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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.

Sheena