Report comment

[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.