Desmontaje de componentes internos

155. The Acheson report treated the NHS differently from the other areas of policy development. It said that equity – the principle of matching needs and services – was a founding principle of the NHS. It examined some of the management and operational issues around healthcare provision and the impact on health inequalities, particularly in relation to:

• access to (and quality of) services

• the distribution of resources across the NHS

• the need for additional capacity to tackle health inequalities.

Policy response

156. There have been many developments in the organisation, structure and financing of the NHS in the 10 years since Acheson reported, in particular the publication of The NHS Plan (2000)86

– a 10-year plan for investment and reform that reaffirmed the core principle of the NHS as a universal service, free at the point of use. It combined this with a commitment to modernise the service shaped around the needs and expectations of patients and the public. This document first announced the Government’s intention to establish national health inequalities targets.

It pledged to reduce inequalities in access to services as well as to act on some of the contributory factors, such as smoking, as well as promoting joint working across government.

157. The High Quality Care for All: NHS Next Stage Review Final Report (Darzi) demonstrated that the NHS has a role in promoting equality through the services it provides, paying particular attention to groups or sections of society where improvements in health and life expectancy are not keeping pace with the rest of the population. The interim report87 _{looked at how the}

NHS can become fairer, more personalised, more effective and safer. Central to the review are the principles of fairness – ensuring services are equally available to all, taking full account of personal circumstances and diversity, and personalised services tailored to the needs and wants of each individual, especially the most vulnerable and those in greatest need.88

Access issues

158. The NHS Plan had emphasised the need for national priorities and national standards to improve NHS performance and achieve greater equity. A small number of national targets on access and quality issues, including waiting times, supported these standards. Guidance on the best treatment was provided by the National Institute for Health and Clinical Excellence (NICE) to ensure a faster, more uniform uptake of treatments. The Plan gave a new emphasis to prevention and to working in partnership with other agencies to tackle the causes of ill-health that lead to health inequalities.

159. It acknowledged the persistence of the ‘inverse care law’ in many parts of the country. This states that communities in the greatest need are least likely to receive the treatment they require. This inequality was part of the legacy inherited by the NHS at its formation in 1948 and was a key issue for Acheson. It sought new ways to address this issue, including through a more equitable distribution of GP and primary care staff, making equitable access to services part of the new NHS performance framework, and a more equitable NHS spending formula. The inverse care law remains a significant challenge to delivering equal access to health services. This was acknowledged

in Our NHS, our future, which set out further plans to strengthen primary care provision in

disadvantaged areas by setting up new health centres in some of the most deprived communities. 160. Commissioning is a key vehicle to achieving greater equity in access to, and quality of, health

services. World Class Commissioning introduced in 2007 set out a new approach to commissioning for health and care services, and it underpins many of the objectives of current health policy. By working in partnership with the NHS, social care and local government, a joint approach has been developed to meet the needs and priorities of the local population and improve health outcomes. 161. One of the aims of World Class Commissioning is to reduce inequalities between the areas

with the worst and best health. Health inequalities are often exacerbated by a lack of access to appropriate services in the community. An assurance process that identifies health inequalities and life expectancy as core business outcomes for every PCT will assist the achievement of this aim. 162. The Quality and Outcomes Framework (QOF) addresses the need to reduce health inequalities

in primary care. The QOF system is based on the recorded prevalence of disease and ensuring that GP practices serving disadvantaged areas with a higher prevalence of disease get more funds to address these issues. Independent research shows that QOF has resulted in a narrowing of the gap between the quality of care in deprived and more affluent areas.89 _{In addition, the agreement}

between NHS Employers and the BMA for the GP contract 2009/10 includes moving to a full prevalence adjustment for QOF payments by April 2010. This will be a major step forward 87 _{Department of Health (2007) Our NHS, our future.}

88 _{Department of Health (2008) High Quality Care for All: NHS Next Stage Review Final Report.}

89 _{Doran, T, et al. (2008) The effect of financial incentives on inequalities in the delivery of primary clinical care in England: analysis of}

in making sure that QOF payments are fairly related to the needs of patients within a practice population, thereby redistributing money to more deprived areas and creating better incentives for case-finding.

Resources

163. Acheson welcomed the progress made in recent years to a more equitable approach to allocating health service and other resources, but highlighted that more needed to be done. In 1997, the Advisory Committee on Resource Allocation (ACRA) was established as the successor to the Resource Allocation Group to oversee the development of the weighted capitation formula used to inform revenue allocations to NHS organisations. In particular, ACRA was charged with advising the Secretary of State for Health on:

• [recommending] a distribution of resources across primary and secondary care that supports

equitable access to healthcare for all;

• [ensuring] equal opportunity of access to healthcare for people at equal risk; and • [contributing to] the reduction in avoidable health inequalities.

164. For the 2001/02 and 2002/03 revenue allocations, a health inequalities adjustment was introduced into the funding formula. This was an interim adjustment that targeted a proportion of the overall allocation for those health authorities that were judged as having the poorest health outcomes. 165. Prior to the 2003/04 revenue allocations, ACRA carried out a wide-ranging review of the

formula. The new formula contained an adjustment for unmet need, that is, the need for healthcare over and above that accounted for by the age of the population. This formula has been used to inform revenue allocations to the NHS from 2003/04 to 2008/09.

166. The weighted capitation formula was extended to primary care with the introduction of the primary medical services component (replacing the previous General Medical Services Cash Limited and Non-Cash Limited resources) into the formula in 2006/07. The age- and sex- related needs and additional need adjustments for this component of the formula were based on research used to derive a new resource allocation formula as part of the new GP contract introduced in 2004/05.

167. The weighted capitation formula is used to determine each PCT’s target share of the resources available. The level of increase which all PCTs receive in order to deliver on local and national priorities is determined by the Pace of Change policy. The Pace of Change policy is decided by ministers for each round of the allocations in light of the commitment to bring all PCTs to their target allocation as soon as is practicable, while ensuring that all PCTs receive sufficient extra funding to enable them to deliver on national and local priorities.

168. A faster Pace of Change policy was adopted in 2006/07 and 2007/08. By the end of 2007/08 no PCT was more than 3.5 per cent below its target (with one exception following PCT reconfigurations). This new approach helped many spearhead areas whose financial allocation runs behind the target set by the ACRA process through the Pace of Change policy. This has involved moving PCTs towards their target allocation as quickly as practicably possible. The Pace of Change policy has been frozen for 2008/09, pending a new formula for 2009/10 and beyond.

169. In the 2006/07 and 2007/08 PCT revenue allocations, additional resources of £550 million were identified to support the delivery of some of the commitments in Choosing Health to enable PCTs to deliver on initiatives which included sexual health services, chlamydia screening, school nurses and health trainers, many of whom contribute to reducing health inequalities. From 2008/09, this funding has been included in PCT baselines.

170. Pending revision of the formula, the Hospital and Community Health Services (HCHS) allocation formula was supplemented by an interim health inequalities adjustment in 2001/02 and 2002/03, designed to help those health authorities with the worst outcomes, pending the introduction of a new formula for 2003/04, which included an element for unmet need. 171. It should be noted that the local spending experience has differed from the national plans.

It has varied over the last few years, either through underspends or through year-on-year pressures, for example to balance budgets. Such pressures can distort plans and priorities and weaken the impetus within NHS organisations to improve health and tackle health inequalities or support partners in this work.

Building capacity

172. The Acheson report declared that in order to take forward a new agenda to tackle health inequalities, the skills, resources and capacity of organisations to work together needed

strengthening, including the public health function of the NHS and cross-government working. 173. The Programme for Action (2003) emphasised the importance of systems and processes to this

new agenda, specifically the idea of ‘mainstreaming’ health inequalities in the work of major national programmes. This approach was aimed at embedding health inequalities as a regular part of NHS and other business, rather than as a separate programme or projects.

174. Equally, it highlighted the roles and responsibilities of key players, from the parts played by local professionals in the NHS and local government, to those played by local, regional and central government. Partnership working, notably through the Local Strategic Partnerships trailed in

The NHS Plan, was seen as critical in moving this work forward.

175. The Director of Public Health (DPH) has a lead role in protecting and improving the health of the local population, reducing health inequalities and ensuring the quality and safety of patient services. The Our health, our care, our say (2006) White Paper recommended joint DPH appointments between PCTs and local authorities as best practice.

176. Following the publication of the Local Government and Public Involvement in Health Act 2007, local government and PCTs have a statutory requirement to undertake JSNAs. In their new roles, DPHs will work in partnership with the Director of Adult Social Services and the Director of Children’s Services to undertake JSNAs, which is vital in ensuring World Class Commissioning and the delivery of more equitable services.