The government's strategy for the NHS considers major variations in health services between areas to be unacceptable. Examples quoted in the white paper The New NHS include emergency re-admissions to hospital, levels of cervical screening, and mortality from coronary heart disease, all of which show substantial differences between health authorities. Although not included in the government's examples, funding for AIDS/HIV treatment and care could be added to the list of inequities.
Statistics available for England show that the level of funding allocated for the treatment and care of people with AIDS/HIV differs significantly from region to region.1, 2 Each year, HAs in North Thames have received an average of 49 per cent more than the national average per person with AIDS treated or 27 per cent more per HIV-positive person treated.2, 3
Even more dramatically, in 1998 Kensington, Chelsea and Westminster HA received£50.5m for AIDS treatment and care while Manchester HA was given only£2.4m. This represented four times as much per person treated in Kensington, Chelsea and Westminster as in Manchester. Such inequity in funding should be cause for concern on its own. But these inequities are affecting the range of services and treatments on offer - and, most important, the prognosis of those diagnosed as HIV-positive.
Previously, few treatments were effective at substantially reducing HIV- related morbidity and mortality, so funding inequities may have had relatively little effect on disease progression. Recently, however, the range of effective treatments has increased dramatically and since such treatments are costly, their availability is likely to be affected by funding. Using routinely published data on AIDS-related deaths in England (currently available for 1995-97) it is possible to examine whether continued inequity in funding has led to unacceptable geographical variations in deaths from HIV.3
Categorising England into two areas, North Thames and outside North Thames, allows comparison of two HIV populations of roughly equal size (8,080 and 6,688 people receiving treatment for HIV in 1997, respectively) but with substantially different levels of treatment and care funding. For each area, the number of AIDS-related deaths can be expressed either as a percentage of all HIV positive people who contacted health services or as a percentage of only those with an AIDS diagnosis (see box, left).
At all times the percentage of HIV-positive people dying from AIDS was lower in North Thames than elsewhere in the country. These differences are all highly statistically significant. And, since 1996, the percentage of people with AIDS dying from AIDS-related illnesses shows the same significant differences.
Between 1995 and 1997 North Thames averaged 4.69 deaths per 100 HIV-positive individuals or 16.52 deaths per 100 AIDS cases compared with 7.32 and 21.92 respectively elsewhere.
Primarily as a result of giving successful combination therapies, the proportion of HIV-positive people in treatment dying from AIDS-related causes has fallen dramatically from 7.88 per cent of HIV-positive people receiving treatment in 1995 to 3.22 per cent in 1997 (data for all England). This factor is a major cause of the 9 per cent increase in the numbers of infected people seen each year by treatment centres, between 1995 and 1997.4
This places additional - and potentially service-limiting - pressures on AIDS/HIV treatment and care budgets to provide expensive combination therapies to more people each year. In addition, people's chances of dying are strongly related to the areas of the country in which they receive treatment.
The combination of expensive new treatments and continued underfunding of services in regions such as Trent and North West inevitably limits the ability of both statutory and voluntary services to deliver optimal care. This has an impact on the morbidity and ultimately the mortality of patients. It also adversely affects staff morale as the workload of clinicians and other healthcare staff increases to compensate for insufficient resources and high expectations.
Few would deny that much of the early development of HIV-related expertise in England was strongly associated with the North Thames area, and this may have contributed to some regional differences in mortality. But now that centres of excellence in HIV treatment are well established throughout England's health regions, flawed funding may be a major and avoidable contributor to regional variation. Whether differences in resources or expertise are the cause of variation in HIV mortality, equitable funding is essential to address either cause.
Funding for 1999-2000
This year's decisions on the special allocations of AIDS/HIV treatment and care and HIV prevention funds were delayed until April while consideration was given to changing funding allocations. For 1999-2000 there will be no inflationary uplift for any HAs on HIV prevention or treatment and care funds. Instead this money has been put into a£7.2m pot, with£6.2 m reallocated to regional offices, shared out on the basis of the number of HIV-positive residents in each region. The other£1m has been retained by the Department of Health as a contingency fund.
While seven inner-London HAs have been excluded from the regional distribution in order to address inequities, the vast majority of funding inequities remain (see table, below).5
For example, based on the 1997 figures for numbers of HIV-positive people being treated in each region and this year's treatment and care allocations, North West HAs will now attract average funding of around£11,000 per HIV-positive person in treatment, while those in London HAs will attract around£16,500 - 50 per cent more.
The opportunity to start redressing the damage underfunding has caused has been lost, while the DoH has retained£1m, which could assist the regions in most need. Any significant move towards fair and equitable funding will have to wait until the next millennium.
Mark Bellis is professor of public health and Jim McVeigh is research associate, Liverpool John Moores University.
Roderick Thomson is chair of HIV Commissioners Liaison Group. Qutub Syed is regional epidemiologist, communicable disease surveillance centre, Fazakerley Hospital, Liverpool.
The government's funding of AIDS and HIV services in England is inequitable.
Spending per patient in North Thames is four times that in Manchester.
Deaths from AIDS in North Thames are significantly lower than in other parts of England.
1 Bellis M, McCullaugh J, Thomson R, Regan D, Syed Q, Kelly T. Inequalities in funding for AIDS across England threatens regional services. Br Med J 1997; 315: 950-51.
2 McKerrow G. Cash Cow. Positive Nation 1998; 35: 16-21.
3 Molesworth A. Results from the 1995 survey of prevalent clinically diagnosed HIV infection in England, Wales, and Northern Ireland. Comm Dis Rep CDR Rev 1997; 7: R77-82.
4 McVeigh J, Rimmer P, Syed Q, Bellis M. HIV and AIDS in the North West of England 1998. Liverpool John Moores University and CDSC North West 1999.
5 National AIDS Trust. 1999-2000 HIV/AIDS Budget Allocation; Briefing Paper, April 1999.