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3.4.1 Historical perspective and revised formula

The Capitation Formula Review Group (CFRG) was responsible for determining the health allocations in Northern Ireland. The Proposals for the Allocation of Revenue Resources (PARR) had a rurality adjustment in the formula for community health and ambulance services. That for community services was based on the distance patients lived from their GP and for the ambulance service it was based on the average miles per patient carried. These adjustments were the subject of criticism for being inaccurate. The community adjustment was based on information from 1983 and the ambulance adjustment took no account of journey time.

The review of rurality costs was undertaken to assess where adjustments were necessary and develop new measures where appropriate. The reports Research into the Effect of Rurality on the Capitation Formula for Health and Social Services in Northern Ireland (PwC 1998) and Modelling the Impact of Rurality on the Provision of Accident and Emergency Services in Northern Ireland (1998) concluded that in addition to empirical research there needed to be research on the impact on the services affected by travel.

A review was commissioned to identify what if any adjustments to the allocation formula were necessary to compensate for the relative effects of rurality across the province. The research was carried out during 1999 by universities including Queens in Belfast and Lancaster and it concluded that the distance from Belfast and the number and size of facilities were the key issues. The review considered the maximum reasonable distance to travel in order to obtain a service. The potential need for more

particular focus. Accident and emergency units were highlighted because of the need for the service to be highly accessible. Non-productive travelling time was also identified as a potential area of increased cost. (Northern Ireland Health and Personal Social Services 1997, 2000)

It was concluded that the information from the NHS was insufficiently robust to be used for the analyses. As a result a series of models were developed to determine additional costs for rural areas. These simulated the situations being studied so that distances and times models could be estimated. Algorithms were used to determine the required number of routes each day and the travel distances and time to complete these routes.

The analyses of acute services indicated that there was a lower utilisation in rural areas. It was concluded that this did not reflect a reduced need but was a consequence of poorer access. The approach developed by the Health and Social Care Research Unit and York University used the assumption that utilisation after taking into account supply considerations was a robust indicator of need. The report concluded that notwithstanding the impact of congestion, rural areas experience additional costs for the same level of demand.

3.4.2 Peripatetic staff, patient transport & emergency ambulance model

The models for calculating the impact on costs for staff who are required to visit patients in their homes and community clinics, and that for patient transport, had the following elements: the distance from each enumeration district to delivery centres; the travelling times from each enumeration district to each delivery centre; and demand rates for each enumeration district. The model for determining emergency ambulance

costs was based on a simulated incident pattern; road speeds in miles per hour for each road type based on time of call out; and response time requirements.

The study concluded that the costs of peripatetic healthcare workers are higher in rural areas due to direct costs associated with increased fuel usage and additional vehicle costs and indirect costs of non-productive health worker travelling time. The staff covered were district nursing, psychiatric nursing, health visiting, occupational therapy, podiatry, community midwifery and community social work. The study quantified the unavoidable costs of rurality in terms of unproductive time spent travelling and costs per mile. The emergency ambulance service analyses used computer simulations of emergency and doctor urgent requests. This has resulted in a quantification of the need for staffing, ambulance vehicles and travel related costs. A similar exercise was completed for non-emergency ambulance services giving the staff, vehicle and travel related costs.

The rurality budget was incorporated in the allocation formula by adjusting the final allocation of Boards. The final monetary allocation was adjusted by the difference between the rurality budget, and the weighted capitation adjusted for age, gender and need.

The review of the effect of rurality (PwC and University of Lancaster, 1998) covered the impact of rurality and made a series of recommendations. The modelling approach was based on three scenarios. Firstly, where a healthcare professional was required to make a series of trips to visit clients/patients in their places of residence; secondly, where patients are transported from their own homes to health or social care institutions and returned; and thirdly where an institution or service located in a sparsely populated area was unable to maximise throughput and thus benefit from

Distance, both physical and travelling time, from major urban centres was also an indication of rurality and in Northern Ireland it was concluded that this factor was effectively a function of the ‘distance from Belfast’.

The key recommendations were that there should be a revised rurality weighting consistent with the findings of the research and that further research should be undertaken as resources permit to isolate the effect of rurality on the relative costliness of providing hospital based services across the Boards in the province.

The subsequent study was carried out by MSA Ferndale and published in 2003. It concluded that there are significantly higher costs in small hospitals and that community service funding needed to reflect the unavoidable inefficiencies that occur due to the fluctuating nature of the workload. It was concluded that large acute hospitals have higher costs but that this could be due to poor management of resources, the impact of teaching or complexities associated with running multiple site hospitals. It was also concluded that additional research was required into the impact of cross boundary flows and the adjustments that need to be made.

3.4.3 Critique of Northern Ireland

The research into the potential impact of rurality and inefficiencies for large multiple site hospitals raised a series of issues that were pertinent to the NHS allocations in the other Home Countries.

The methodology adopted to develop the transport adjustment appears to be a rigorous approach for community based staff. It may not fully reflect patient accessibility issues as there was no assessment of key issues like the provision of

public transport. This can be an important factor as patients may not be able to drive, or have access to a car. In addition they may not be sufficiently healthy to drive but may be fit enough to use public transport. Despite these reservations it was concluded that the calculation of travel times was a significant advance on the systems used for GMS in England and HCHS and GMS in Scotland.

Like other systems where the need adjustments are based on proxies, there was the potential for the measures and the coefficients selected to under or over predict the actual differences in healthcare needs.

3.5 WALES

3.5.1 Historical review

The resource allocation system used in Wales was like that for the rest of the UK as it was based on weighted capitation formulae, so that if no adjustments were applied, each area would have received allocations based solely on population. As with England the factors could be categorised as either cost or need adjustments.

The sparsity adjustment was calculated and used for the ambulance and some of the community health services. These weights were different for each area. For community health services the sparsity measure was used in the calculation of modified population shares to reflect the staff time spent in travelling.

For each staff group, health visitors, district nurses, midwives and auxiliary nurses, what was referred to as the “Monte Carlo” simulation was used to give an estimated average distance per visit. This was then applied to the expenditure and SMR

travelling time distribution. The travelling time distributions were also directly combined to give an overall health authority share to apply to an estimate of the expenditure on travel and subsistence for community health staff. This approach was similar to the approach adopted by later studies in Northern Ireland.

For the ambulance sector, the sparsity factor was calculated by taking the road length per 1000 population added to the Wales average road length per 1000 population. This factor was applied to a weighted sum of the in-patient and out-patient weighted populations for each health authority. The out-patient weight was 5 and the in-patient weight was 1.

The estimate of the proportion of time spent travelling was taken from a 1982 OPCS survey “Nurses Working in the Community”. The community health service weightings were based on the simulation study carried out by the University of Swansea in 1983.

3.5.2 Townsend system to adjust for differences in health need

The Welsh National Assembly commissioned research by the universities of Bristol, Cardiff and Lancaster and additional statistical analyses were completed by the Office for National Statistics. The report of the independent research team concluded that it was more appropriate to allocate NHS funding according to statistics that directly relate to the need for health care rather than using proxies for health need (Gordon et al 2001).

A comprehensive review was led by Professor Peter Townsend of the London School of Economics and Bristol University (Townsend 2001). Like other health weighted capitation formulae used in the UK the recommended formula was based on making

adjustments to compensate for differences in health needs and unavoidable differences in the cost of providing services.

The review concluded that the data required to complete an equivalent analysis to that for Scotland would take two years because of a lack of robust information and because some of the required information was not collected at postcode level. Areas of particular concern included the reliability of the Trust Financial Returns (TFR2) data from Trusts on expenditure the Welsh Health Survey (WHS), the validity of the indicators and their links to blocks of expenditure. It was concluded that the WHS and TFR2 data may not be robust and that this was a key issue because they were key components of formula and it was therefore essential that they were accurate and reliable enough for ranking between areas to be robust.

It was also concluded that the “indirect measures of capturing relative need” used in the Scottish, English and Northern Ireland formulae were all based on proxies for health need rather than the actual health need. It also asserted that the Scottish report was based on complex statistical analyses and that this hindered transparency and comprehensibility.

The report of Task Group C on the impact of rurality and remoteness concluded that significant adjustments needed to be added to the formula to compensate for rural factors, but it was acknowledged that this would require individual analysis because of the specialist nature of the service. It was concluded that the extant adjustment for rurality should continue until further research had been completed. The group concluded that there was insufficient information to justify a cost weighting for the costs of providing hospital services.

It was recommended that the new Welsh system should be introduced for allocations from 1 April 2004 however it was subsequently decided to phase in the adjustment as a result the adjustment applied to a proportion of the need factor but majority of the weighting was based on the previous system in 2004/5.

3.5.3 Critique of Townsend Welsh NHS Allocation Formula

It has been concluded by other researchers that the Welsh formula has theoretical and practical advantages over the proxy measures systems for identifying differences in need. One of the strengths of the system was that it recognises the historical link and funds existing facilities. I believe that this needs to be considered by any system that aims to adjust for unavoidable differences in costs as considerable resistance is encountered when there are proposals to rationalise health care facilities in rural areas (Banyard 1997).This means that areas like Dyfed Pows which had a large number of small community hospitals as shown in Figure 3.5 would have little prospect of rationalising facilities. However it is also the proverbial ‘double edged sword’ as this strength was also a potential weakness as it did not progress the issue of whether or not the facilities should be there and therefore it maintains the status quo (Asthana et al 2002). It was concluded that the formula should have recommended that efficiency improvements based on sound clinical practice for improving efficiency and minimising the unavoidable additional costs should have been key criteria for the detailed review of rurality.

It was concluded that rural areas need to develop and innovate. There have been significant advances in practice in rural areas. Scottish GPs led the use of thrombolysis in community hospitals and this was followed by treatment in the community, mobile screening for retinopathy has been introduced and it has been

proved that GP and Midwife led community hospitals offer safe and effective maternity care (Murray et al 2002)

The key advantage of the Townsend approach was that the allocation would be clearly targeted at the need experienced by the health service rather a theoretical proxy of what the need should be. The approach would also have the major advantage of improving the focus on the quality of data on activity, outcome and costs.

Figure 3.5 Hospitals within the Dyfed Powys Health Authority area

River S evern