Share and share alike

Greater Glasgow is an area of health extremes. Life expectancy in the most affluent areas is 10 years more for men and over six years more for women than it is in the most deprived areas.

In these most poverty-stricken areas, the standardised mortality ratio is two to three times higher, and suicide, self-inflicted injury and murder are about eight times more common among young adults.

But this deprivation has never been recognised by the Scottish health authorities revenue equalisation (SHARE) formula, which has been used to distribute health funds in Scotland for the past 20 years, says Unison in a report on the future of Glasgow's health services.

Consequently, Greater Glasgow health board has 'lurched from one financial crisis to another for many years', argues Unison regional officer Dave Watson.

'Glasgow has been robbed of pounds80m in the past nine years because of the way the SHARE formula operates. The current year includes a further reduction of pounds5.1m, followed by a 'holiday' in 1998-99, but then a further reduction of pounds5.5m in 1999-2000. This has a knock-on effect of increasing the pressure on services.'

The key element of the SHARE formula is population, and it is estimated that Glasgow's population will continue to decline from 910,153 in 1996 to 866,992 in 2006, a drop of 4.7 per cent, says Mr Watson.

Between 1996 and 2001, Scotland's population is expected to have decreased by 2.8 per cent, but in the first 10 years of the next century Glasgow's population will continue to fall while the rest of Scotland stabilises.

'As a consequence Greater Glasgow health board's five-year financial strategy makes grim reading,' says Mr Watson.

'The bottom line is a carry-forward deficit of pounds648,000 from 1997-98 and a forecast deficit of pounds6.8m in 1998-99. But even these figures do not take account of a number of risks and provide no money for developments other than forensic services.

'To achieve a financial balance the board is looking towards reshaping services in the longer term and, in the shorter term, is embarking on another series of cost-saving projects, including further cuts in management costs and the closure and privatisation of elderly medical inpatients.'

The financial position could be even worse if the SHARE formula is amended to Glasgow's disadvantage, Mr Watson warns.

'A Scottish Office working party is looking at a number of capitation funding models, some of which would be disastrous from Glasgow's perspective.'

Scottish health minister Sam Galbraith announced in December that the steering group to review the distribution of NHS funds in Scotland would be chaired by Professor John Arbuthnott, principal and vice-chancellor of Strathclyde University.

The steering group, which will include representatives from the NHS Management Executive, the NHS, academics and outside organisations, will look at whether the distribution of resources can more fairly reflect the needs of local populations and will report back to ministers by the end of the year.

'Ensuring fairness in the distribution of funding is fundamental to the renewal of the NHS in Scotland,' said Mr Galbraith, announcing Professor Arbuthnott's appointment.

It was 'high time' the SHARE formula was reviewed, he added. But the steering group would have 'a challenging task' in achieving a sharing of health funds which would be fair to all parts of Scotland.

Mr Watson insists any new formula must include a stronger needs element, and he is backed by Phil Hanlon of Glasgow University's department of public health and chair of the Scottish needs assessment programme think- tank.

'Resource allocation must be based on a robust assessment of need,' says Dr Hanlon. 'Glasgow has some of the most profound health problems in the UK.'

But, he adds, careful thought needs to be given to what proxy indicators best reflect the needs of an area. 'At the moment standardised death rates are used, but work should be carried out to determine whether there are better indicators.'

Danny Crawford, chief officer of the Glasgow health council, says the people of Glasgow have felt aggrieved about the SHARE formula for years. 'Our view is that the health needs of Glasgow should be what is measured, and we feel deprivation has not been given enough weighting in the system,' he says.

'Mr Galbraith is well aware of the concerns of the health council and others about the SHARE formula. Despite Glasgow being such a blackspot for health it is losing money most years - this year is an exception.

'Clearly it could be argued that more money could be spent on improving the environment, housing and employment, but until these problems are dealt with the health service will continue to be put under pressure.'

At present, according to Unison, Glasgow city council's financial position 'is worse than the health board's'.

A spokeswoman for Greater Glasgow health board says the board welcomes public debate about the future of the city's health services.

'Some of the changes Unison refers to reflect trends in healthcare generally throughout the developed world, and Glasgow can't be insulated from them. It is also the case that Glasgow's population has declined and continues to do so, which has an inevitable effect on the amount of money allocated to us,' she says.

'The health board is determined that in reshaping services to respond to all these influences we will keep the health needs of our resident population firmly in mind.

'This is not a health board that is preoccupied by financial issues to the exclusion of our fundamental role as guardian of the population's health, and our health improvement programme, to be published in a few weeks' time, will put all of this in context.'Glasgow's Health Service: the future. From Unison Glasgow Area Health Committee, 14 West Campbell Street, Glasgow G2 6RX. Tel: 0141-332 0006.