Expenditure on Mental Health Care by English Health Authorities

BRITISH JOURNAL OF PSYCHIATRY #2000), 177, 267^274 Expenditure on mental health care by English Executive, 1997). Using the approach described by Glover 1999), the proportion health authorities: a potential cause of inequity of the total allocated to the purchase of mental health services was assumed to be the proportion of the weighted capitation JONATHAN BINDMAN, GYLES GLOVER, DAVID GOLDBERG derived from theuse of the YorkPsy- and DANIEL CHISHOLM chiatric Carr-HilllCarr-Hil et aletal, 1994,1994aa) and Com- munity Psychiatric Buckingham et aletal,, 1996) Need indices. In 1997±1998, the de- cision was taken to weight 11.08% the `programme weight') of the age- and cost- weighted population of each area using Background TheYork resource The importance of equity in mental health these two indices, applied in the ratio allocation formula includes a calculation of services has recently been re-emphasised 88.06:11.94 NHS Executive, 1997). Acheson, 1998). Painstaking efforts are the amount needed to purchase mental made to ensure that National Health Service health services equitablyin each health NHS) resources are allocated equitably be- authority in England.However, the tween health authorities, using a formula Special allocations for purchasing amount whichis actually spenton services which takes account of the need for mental mental health services is at the discretion of the authority. health services Carr-Hill et al, 1994,1994aa;Smith In addition to the general allocation, health et al, 1996), although the final allocation is authorities receive other sums, special allo- Aims To compare expenditure on not divided according to different clinical cations, intended for the purchase of mental mentalhealth services with allocation, and areas. Although the effectiveness of the health services Fig. 1). The largest of these allocation process in achieving equity has is the `old long stay' OLS) allocation, to test the hypothesis that differences been criticised Glover, 1996; Jarman & cover the continuing care costs of individual betweenbetweenthemaretothedisadvantageof them are to the disadvantage of Bajekal 1996; Lelliott, 1996), the question patients with mental illness who were in servicesin deprived areas. of how resources are spent, which is at the hospital prior to 1971, and patients with discretion of each authority, has been insuf- learning disabilities who were in hospital MethodMethod A comparison of routine ficiently considered. However, it is likely to prior to 1970. The total OLS allocation expenditure and allocation data, andlinear be the more important source of inequity figures for each health authority in 1997± regression modelling of the ratio of Sheldon, 1997). 1998 were available from the NHS Execu- National comparisons of health author- tive 1996), but the proportions of the total expenditure to allocation. ity expenditure on mental health care have allocated to patients with mental illness ResultsResults TheTheratioofexpenditureto ratio of expenditure to not previously been published. In this paper were not available centrally. Regional we compare expenditure and allocation for offices provided details of the proportion allocation varies widely.Relative all the health authorities in England. We of the total OLS allocated to 21 authorities underspending occurs more frequently in test the hypothesis that the way in which re- for patients with mental illness in 1997± deprived areas, although notinthe four sources are spent contributes to inequity, to 1998. For a further 52 authorities, regional inner-London health authorities. the disadvantage of those areas with the offices provided these details for 1996, and greatest needs. for the remaining 27 authorities this propor- Conclusions The intentions of theYork tion was provided for 1999. The 1996 or formula are not achieved in practice.The 1999 proportions were combined with the total OLS allocation for 1997±1998 to implications of the formula for mental METHOD estimate the total amount of OLS allocated health should be made explicitexplicitto to health General allocation for purchasing to each authority for patients with mental authorities, and shortfallsin mentalhealth mental health services illness in 1997±1998. expenditure relative to allocation should In 1997±1998, health authorities were allo- A smaller special allocation, `joint be justified at a local level. cated £24 367 million to purchase hospital finance', has an identifiable `mental health and community health services HCHS), of target' element based on the community Declaration of interest None.None. which £21 816 million was given as a psychiatric index, and this was calculated general recurrent allocation based on a from published data NHS Executive, weighted capitation formula Fig. 1). The 1996) using a method similar to that used total weighted capitation of each area, on for the general allocation. Two other special which the general allocation is based, is allocations are available to purchase psy- arrived at by weighting the mid-year chiatric care: the drug misuse allocation 1997) crude population for age, for local and the mental health challenge fund. The costs, and for the need for four types of figure for the former is available from health care: general and acute, psychiatric, published data NHS Executive, 1996) and community psychiatric, and community, that for the latter was supplied by the each expressed as an index NHS NHS Executive. 267267 Downloaded from https://www.cambridge.org/core. 26 Sep 2021 at 06:21:11, subject to the Cambridge Core terms of use. BINDMAN ET AL programme weight of 11.08% used in the calculation of the mental health general allocation in 1997±1998 was based on the proportion of total expenditure on mental health in 1992±1993 and 1994±1995, the most recent data available at the time. Changes in this proportion over the inter- vening years need to be accounted for before attempting comparisons for 1997± 1998, and we therefore reworked the calculation using a nominal programme weight of 12.345%, the actual proportion of total expenditure on mental health in 1997±1998. The estimated total allocation to mental health for each health authority was calculated by adding all the mental health special allocations to the mental health general allocation. Using a nominal programme weight as described has the effect of ensuring that our estimate of the national total allocation is approximately equal to the national total spend Table 1), and therefore for an authority which is spending the amount on mental health services which is implied by the formula, expenditure and allocation should also be approximately equal. Comparisons between expenditure and allocation were made using both the absolute excess of expenditure over allocation, and the ratio of mental health expenditure to allocation in each health authority. Measure of deprivation We used the YorkPsychiatric Need Index, the main index of psychiatric need included Fig. 11Fig. Resource allocation and expenditure in the National Health Service $NHS) $hospital and community within the allocation formula itself Carr- health services) 1997^1998 $»). $Figures in normal or bold typeface are derived from central sources $NHS Ex- HillHill et aletal,1994,1994aa), as a proxy for deprivation. ecutive, 1996, and NHS Common Information Core); figures in italics are estimated as described in the text.) Mental health expenditure variables were: the total number of patients Statistical analysis and service activity under the care of the service in the fourth All data were analysed using the STATA The Department of Health collects data quarter of 1997±1998) and the number of software package STATA Corporation, annually the Common Information Core, occupied bed-days purchased in the public 1997). The ratio of expenditure to allocation CIC) on the clinical activities which health and private sectors) for mentally disordered was used as the dependent variable in a linear authorities contract to purchase from offenders, each expressed per capita of the regression model, using backward stepwise health trusts, and the associated expendi- population served. In addition, two mea- selection to identify a simplified model the ture. Total mental health expenditure for sures derived from the CIC were used as criteria being PP440.05 for removal from 1997±1998 was derived from the expendi- crude proxies for the extent of development andand PP550.1 for addition to the model). The ture on five types of activity: in-patient, of community services: the number of com- Psychiatric Need Index and the activity vari- out-patient, day care, residential, and community psychiatric nurse CPN) contacts ables described above were entered into the munity care for mental illness. The total per capita, and the fraction of total expen- model as explanatory variables. expenditure on these activities formed diture which was spent on in-patient beds. 12.345% of the total expenditure on all RESULTSRESULTS hospital and community health services reported in the CIC. Other types of activity Comparing allocation Allocation and expenditure recorded in the CIC were not costed, but and expenditure Figure 1 shows the total allocations made were used in this study as possible explana- The absolute levels of allocation and to health authorities for hospital and tory variables to model the relationship expenditure, derived as described above, community health services in 1997±1998, between expenditure and allocation. These are not directly comparable, because the the reported expenditure by them, and our 268 Downloaded from https://www.cambridge.org/core. 26 Sep 2021 at 06:21:11, subject to the Cambridge Core terms of use. EXPENDITURE ON MENTAL HEALTH CARE estimates of the total allocation for mental health services in italics). It can be seen that the special allocations to mental health form only a small proportion 7%) of the total allocation. The largest part of this, the OLS allocation, varies widely from zero in six health authorities to £6.8 million in East Surrey) and is unrelated to the Psychiatric Need Index rr0.13,0.13, PP0.2),0.2), as might be expected given the historical origins of its distribution.

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