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Money for mental health care in 2003/4

Published online by Cambridge University Press:  02 January 2018

Gyles R. Glover*
Affiliation:
Centre for Public Mental Health, Durham University, Elvet Riverside Building, Durham DH1 3JT
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Extract

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.

Type
Opinion & Debate
Creative Commons
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This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright
Copyright © Royal College of Psychiatrists, 2003

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 (Reference GloverGlover, 1999). Bindman et al (Reference Bindman, Glover and Goldberg2000) 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.

Table 1. 2003/4 Total resource limits for Primary Care Trusts and amount and percentage attributable to hospital and community health services (HCHS) for mental health

Primary Care Trust Mental HCHS £1000s % of total Total £1000s
Cheshire and Merseyside Health Authority (HA)
Bebington and West Wirral 9,798 9.82 99,784
Birkenhead and Wallasey 27,043 12.00 225,399
Central Cheshire 22,916 11.29 203,024
Central Liverpool 39,782 13.65 291,342
Cheshire West 13,817 10.12 136,582
Eastern Cheshire 17,320 10.73 161,425
Ellesmere Port and Neston 7,280 9.47 76,839
Halton 14,399 11.83 121,696
Knowsley 19,358 11.92 162,420
North Liverpool 14,737 12.31 119,751
South Liverpool 13,022 12.80 101,775
South Sefton 20,401 12.45 163,872
Southport and Formby 13,223 11.31 116,952
St Helens 20,354 11.14 182,712
Warrington 17,982 11.06 162,534
County Durham and Tees Valley HA
Darlington 11,122 11.41 97.490
Derwentside 9,508 11.42 83,267
Durham and Chester-Le-Street 14,317 10.95 130,724
Durham Dales 10,268 11.99 85,609
Easington 9,806 10.02 97,900
Hartlepool 11,165 11.91 93,717
Langbaurgh 10,399 10.85 95,826
Middlesbrough 21,409 11.92 179,612
North Tees 17,961 11.46 156,705
Sedgefield 10,007 11.05 90,565
Cumbria and Lancashire HA
Blackburn With Darwen 18,909 13.19 143,337
Blackpool 19,595 12.70 154,308
Burnley, Pendle and Rossendale 28,715 11.97 239,877
Carlisle and District 11,432 11.12 102,761
Chorley and South Ribble 19,658 11.37 172,858
Eden Valley 5,833 9.94 58,697
Fylde 6,527 10.24 63,715
Hyndburn and Ribble Valley 11,955 11.58 103,228
Morecambe Bay 32,589 11.17 291,800
Preston 18,700 13.01 143,699
West Cumbria 13,579 11.00 123,486
West Lancashire 11,528 11.81 97,616
Wyre 12,530 11.10 112,919
Greater Manchester HA
Ashton, Leigh and Wigan 34,763 11.85 293,331
Bolton 31,202 12.43 251,073
Bury 19,056 11.74 162,270
Central Manchester 28,979 15.58 185,987
Heywood and Middleton 9,002 12.28 73,321
North Manchester 25,113 13.61 184,492
Oldham 26,801 12.72 210,699
Rochdale 16,370 12.66 129,293
Salford 32,823 13.11 250,397
South Manchester 19,074 13.48 141,478
Stockport 30,178 11.91 253,371
Tameside and Glossop 27,587 12.62 218,588
Trafford North 11,246 12.64 88,995
Trafford South 12,163 11.09 109,671
North and East Yorkshire and Northern Lincolnshire HA
Craven, Harrogate and Rural District 17,016 10.25 166,090
East Yorkshire 12,143 10.08 120,493
Eastern Hull 15,172 13.00 116,700
Hambleton and Richmondshire 8,690 9.52 91,264
North East Lincolnshire 16,423 11.39 144,167
North Lincolnshire 14,310 10.70 133,772
Scarborough, Whitby and Ryedale 14,004 10.18 137,599
Selby and York 23,557 10.84 217,398
West Hull 18,806 12.57 149,648
Yorkshire Wolds and Coast 13,229 10.42 126,904
Northumberland, Tyne and Wear HA
Gateshead 26,339 12.84 205,181
Newcastle 37,143 13.23 280,787
North Tyneside 23,823 12.22 194,922
Northumberland Care Trust 32,691 11.61 281,575
South Tyneside 20,853 13.06 159,688
Sunderland Teaching 35,707 12.27 290,974
South Yorkshire HA
Barnsley 23,800 10.54 225,877
Doncaster Central 12,071 12.31 98,025
Doncaster East 9,819 11.46 85,707
Doncaster West 12,157 11.90 102,185
North Sheffield 16,077 12.58 127,814
Rotherham 23,987 10.54 227,557
Sheffield South West 12,337 11.15 110,614
Sheffield West 13,630 12.55 108,612
South East Sheffield 20,504 12.24 167,555
West Yorkshire HA
Airedale 12,039 11.63 103,484
Bradford City 20,135 15.27 131,851
Bradford South and West 16,689 12.64 132,051
Calderdale 20,671 11.43 180,860
East Leeds 17,983 11.81 152,221
Eastern Wakefield 20,173 11.58 174,251
Huddersfield Central 13,926 11.53 120,786
Leeds North East 17,398 12.77 136,255
Leeds North West 18,925 12.99 145,681
Leeds West 12,766 12.16 104,968
North Bradford 10,867 13.00 83,620
North Kirklees 17,570 11.88 147,930
South Huddersfield 7,023 10.40 67,509
South Leeds 17,205 12.48 137,895
Wakefield West 16,412 12.30 133,409
Bedfordshire and Hertfordshire HA
Bedford 14,427 11.93 120,974
Bedfordshire Heartlands 19,672 10.87 181,032
Dacorum 12,935 11.08 116,762
Hertsmere 9,019 11.57 77,939
Luton 20,051 12.79 156,783
North Hertfordshire and Stevenage 18,482 11.98 154,332
Royston, Buntingford and Bishop's Stortford 6,232 10.58 58,903
South East Hertfordshire 14,714 11.30 130,159
St Albans and Harpenden 11,713 11.07 105,836
Watford and Three Rivers 18,268 11.87 153,917
Welwyn Hatfield 9,715 11.43 84,991
Birmingham and The Black Country HA
Dudley Beacon and Castle 11,536 12.25 94,186
Dudley South 18,428 11.07 166,522
Eastern Birmingham 31,116 13.08 237,866
Heart of Birmingham 42,326 15.48 273,354
North Birmingham 16,387 11.43 143,426
Oldbury and Smethwick 14,067 13.77 102,171
Rowley, Regis and Tipton 10,528 13.26 79,391
Solihull 18,238 10.84 168,307
South Birmingham 47,196 14.15 333,648
Walsall 30,982 13.01 238,186
Wednesbury and West Bromwich 14,877 13.25 112,243
Wolverhampton City 29,356 12.86 228,234
Coventry, Warwickshire, Herefordshire and Worcester
Coventry 35,594 12.34 288,328
Herefordshire 13,535 9.66 140,098
North Warwickshire 15,898 10.89 145,995
Redditch and Bromsgrove 13,334 10.96 121,706
Rugby 7,874 10.76 73,156
South Warwickshire 20,770 10.83 191,845
South Worcestershire 23,279 10.72 217,159
Wyre Forest 9,558 11.01 86,799
Essex HA
Basildon 11,015 11.91 92,455
Billericay, Brentwood and Wickford 13,493 11.84 113,929
Castle Point and Rochford 12,329 9.51 129,591
Chelmsford 10,998 11.29 97,432
Colchester 14,877 11.55 128,776
Epping Forest 10,798 11.58 93,209
Harlow 9,635 12.31 78,245
Maldon and South Chelmsford 6,485 10.87 59,643
Southend-on-Sea 16,713 10.93 152,867
Tendring 14,790 11.40 129,742
Thurrock 14,763 12.38 119,272
Uttlesford 5,918 11.08 53,420
Witham, Braintree and Halstead Care Trust 11,821 11.61 101,820
Leicestershire, Northamptonshire and Rutland HA
Charnwood and North West Leicestershire 20,578 11.15 184,554
Daventry and South Northamptonshire 6,882 9.77 70,436
Eastern Leicester 21,918 15.23 143,941
Hinckley and Bosworth 7,731 10.68 72,385
Leicester City West 16,774 13.33 125,884
Melton, Rutland and Harborough 10,907 10.49 103,982
Northampton 19,210 11.22 171,247
Northamptonshire Heartlands 24,032 10.88 220,957
South Leicestershire 11,671 10.31 113,246
Norfolk, Suffolk and Cambridgeshire HA
Broadland 9,366 10.12 92,543
Cambridge City 11,905 11.42 104,205
Central Suffolk 6,468 8.92 72,548
East Cambridgeshire and Fenland 11,861 10.17 116,645
Great Yarmouth 9,884 11.66 84,777
Huntingdonshire 11,418 10.50 108,779
Ipswich 14,119 11.24 125,580
North Norfolk 9,438 10.54 89,552
North Peterborough 10,546 11.18 94,329
Norwich 14,549 12.03 120,956
South Cambridgeshire 7,840 9.99 78,487
South Peterborough 7,076 10.03 70,526
Southern Norfolk 16,245 10.32 157,485
Suffolk Coastal 7,350 9.18 80,053
Suffolk West 17,863 10.05 177,430
Waveney 10,546 9.44 111,682
West Norfolk 12,381 10.03 123,447
Shropshire and Staffordshire HA
Burntwood, Lichfield and Tamworth 12,521 10.91 114,739
Cannock Chase 10,874 10.88 99,977
East Staffordshire 10,146 10.57 95,947
Newcastle-under-Lyme 10,472 11.40 91,841
North Stoke 16,039 12.45 128,853
Shropshire County 24,801 10.78 230,088
South Stoke 15,027 11.81 127,248
South Western Staffordshire 14,269 10.09 141,467
Staffordshire Moorlands 10,133 11.02 91,971
Telford and Wrekin 14,251 11.53 123,588
Trent HA
Amber Valley 10,049 9.60 104,717
Ashfield 6,858 10.22 67,129
Bassetlaw 8,855 10.12 87,521
Broxtowe and Hucknall 11,411 10.06 113,472
Central Derby 16,458 15.18 108,422
Chesterfield 9,897 10.09 98,068
Derbyshire Dales and South Derbyshire 6,137 9.29 66,034
East Lincolnshire 25,115 10.47 239,940
Erewash 8,424 9.86 85,437
Gedling 7,367 9.29 79,311
Greater Derby 11,917 9.82 121,325
High Peak and Dales 8,601 9.84 87,399
Lincolnshire South West Teaching 14,531 10.15 143,190
Mansfield District 8,321 9.92 83,844
Newark and Sherwood 9,657 9.76 98,943
North Eastern Derbyshire 12,869 9.50 135,465
Nottingham City 33,434 12.21 273,890
Rushcliffe 8,273 8.95 92,448
West Lincolnshire 19,806 11.03 179,584
North Central London HA
Barnet 43,196 13.95 309,617
Camden 36,816 13.60 270,641
Enfield 29,602 12.15 243,574
Haringey 34,676 14.05 246,747
Islington 34,051 13.67 249,059
North East London HA
Barking and Dagenham 18,003 11.84 152,039
Chingford, Wanstead and Woodford 13,326 12.06 110,492
City and Hackney 38,202 14.28 267,490
Havering 21,308 9.96 213,922
Newham 39,623 14.22 278,603
Redbridge 20,025 12.45 160,850
Tower Hamlets 35,755 14.89 240,062
Walthamstow, Leyton and Leytonstone 23,534 14.23 165,368
North West London HA
Brent 44,137 14.97 294,906
Ealing 43,242 13.22 327,124
Hammersmith and Fulham 26,294 13.45 195,459
Harrow 24,228 13.43 180,391
Hillingdon 26,297 11.87 221,587
Hounslow 30,069 13.61 220,869
Kensington and Chelsea 27,803 13.56 205,096
Westminster 35,828 13.48 265,760
South East London HA
Bexley 19,563 10.67 183,314
Bromley 36,930 13.45 274,614
Greenwich 30,770 12.84 239,638
Lambeth 46,296 14.04 329,857
Lewisham 38,522 13.41 287,339
Southwark 38,761 13.61 284,695
South West London HA
Croydon 40,743 13.51 301,630
Kingston 18,165 12.44 145,966
Richmond and Twickenham 22,541 13.63 165,346
Sutton and Merton 46,880 13.99 335,186
Wandsworth 46,468 16.15 287,642
Avon, Gloucestershire and Wiltshire HA
Bath and North East Somerset 14,795 10.42 142,015
Bristol North 21,906 10.75 203,735
Bristol South and West 30,113 16.38 183,885
Cheltenham and Tewkesbury 13,362 10.78 123,964
Cotswold and Vale 15,925 10.02 158,933
Kennet and North Wilts 15,579 10.32 150,965
North Somerset 17,352 11.28 153,822
South Gloucestershire 27,551 14.88 185,115
South Wiltshire 9,768 9.76 100,106
Swindon 17,252 11.22 153,760
West Gloucestershire 20,186 10.75 187,752
West Wiltshire 8,849 9.77 90,549
Dorset and Somerset HA
Bournemouth 16,084 10.79 149,097
Mendip 8,569 10.30 83,181
North Dorset 6,625 8.88 74,628
Poole 14,288 9.81 145,712
Somerset Coast 11,916 10.25 116,205
South and East Dorset 11,625 8.82 131,863
South Somerset 12,514 10.04 124,612
South West Dorset 11,267 9.22 122,135
Taunton Deane 8,876 10.31 86,071
Hampshire and Isle of Wight HA
Blackwater Valley and Hart 11,880 9.21 128,976
East Hampshire 16,612 10.27 161,786
Eastleigh and Test Valley 10,716 9.69 110,575
Fareham and Gosport 17,842 11.64 153,330
Isle of Wight 14,204 10.72 132,508
Mid-Hampshire 13,045 9.65 135,193
New Forest 14,629 9.56 153,050
North Hampshire 14,862 10.07 147,617
Portsmouth City 19,169 11.59 165,393
Southampton City 24,032 11.62 206,816
Kent and Medway HA
Ashford 8,628 10.13 85,140
Canterbury and Coastal 15,645 10.46 149,606
Dartford, Gravesham and Swanley 22,451 11.37 197,490
East Kent Coastal 26,109 11.10 235,284
Maidstone Weald 21,047 11.32 185,973
Medway 25,685 12.16 211,147
Shepway 10,616 11.17 95,035
South West Kent 16,882 11.67 144,624
Swale 9,616 12.07 79,657
South West Peninsula HA
Central Cornwall 17,562 10.22 171,802
East Devon 8,414 8.04 104,592
Exeter 17,807 15.37 115,825
Mid Devon 6,971 8.58 81,203
North and East Cornwall 14,047 10.27 136,777
North Devon 12,495 9.61 130,069
Plymouth 25,746 11.16 230,757
South Hams and West Devon 8,506 9.46 89,935
Teignbridge 9,830 10.37 94,835
Torbay 13,876 10.78 128,764
West of Cornwall 15,522 10.79 143,918
Surrey and Sussex HA
Adur, Arun and Worthing 22,814 10.58 215,657
Bexhill and Rother 7,410 8.95 82,804
Brighton and Hove City 30,735 12.38 248,356
Crawley 10,360 11.35 91,274
East Elmbridge and Mid Surrey 42,361 17.47 242,428
East Surrey 29,658 20.13 147,297
Eastbourne Downs 18,254 10.22 178,619
Guildford and Waverley 19,630 9.92 197,969
Hastings and St Leonards 10,114 10.94 92,444
Horsham and Chanctonbury 8,124 11.40 71,244
Mid-Sussex 10,017 9.49 105,512
North Surrey 21,874 12.28 178,063
Sussex Downs and Weald 10,371 8.64 120,074
Western Sussex 18,716 9.87 189,596
Woking 18,680 11.85 157,653
Thames Valley HA
Bracknell Forest 9,372 12.06 77,694
Cherwell Vale 9,668 10.54 91,708
Chiltern and South Bucks 11,556 9.77 118,329
Milton Keynes 18,935 11.23 168,688
Newbury and Community 8,842 11.77 75,113
North East Oxfordshire 5,550 10.90 50,910
Oxford City 16,360 11.29 144,874
Reading 20,644 12.58 164,108
Slough 15,395 15.16 101,527
South East Oxfordshire 7,117 12.02 59,198
South West Oxfordshire 14,625 10.39 140,745
Vale of Aylesbury 15,651 10.80 144,940
Windsor, Ascot and Maidenhead 15,488 11.79 131,388
Wokingham 10,715 10.57 101,338
Wycombe 11,904 11.04 107,783
England total 5,367,596 11.85 45,312,830

How is this calculated?

A full explanation of this calculation and the assumptions underlying it is beyond the scope of this short article (Reference GloverGlover, 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:

  1. 1) Age profile (older people require more spending than young adults)

  2. 2) Health need (areas where the population is likely to be sicker need more)

  3. 3) Market forces factors (in some areas anything is costlier)

  4. 4) Emergency ambulance costs (allowing for geographic influences)

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, 267274.Google Scholar
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.Google Scholar
Glover, G. (1999) How much English health authorities are allocated for mental health care. British Journal of Psychiatry, 175, 402406.Google Scholar
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.Google Scholar
Figure 0

Table 1. 2003/4 Total resource limits for Primary Care Trusts and amount and percentage attributable to hospital and community health services (HCHS) for mental health

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