NHS inequalities row is shrouded in secrecy

A debate has been raging for nine months over the fundamental principles of the NHS. The choice, participants claim, is the lofty ideal of a universal service funded through taxation or the spectre of a residual service for the poor.

But you won't find the debate showcased in a public auditorium near you. There are no X-Factor style citizen polls or charismatic ministerial hosts this time.

Instead, the question of whether the NHS should aim to provide all with equal health or just equal access to healthcare will be determined behind closed doors in the Department of Health, guided by its secretive advisory committee on resource allocation, which is barred from public discussion by confidentiality agreements.

The answer, when it comes, will determine whether NHS funding allocations continue their current trend towards higher funding for deprived urban areas, or a radical shift is made to give more funds to the relatively rich and rural areas with significantly older populations and a history of financial troubles.

A fundamental issue

Manchester primary care trust chief executive Laura Roberts explains: "This is more than a technical question and it has a widespread impact. It is more fundamental than the top-up debate, so it would be good if it were aired more publicly."

"Progress is being made on health inequalities and we don't want that to now be overturned."

The Department of Health first signalled its uncertainty over the formula used to determine PCT allocations last November, when it unexpectedly told PCTs what their allocations would be for just one year. Figures on the remaining two years through to 2010-11 would be made "by summer 2008", health minister Ben Bradshaw said.

But with summer came the decision there will be no announcement on the allocations and any formula revisions before ministers return in October. It is now expected alongside the operating framework for 2009-10 at the end of October.

The wait is bothering PCT Network director David Stout. "We are getting closer and closer to the start of the financial year and the delay can't be helpful for developing world class commissioning and an investment based approach to commissioning," he says.

"They are clearly struggling because they have missed their own deadline. Something is proving tricky and I can only assume it's this debate between rich areas who say they are underfunded because they have so many old people and poor urban areas who say they need to address health inequalities."

Regional needs

In an ideal world NHS resources would be distributed according to the health needs of each region. But in an ideal world the use and provision of NHS services and resources would closely mirror need.

Because they do not, and because reliable and systematic data on health need is hard to come by, the formula used since 2003-04 is based on a careful analysis of the average impact of different socioeconomic and demographic factors - such as age, income, educational attainment and percentage of babies born at a low birth weight - on the use of NHS resources in England (see below).

The result is a model used to predict the impact 20 main population characteristics will have on a PCT population's additional need for NHS resources. Data on these are fed into one end of the model and the overall need of the PCT relative to the England average is produced at the other end in the form of a weighted population.

This weighted population size will be more or less than the actual number of people in the PCT area depending on how the population scores against the 20 characteristics. In 2006-07 the rate of deprivation in Tower Hamlets PCT boosted its population by 36 per cent.

The same year Richmond and Twickenham PCT's population was shrunk for the purposes of funding allocations by 18 per cent, to take into account its relatively affluent and healthy population.

But when NHS deficits appeared to concentrate in wealthier regions in 2005 and 2006, academics and PCTs in the south started to blame the allocation formula.

Age is a factor

Sustained criticisms have come from Sheena Asthana of Plymouth University. Professor Asthana has set out her critique in several publications but she has also been commissioned to undertake at least two pieces of work for the allocations advisory committee.

She argues that the current formula does not take enough account of the impact old age will have on demand and is skewed towards use of health services and socioeconomic characteristics such as low income, poor housing and educational attainment.

Because areas with the most older people tend to be richer, Professor Asthana says the cumulative effect of the characteristics in the allocation model leads to richer, older and more rural areas being systematically underfunded while poor urban areas are relatively overfunded.

"If you look at the factors that drive prevalence you know getting old is the big whammy," Professor Asthana claims. "Mental health is the only exception to that rule I can think of in terms of the relative importance of ageing and deprivation in driving disease prevalence."

Professor Asthana acknowledges that, adjusted for their relatively low numbers of old people, the mortality rates and burden of disease in deprived urban areas such as central Manchester are "shocking".

But the problem for her is that the NHS has got so used to comparing those age-adjusted or standardised indicators of health need - which show, for example what the disease prevalence of different populations would be if they had identical age profiles - that it has "forgotten" that it is in the business of providing healthcare to real, not statistically standardised, populations.

"These measures don't mean that central Manchester has a greater need for curative care," she says. "If you look at epidemiological indicators and a range of direct measures, then you will find central Manchester has a significantly lower rate of prevalence than a rich, old area like north Dorset."

Philosophical argument

"We then need to get into some kind of philosophical argument about what the NHS is actually there for. To provide curative treatment for people with chronic illnesses and mental health problems, or to close the health inequalities gap?" asks Professor Asthana.

The idea that it is the NHS's role to bring about equal health is a flawed "medicalisation of socioeconomic inequality," Professor Asthana says. There is a role for public health and primary care, but real differences can only be made by addressing such causes of ill health as housing, employment and education. The alternative, that the NHS is there to provide equal healthcare for equal health need, has the clear implication for Professor Asthana that the formula must be revised to redirect more funding to areas with older populations.

Manchester PCT not surprisingly disagrees. A research paper prepared by the Manchester joint health unit - funded by the city council and PCT - shows that the standardised mortality rates gap between the majority of the North West's deprived PCTs and the rest of England is widening, as is the gap between life expectancies.

There have been boosts to under-doctored areas and preventive measures such as screening, the PCT says, but this has to be "scaled up", ideally with a strengthening of the weight given to deprivation indicators in the allocation formula.

Manchester's research points to data collected in the 2001 census on the percentage of people reporting poor health. If NHS resources were distributed according to that measure, funding to the North West would rise 7 per cent, while that to the South East would fall 13 per cent, despite a trend for poor people to under-report poor health out of lower expectations.

A technical adjustment to account for unmet need in the current model would further increase funds for deprived areas by another 7 per cent, and a similar adjustment has been made to the allocation formula used in Scotland.

Secret arrangements

"Because of the secrecy of [the advisory committee] we don't know if these have been looked at," says health unit report author John Hacking. "The issue is worsening national health inequalities. I'd be surprised if the DH planned to take money away from areas like us but we don't know if politically they are prepared to continue the slow increase in funding we have had in recent years."

The compromise could lie in a "person based" allocation formula which uses the sophistication of NHS data to eschew the need to model, and instead ascertains the real health service need of the individuals in each PCT population.

Grant disclosures indicate that both Professor Asthana and the Nuffield Trust are working to this end. The NHS Information Centre has also begun work on its GP data extraction service, with the intention of collating data on primary care treatments and diagnoses for use in a future allocation formula.

The DH has already said it has decided the health inequalities element of the formula, but has not said what it is or how strong its influence will be in determining the overall funds a PCT receives. North Dorset and Manchester eagerly await. L

Who gets what?

Factors determining allocations in the current formula

• Population

• Age profile

• Educational attainment

• Birth rate

• Low birth-weight babies

• Over-60s on income support

• Under-75 death rate

• 75-year-olds living alone

• Low income

• Diseases of the nervous system

• Diseases of circulatory system

• Musculoskeletal disorders

• Morbidity in under-65s

• Poor housing

• Psychosocial problems

• Cost of providing services

• Emergency ambulance costs

• HIV/AIDs

• Prescribing rates

• Primary care services