Deprived areas will lose out with proposed new capitation formula
BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f6146 (Published 15 October 2013) Cite this as: BMJ 2013;347:f6146All rapid responses
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CCG cuts mirror those for Local Authorities, with a shifting of resource away from areas of greatest need. Coupled with significant cuts in benefits, again disproportionately hitting those suffering the most, we have a powerful triple squeeze on community, health and personal income. This will ferment a generation of austerity and decline (and resentment) for vast swathes of our country, not just the Northeast.
This feels like a 'Help, is anyone listening?!' moment, where we have to appeal to the moral conscience of those in positions of power and influence (beyond those who simply punch the numbers into the calculator), and ask quite simply for fairness, however that's decided, because greater inequalities in society are of no benefit to anyone.
The coalition might suggest 'we're all in it together' but clearly intend that many are 'in it' more than others. Further review of the capitation formula for CCGs is chance tor them to prove the skeptics wrong.
Competing interests: No competing interests
The authors seem to be unaware of the history of problems with NHS resource allocations based on weighted capitation. Since 1976, attempts have been made to use increasingly sophisticated formula to take account of deprivation, while ignoring the inescapable and undisputed connection between need and old age. The demographic time bomb has exploded, as people born in huge numbers after the First World War become increasingly frail. The current difficulties in A&E departments are attributable at least in part, to this effect, felt most keenly in what was once called, pejoratively, the Costa Geriatrica. Coastal West Sussex illustrates the situation dramatically, and is long overdue some extra money to help cope with the demand.
Competing interests: No competing interests
A visit to the NHS England website via the link provided reveals that the workshops to engage in discussion about this subject took place last month, prior to the media reports. Also notable is that the location of the workshops reflected the same bias as the formula itself with Leeds the most Northerly and Newbury the most Southerly. All the workshops appeared to be sited in the areas where NHS area teams stood to gain the most producing a risk of sampling bias.
Rural deprivation often appears overlooked in central health policy where the dual effects of a dispersed and deprived population magnify the difficulty in delivering effective health care. The ex-mining communities of the North East continue to bear the consequences of decisions made by the last Conservative government and these proposals if they go ahead are a throwback to the 1980s.
Most concerning of all, the NHS England website does not list this as an active consultation and it is unclear how concerned practitioners may respond.
Competing interests: No competing interests
Re: Deprived areas will lose out with proposed new capitation formula
It would seem to me that every twist and turn of the capitation formula saga leads to a ‘new’ approach with winners and losers relative to the last version of the formula. The problem is that no one knows what a true fair share is against which to benchmark each new formula.
However, I do have a number of issues with the current approach. Firstly, person-based funding ignores the effect of the environment upon health (1) or at the very least assumes that its impact, in so far as costs are concerned, is negligible – which, alas, is a very flawed assumption (1-4).
Secondly, the costs associated with acute medical admissions appear to be behaving as if they were driven by a repeating series of infectious outbreaks (5-8), hence national costs for medical admission showed step increases in 1993, 1996, 2002, 2007 and 2012 along with simultaneous increases in deaths, A&E attendance and to a far more variable extent GP referrals (9-16), while the onset of each ‘outbreak’ also appears to trigger a cycle in the gender ratio at birth (17). At small area level these increases show high spatial granularity (in preparation) which creates very large financial pressures which no formula can ever hope to predict.
The final problem with the current approach is that it is nearness to death rather than age per se which drives a large proportion of health and social care costs (18-21) and hence a genuinely fair formula should have a component which is contingent on the number of deaths in each location rather than on indirect estimates based on age and morbidities.
No doubt issues for the next version of the formula …….. depending on policy flavour of the month?
References
1. Jones R (2013) A fundamental flaw in person-based funding. British Journal of Healthcare Management 19(1): 32-38.
2. Jones R (2011) Infectious outbreaks and the capitation formula. British Journal of Healthcare Management 17(1): 36-38.
3. Jones R (2012) Why is the ‘real world’ financial risk in commissioning so high? British Journal of Healthcare Management 18(4): 216-217.
4. Jones R (2010) Trends in programme budget expenditure. British Journal of Healthcare Management 16(11): 518-526.
5. Jones R (2013) Could cytomegalovirus be causing widespread outbreaks of chronic poor health. In Hypotheses in Clinical Medicine, pp 37-79, Eds M. Shoja et al. New York: Nova Science Publishers Inc
6. Jones (2013) Recurring outbreaks of a subtle condition leading to hospitalization and death. Epidemiology: Open access 3:4
7. Jones R (2010) Nature of health care costs and financial risk in commissioning. British Journal of Healthcare Management 16(9): 424-430.
8. Jones R (2012) Time to re-evaluate financial risk in GP commissioning. British Journal of Healthcare Management 18(1): 39-48.
9. Jones R (2010) Forecasting emergency department attendances. British Journal of Healthcare Management 16(10): 495-496.
10. Jones R (2011) Cycles in inpatient waiting time. British Journal of Healthcare Management 17(2): 80-81.
11. Jones R (2012) Increasing GP referrals: collective jump or infectious push? British Journal of Healthcare Management 18(9): 487-495.
12. Jones R (2012) Age-related changes in A&E attendance. British Journal of Healthcare Management 18(9): 502-503.
13. Jones R (2012) GP referral to dermatology: which conditions? British Journal of Healthcare Management 18(11): 594-596.
14. Jones R (2012) Trends in outpatient follow-up rates, England 1987/88 to 2010/11. British Journal of Healthcare Management 18(12): 647-655.
15. Jones R (2013) An unexplained increase in deaths during 2012. British Journal of Healthcare Management 19(5): 248-253.
16. Jones R (2013) A recurring series of infectious-like events leading to excess deaths, emergency department attendances and medical admissions in Scotland. Biomedicine International (in revision)
17. .Jones R (2013) Do recurring outbreaks of a type of infectious immune impairment trigger cyclic changes in the gender ratio at birth? Biomedicine International 4(1): in press
18. Jones R (2011) Death and future healthcare expenditure. British Journal of Healthcare Management 17(9): 436-437.
19. Jones R (2013) Population density and healthcare costs. British Journal of Healthcare Management 19(1): 44-45.
20. Jones R (2011) Does hospital bed demand depend more on death than demography? British Journal of Healthcare Management 17(5): 190-197.
21. Jones R (2012) End of life care and volatility in costs. British Journal of Healthcare Management 18(7): 374-381.
Competing interests: The author provides consultancy to health care organisations.