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Opinion & debate |
Centre for Public Mental Health, Durham University, Elvet Riverside Building, Durham DH1 3JT
Correspondence: Gyles.Glover{at}durham.ac.uk
On Christmas Eve 2002, the Department of Health published the financial allocations to Primary Care Trusts (PCTs) for 2003/4. As usual, this was accompanied by a detailed ‘exposition book’, setting out how the distribution of the available £45.3 bn was decided (Department of Health Finance and Investment Directorate, 2002). Three years ago, I wrote a short article showing how a close reading of this publication could be used to identify notional mental health budgets in these allocations (Glover, 1999). Bindman et al (2000) demonstrated that many health authorities, particularly those that service more deprived areas, spend substantially less on mental health care. As this is the first time financial allocations have been made directly to PCTs, it is helpful to repeat that calculation for the new organisations.
The total resources available for the NHS are determined politically. Each PCT is allocated a share of this with which to meet the health care needs of its population. For the most part, the Department of Health does not identify sub-divisions in these allocations, and PCTs' discretion in using the money is largely unfettered. However, the formulae used to determine the share allocated effectively consider five distinct areas (including mental health) in which PCTs will need to spend. These are considered separately in the formula because their distributions around the country differ. If all PCTs were to use their resources in line with the formulae, their spending patterns would look very different; East Devon would spend 8.04% of its budget on mental health, while East Surrey would spend 20.13%. The figures for each PCT are shown in Table 1. East Surrey tops the league as a result of re-allocation of resources for the old long-stay patients of the Epsom cluster of mental hospitals.
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How is this calculated?
A full explanation of this calculation and the assumptions underlying it is beyond the scope of this short article (Glover, 2003). However, the principles are as follows. The resource allocation process starts by identifying the ‘weighted population’ that is the responsibility of each PCT. For hospital and community health services (HCHS), the population is assigned four weightings. These are for:
The health needs relating to mental health care (not including learning disabilities) and other types of care are calculated separately, allowing parallel analyses. For prescribing costs, effects of age and sex profiles, proportions exempt from prescription charges and some specific types of morbidity are calculated. For cash-limited general medical services costs (GMSCL), age, Jarman scores, rates of limiting long-standing illness and market forces factors are considered and for HIV/AIDS, infection rates are used. To arrive at an appropriate single figure combining these elements, the department looks to the most recent available national spending profile for a weighting of the proportion of allocations that should follow each set of needs weights.
Having identified a fair share (or ‘target’) of the available national resource for each PCT, this is compared with what was available to the PCT area in the previous year and a set of rules is devised for the speed at which it is realistic to move individual allocations towards the target. For 2003/4, every PCT will get an increase of at least 8.33%. None will be left more than 10% under its target, but with the constraint that none will be pushed closer to its target share by more than 2%. (This leaves nine PCTs at 10% or more below target — Easington, -20.23%, Tendring, -15.05%, Knowsley, -14.91%, Barking and Dagenham, -14.70%, Ashfield, -12.82%, North Liverpool, -12.51%, Central Liverpool, -10.61%, Heart of Birmingham, -10.55% and Tower Hamlets, -10.00%.)
Finally, two types of further adjustment are made. Additions are made of new allocations to address specific issues (this year these are hospital weighting lists, new cost of living increases, out of hours improvements for general practice and the cost of taking on prison health care). Redistributions between PCTs are made where individuals are treated outside the PCT responsible for them (the largest of these is for mental illness and patients with learning disability institutionalised prior to 1970).
To calculate the figures shown in Table 1, all these steps were followed from the Department of Health spreadsheets, the only difference being that the allocations for the clinical areas were kept separate. Where additional allocations and distributions relate to one clinical area, these were attributed accordingly. Otherwise, they were applied to the general total. The resulting total figures are the same as those for PCTs 2003/4 Resource Limit (row L in the DH Initial Resource Limit spreadsheets).
What does it mean?
The actual task confronting PCTs in determining how to spend the resources allocated to them is, of course, much more complex than to be calculable on a few spread-sheets. Established patterns of spending cannot be overturned in a short period. Local profiles of buildings and other relatively fixed elements make particular services more or less efficient in ways that cannot be quickly altered. Rising or falling population numbers give rise to over- or under-use of facilities, with inevitable consequences for unit costs. Finally, national allocation rules can only really allow for influences that have a broadly national effect. Because of this, local decisions need to be made to take into account additional or differing influences.
The department's resource allocation team goes to considerable lengths to calculate the fairest possible share-out of resources, but it is national policy that the use of local resources is at the discretion of PCTs. Thus, it would be difficult for the department to publish the type of analysis presented here, which could be seen as fettering local discretion. However, given the thoroughness of the work they undertake, it seems appropriate to present this perspective as at least one element that PCTs should be thinking about in reaching the important decisions they have to take.
References
BINDMAN, J., GLOVER, G., GOLDBERG, D., et al
(2000) Expenditure on mental health care by English health
authorities: a potential cause of inequity. British Journal of
Psychiatry, 177,
267-274.
DEPARTMENT OF HEALTH FINANCE AND INVESTMENT DIRECTORATE (2002) 2003/4 to 2004/5 Primary Care Trust revenue resource limits exposition book and Health Services Circular 2002/012 Primary Care Trust Revenue resource limits 2003/04, 2004/05 and 2005/06. http://www.doh.gov.uk/allocations/2003-2006/index.htm.
GLOVER, G. (1999) How much English health authorities
are allocated for mental health care. British Journal of
Psychiatry, 175,
402-406.
GLOVER, G. (2003) Allocations within allocations: how should PCTs spend their money? Centre for Public Mental Health: http://www.dur.ac.uk/mental.health/ResourceAllocation.
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| British Journal of Psychiatry | Advances in Psychiatric Treatment | All RCPsych Journals |
