence of people reporting having any health problems lasting more than 1 year in the Annual population Survey/ LFS, is highest in the Tyne and Wear (43%), Merseyside (44%) and South Yorkshire (45%) and lowest in Inner London (28%) outer London (35%) and the South East (38%). So even with no age adjustment the burden of ill health, is still higher in poorer northern areas that in affluent Southern areas.

    You question why more deprived areas with a similar prevalence of long term conditions as more affluent areas, may still have a greater demand for health care and require more resources, yet you go on to give an excellent explanation as to why this might be “a lack of adequate support at home for early discharge; differences in patient behaviour (e.g. with respect to adherence to medication and physical recovery regimes); differences in disease severity (e.g. due to late presentation); and differences in co-morbidity”.

    You suggest that the lower utilization of health services in more affluent areas, could reflect, poorer access in these areas due to lower funding. There is evidence of poor access in more deprived parts of the country, so this same argument could be used to argue that utilization in these areas is actually an underestimate of demand.

    Clearly age is an important determinant of demand and need for health services, but so is deprivation. I am not arguing that age should be taken out of the resource allocation formula. It is however is clearly not the case that “Age trumps poverty”, when all conditions are taken into account, the crude prevalence of illness is actually greater in poorer parts of the country.

    As health inequalities rise, and the difference in life expectancy between deprived and affluent areas of the country increase, the situation may arise that demand for health care is lower in poorer parts of the country as people die before they can take advantage of the latest medical advances that can prolong life and independence at ever greater ages. Whilst on the other hand these services are demanded at greater levels in more affluent areas, where advantage in other spheres (wealth, education, employment etc) has enabled people to live long enough to take advantage of them. The just response to this however would seem to be allocate resources to reduce these health inequalities, rather than to exacerbate them by taking further resources away from already disadvantage populations.

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  • ORIGINALLY POSTED AT 11AM ON 18 MAY There are so many things wrong with this article it is hard to know where to start.
    1. Comparing crude mortality between areas as a measure of health need or even demand is meaningless. No health service seeks to prevent death, only to postpone it, so the age at which people die is what is important, in any rational perspective.
    2. Sheena Asthana states that deprived populations have lower crude rates of illness because they are younger, but then chooses one particular disease, cancer because this reflects her view. Cancer prevalence is lower in more deprived areas because we have a great preventative measure for Cancer in these areas, its called cardiovascular disease. Actually if you take all long term conditions together (accounting for 70% of NHS activity) crude prevalence is is about the same in the 20% most deprived PCT populations ( 22%) as in the 20% least deprived PCT population (23%). The difference is that in the deprived areas these people will be more likely to have multiple comorbidities ( see Barnett et al in the Lancet) and of course will be younger.

    3. The argument is made that there is no good reason to prioritizing treating disease in people at younger ages. This is not due to a "fair innings" approach. Need is defined as the capacity to benefit. It is a simple fact that treating disease at a younger age has the potential to result is a greater benefit in terms of years of life gained.

    4. It is not even true that health service utilization is higher in more affluent areas due to their older populations. The 20% most deprived PCT populations in 2010-11 experienced 1206 bed days in hospital per 1000 population, compared to 960 in the 20% least deprived PCT populations.

    This insidious attempt to pit the needs of the elderly against the needs of the poor has to be challenged, both are important determinants of health care need and demand.

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  • Dear Mr McLellan,

    As Chairman of The Community Voice, an umbrella organisation concerned exclusively to promote the patients' voice in NHS services, I received from a member, Prof. Mervyn Stone, the following comment on the Asthana article in this week's HSJ, which I think I should share with you.

    “The Asthana piece deserves welcome as a closely reasoned antidote to the “predictable outrage” that permeates media comment on Lansley’s speech. But the antidote will work only if it is read carefully. Its author may well be the only commentator with proven understanding of both the complex financial instrument that, without any rational justification, dictates large per capita funding differences - and someone who has identified blatant political manipulations of its structure. It is by now fairly obvious that the formula is being judged by its outcomes (does it look right?) - by both policy-makers and commentators. In effect, the huge, pretentious formula has been a chimera distracting from the need for a different sort of “number-crunching”. Mr Lansley is suggesting that ACRA is doing that, and that we should all wait to see what will be done for CCGs. Instead of holding our breath, however, why not use the breather to read the Asthana piece again and, if there are bits we don’t really understand, look at the piece ‘Formulas at War’ in the Statistics Corner of the Civitas Institute’s home-page?”

    Yours sincerely,

    Joan Davis

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  • Sheena Asthana

    Ben, Thanks. I did try (and failed completely!) to keep the following comments brief.

    First, you are absolutely right to point out the need to distinguish between need, demand and utilisation. The basic problem is that our current approach to resource allocation does not do this adequately.

    The current system reads ‘need’ indicators for health services from patterns of historic use (which has to assume that variations in use between different care groups are appropriate). Because systematic patterns of unmet need, as well as the geographically-varied impact of supply-side factors are difficult to isolate, utilisation-based methodologies run the risk of distorting the relationship between the need for and use of services.

    The scenario is simple: where services are better funded (relative to need) they will tend to be more accessible and thus more heavily used (relative to need). This will be reflected in utilisation data and result in models – and allocations – which overestimate the actual level of need. Services remain well-funded, utilisation remains high and a positive funding feedback loop is created. Conversely, of course, utilisation-based models risk underestimating the needs of populations which make poor use of services precisely because service provision is already poor.

    Evidence suggests that this is precisely what has happened over the past ten years. Due to some problems with the way in which the AREA formula was implemented, PCTs serving younger, deprived populations were funded to a higher level than implied by underlying needs; PCTs serving older, more affluent populations to a lower level. This was basically confirmed with the CARAN analysis (which made some steps to address the fact that, in the previous formula, age was effectively cancelled out by deprivation). However, the fundamental redistribution implied by CARAN did not take place due to the introduction of the health inequalities adjustment.

    Personally, I do not think that utilisation is the right approach (philosophically or methodologically) for resource allocation. My particular expertise lies in drawing upon SURVEY based data to generate more direct estimates (i.e. I don’t use crude mortality rates in my own work either – they are, however, a useful (and familiar) way of highlighting differences in the limited space available in an opinion piece).

    Using synthetic estimates (and to address your third point), you get slightly different patterns by condition. As noted in my previous comment, mental health estimates reflect the higher impact of deprivation on the prevalence of this particular condition but also highlight high prevalence in ageing areas. Patterns of CHD, cancer etc prevalence are more strongly associated with demography.

    This leads me back to your second point. Ben, nobody (including Andrew Lansley, for whom I am not an apologist) is suggesting that allocations should be based on age alone. If you look at what he originally said, it was that allocations should reflect the respective burden of disease. To get a handle on this, you need to reflect how age and deprivation proportionately affect disease prevalence etc (the current approach honestly doesn’t do that!).

    What he is talking about, obviously, is the budget to promote health CARE equity (i.e. equal access for equal needs). He rightly separates this from the budget to promote health equity (i.e. address health inequalities) and has said quite clearly that that funding would be based on indices of deprivation with a ‘direct expectation’ that money would be spent on tackling poverty-related health need.

    I think it’s important to get that distinction clear and THEN to be honest about what the NHS can actually do about health inequalities (i.e. what proportion of any health inequalities adjustment should go to the NHS, and what proportion to Local Authorities?).

    There is also a wider political point. I have worried for some time about the medicalisation of the widening health gap. We seem to spend so much time worrying about NHS allocations (which currently do strongly favour deprived areas with little apparent impact on health inequalities) that I’m always amazed about how little is said about growing socio-economic polarisation. Seriously, the meta-narrative that has emerged in the public health community really suits the establishment!!!

    I care passionately about health care equity, health equity and social justice. My problem is that I don’t think that any of these goals are being met in the current approach. We are effectively robbing Peter (the old) to pay Paul (the young, deprived) in a way that I don’t think actually addresses health inequalities at all.

    What I worry about most, however, is that if we continue to direct resources away from areas that have legitimate levels of health care need, my beloved NHS will no longer function as a UNIVERSAL service, but as a residual service for the poor.

    I think it’s really important to look at alternative explanations with an open mind. You pick up on my suggestion that, yes, there are reasons why longer LoS in deprived areas may be justified. But I also offered two more!!! On a similar note (and I write this expecting to be struck down by a thunderbolt!), evidence of inverse care is actually pretty thin nowadays. This should not really come as a surprise because, for the past 30 years, we have been developing policies and directing resources to address inverse care. Why are we so keen to hang on to this meta-narrative when empirical evidence is so patchy and contradictory?

    I wish we could take the politics and ideology out of all of this. E.g. I get the distinct impression that you probably think I am some fox hunting Tory hell-bent on stripping deprived areas from the resources they sorely need. Read my book on health inequalities and you might get a clearer idea about where my (rather more radical) political ideas about health inequalities lie! I do, however, take a slightly different perspective on health CARE equity. Here, I strongly believe that, provided that you can still benefit from health intervention, you should have an equal chance of receiving APPROPRIATE care, regardless of age.

    I’m not convinced that resources are currently distributed to support that kind of equality. I recently spent some days recuperating in a ward which comprised some elderly women (who probably shouldn’t have been there but the same problems I’ve raised with regard to the NHS also apply to social care in less deprived areas). I cannot fault the care and patience of the nursing staff, particularly the nurse auxiliaries. But the fact is there were not enough staff around to e.g. accompany these women to the toilet, help them to become mobile, ensure they were eating enough etc.

    We need to see these things in the round, not just from the point of view of one (robustly but perhaps overly-defended?) group. However, I suspect we disagree less that appears at first sight. It has therefore been most interesting to be able to have had a debate about it all.


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  • Sheena/Ben
    Enjoying your debate. Can either of you share your views on the age as a red herring argument as discussed by Wong et al and others? There is a link to the original paper in here In summary age isn't a problem for healthcare expenditure but proximity to death is. My studies show that, systemically, there is no understanding of demand from a users perspective. As a result indicators like utilisation and LoS are blunt tools at best.

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  • Sheena Asthana

    Hi Mark.

    This is not an area I have been keeping up with (and I should have done). However, my understanding has always been that, because progressive and fatal illness often requires high intensity care, this has important cost implications (Seshamani and Gray, 2004). And, as we know, older people are far more likely to die than younger people

    So, although age has a more modest impact on expenditure than proximity to death in the Wong et al study, this is when the latter is controlled for. As the two things tend to go together, I don't really see age as a red herring when it comes to identifying where the really high demand (and I'd say need) AREAS are lkely to be.

    I guess focusing on proximity to death alone could offend those who want resources to reflect capacity to benefit??? However, I can't see many people being happy with the idea of denying older patients with e.g. cancer care that may increase their life expectancy, if only by a few years. That said, we know that cancer treatments do vary by age for clinically justifiable reasons (e.g. in terms of the emphasis placed on chemo and radiotherapy).

    I absolutely agree that indicators like utilisation and LoS are blunt tools, primarily because they have been distorted by systematic biases in supply over the past decade or so.

    I hope this makes sense (and I haven't got the wrong end of the stick!).


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  • Thanks very much for replying Sheena I really appreciate it. It does make sense, although I think there may be more to explore, both in terms of what the system understands about demand (not a great deal it seems from my studies) and around end of life and what we do with/for people.

    Its an interesting point you make about the denial of treatment. I also see what you mean about age and dying going together but I think there is a more nuanced aspect to this. What I see is that despite the evidence that exists that talking to people about their options leads them to make less resource intensive decisions we don't do it. Aetna, a medical insurance group, ran a two year program where patients were allowed to receive hospice treatment without forgoing other treatments. They found that visits to the emergency room dropped by almost half and the use of hospitals and ICUs dropped by more than two thirds, compared to the control group.

    In a smaller but broader study, they found the use of ICU reduced by over 85%. The reasons for these findings? People were involved in decisions about their life and, rather than choose the heroic, life saving interventions - the greater consumption options - they chose to die with dignity and with the ability to say "goodbye" or "I love you", a choice foregone if unconscious and intubated on an ICU.

    My, as yet unpublished, studies show similar reductions in consumption of other services (nursing/residential homes etc) by taking the time to understand people in the context of how they live their life.

    So right now my studies are leading me to conclude that age is not the problem that it is described as (e.g. time bomb etc). Studies like Wong and others are leaning me further in that direction too. Admittedly I am no expert in epidemiology or the methodology they used so remain open minded.

    Not sure if this adds anything to the particular debate about funding formula but certainly what I am seeing is that costs are being driven by a system response that makes people live the life the system has decided rather than live the life they want, the latter being significantly more affordable ironically.

    Not sure if links work here but if they do and it helps you can read a bit more about where I am coming from here

    Thanks again. Its an interesting debate.

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