BRITISH JOURNAL OF PSYCHIATRY #2000), 177, 267^274

Expenditure on mental health care by English Executive, 1997). Using the approach de- scribed 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 .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 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.

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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 calcu- lation 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 calcu- lated 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 alloca- tion 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 abso- lute 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 com- munity 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

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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 rrˆ0.13,0.13, PPˆ0.2),0.2), as might be expected given the historical origins of its distribution. Table 1 shows the estimated mental health allocation and the expenditure, the ratio between them, and the excess of expenditure over alloca- tion for each of the 100 health authorities in England.

The relationship between expenditure and allocation As can be seen from Table 1, the ratio of Fig. 22Fig. Expenditure allocation ratio and need for100 health authorities in England, 1997^1998. $KCW, expenditure to allocation varies consider- Kensington, Chelsea and Westminster; ELCHA, East London, City and Hackney; LSL, Lambeth, Southwark ably, ranging from 0.55 to 1.48. The distri- and Lewisham; C&I, Camden and Islington; Man, ; Liv,.) bution is approximately normal, with a standard deviation of 0.20. This alone 30% of the variation in the ratio. That is, for mentally disordered offenders are re- suggests that if the allocation process is the tendency of areas of greater need to tained in the model, which explains 24% equitable, then expenditure cannot be. spend less in relation to their allocation is of the variance. However, the effect of The hypothesis that the inequity introduced both significant and of moderate strength these bed-days in the model is simply to ex- by variable expenditure acts to the dis- outside inner London, although there is still plain part of the high level of expenditure advantage of areas with greater need can considerable unexplained variation. in London. This can be demonstrated by be tested by regressing the expenditure: Our second hypothesis is that the re- reintroducing the dummy variable for inner allocation ratio on the Psychiatric Need lationship between expenditure and alloca- London into the model. This causes bed- Index. This shows a significant negative tion is explained by the levels of service days for mentally disordered offenders to relationship, areas with greater levels of activity purchased. A number of measures be excluded, as having no independent need tending to spend less than their alloca- of activity available in the CIC can be explanatory power for health authorities tion on mental health services coefficient hypothesised to explain higher levels of outside London, and the resulting model 772.55, 95% CI 774.1 to 1.0,1.0,4.1to PPˆ0.001).0.001). expenditure in relation to allocation. It is the same as model 1 Table 2). However, the relationship is not a strong has been shown previously that the number one, only 9.2% of the variance in the ratio of patients cared for by specialist mental Regional variations in the ratio health services is variable, even when need being explained by deprivation. Figure 2 of expenditure to allocation illustrates this with a scatter plot of the is taken into account Bindman et aletal,, ratio plotted against need, with the regres- 1999), and it might be that services which Figure 3 illustrates the geographical varia- sion line described above shown on the spend more are attempting to serve a great- tion in the ratio of expenditure to allocation. graph. A small number of more deprived er proportion of their local population. The It suggests that although there is some varia- health authorities are identified. It can be numbers of mentally disordered offenders bility in the ratio, even between neighbour- seen that the four inner-London authorities for whom care is purchased is known to ing health authorities, there is also a appear as outliers, with high levels of need, be particularly high in London McCrone degree of regional clustering. This is con- but high expenditure relative to allocation. et aletal, 1997), suggesting this is a possible firmed by the regional average Table 1), By contrast, Manchester and Liverpool, cause of excess expenditure over alloca- showing an average underspend in North- which also have high levels of need, spend tion. Health authorities purchasing services ern, Trent, West Midlands and North West less than their allocation, consistent with which have less well-developed community regions, and corresponding overspends in the relationship shown by the regression care, spending a high proportion of their the remaining regions. line. If the outlying position of the inner- resources on in-patient beds or having London authorities is taken into account low levels of CPN activity, might also be DISCUSSION by including a dummy variable for inner- expected to spend more in relation to allo- London status in a linear regression model, cation. Entering the activity variables into Limitations of the study a considerably stronger negative relation- a stepwise linear regression model together This study concerns only geographically ship between the ratio of expenditure to with the YorkPsychiatric Index model 2 equitable resource allocation and expenditure allocation and need is revealed model 1, in Table 2), only the need index and the at the health authority level. We do not ad- Table 2), and the model explains nearly per capita number of bed-days purchased dress the question of the overall adequacy

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Ta b l e 1 Allocation and expenditure on mental health services byby100 100 health authorities in England, 1997^1998 $»000/» per capita total population)

Health authority or regionAllocation Expenditure Per capita Per capita RatioRatio Expenditure, Per capita expenditure, $»000) $»000)$»000) allocation expenditure expenditure:allocation excess $+) or excess $+) $»)$») $»)$») deficit $77)) or deficit $$ordeficit 77)) $»000)$»000) $»)

Northern 388 592354 72561.78 57.48 0.94 7733 867 774.304.30 Bradford 32 01225 02465.72 51.37 0.78 7769886988 7714.3514.35 and 37 798 26 86926869 64.6864.68 45.9745.97 0.71 7710 929 7718.70 Durham 37 47039 09561.53 64.2064.20 1.041.04 16251625 2.672.67 East Riding 29 97525 00451.54 42.9942.99 0.83 774971 778.55 and South Tyneside25 79731 37971.97 87.54 1.221.22 55825582 15.5715.57 Leeds 45 84038 17963.14 52.59 0.83 7776617661 7710.55 Newcastle and North Tyneside35 93329 658 75.6375.6362.43 0.83 7762756275 7713.2113.21 North Cumbria 16 37217 784 51.2951.2955.71 1.09 1412 4.42 34 06838 62446.00 52.15 1.13 4556 6.15 17 45819 59356.40 63.2963.29 1.12 2135 6.90 SunderlandSunderland 19 996 21 09809821 67.52 71.24 1.06 1102 3.72 TeesTees 35 4223542226 326 63.5463.54 47.2247.22 0.74 7790969096 7716.3216.32 Wakefield 20 4502045016 09264.19 50.5150.51 0.79 774358 7713.68 Trent 277 140277140 265 045045265 53.84 49.99 0.93 7712 09509512 773.843.84 BarnsleyBarnsley 12 525 12 0461204655.06 52.9552.95 0.96 77479479 772.11 DoncasterDoncaster 16 50450416 14 36636614 56.0256.0248.76 0.87 7721382138 777.267.26 Leicestershire 48 33853 23951.75 57.00 1.10 4901 5.25 Lincolnshire 29 384 26 22826228 47.2647.2642.18 0.89 773156 775.085.08 North Derbyshire 17 10617 76045.55 47.2947.29 1.041.04 654654 1.74 North Nottinghamshire 19 20720719 16 12049.33 41.40 0.84 773087 777.937.93 Nottingham 37 649 39 80239802 57.9857.9861.30 1.06 2153 3.323.32 Rotherham 14 19112 15055.35 47.39 0.86 7720412041 777.967.96 Sheffield 36 82533 33470.02 63.3863.38 0.91 7734913491 776.64 South Derbyshire 29 27228 08352.36 50.23 0.96 7711891189 772.13 South Humber 16 13911 917 51.5051.50 38.0338.03 0.74 7742224222 7713.47 Anglia and Oxford 239 726278 32744.44 51.04 1.16 38 60138601 6.60 Bedfordshire 26 99026990 23 80480423 48.88 43.11 0.88 773186 775.775.77 BerkshireBerkshire 34 23642 34643.11 53.3353.33 1.24 8110 10.21 Buckinghamshire 28 736 31 89389331 42.2242.2246.85 1.11 31573157 4.64 Cambridge and Huntingdon 17 58322 773 38.5138.5149.87 1.30 51905190 11.37 East Norfolk 29 338 36 08636086 47.0147.01 57.8357.83 1.23 6748 10.8110.81 North West Anglia 20 04418 519 48.5848.5844.89 0.92 7715251525 773.70 Northamptonshire 28 647 32 25625632 46.9646.9652.87 1.13 3609 5.92 Oxfordshire 24 08332 21939.57 52.94 1.34 8136 13.37 Suffolk 30 06738 43145.11 57.6657.66 1.281.28 83648364 12.55 North Thames 502 824 533 709709533 75.07 79.78 1.051.05 30 885 4.70 Barking and Havering 23 56222 26161.29 57.91 0.94 771301301 1 773.39 BarnetBarnet 22 081 22 5462254670.02 71.49 1.02 465 1.48 Brent and Harrow 38 4053840533 93283.81 74.05 0.88 774473 779.76 Camden and Islington 46 40346403 53 76976953 126.42 146.48 1.161.16 73667366 20.0720.07 East and North Hertfordshire22 13325 06644.71 50.63 1.13 2933 5.925.92 Ealing, Hammersmith and Hounslow56 202 55 82182155 85.5685.5684.97 0.99 77381 770.580.58 East London and City 62 85966 071102.52 107.75 1.05 3212 5.24 Enfield and Haringey 40 29540 15184.67 84.3784.37 1.00 77144144 770.300.30 Hillingdon 14 618 12 61961912 59.09 51.0 1151.0 0.86 7719991999 778.08 Kensington, Chelsea and Westminster38 154 52 61161152 107.26 147.91 1.38 14 45745714 40.64 North Essex39Essex 130 39 13048 318 44.2044.20 54.5854.58 1.23 9188 10.38

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Ta b l e 11Tab continued)continued)

Health authority or region Allocation Expenditure Per capita Per capita RatioRatio Expenditure, Per capita expenditure, $»000) $»000)$»000) allocationallocation expenditure expenditure:allocation excess $+) or excess $+) $») $») deficit $77)) or deficit $77)) $»000) $»)$»)

Redbridge and Waltham Forest 34 6233462337 57576.51 83.04 1.09 2952 6.52 South Essex36Essex 255 36 25535 59151.48 50.54 0.98 77664664 770.940.94 West Hertfordshire 28 103 27 37837827 53.50 52.12 0.97 77725 771.381.38 South Thames 438 778482 729 64.8364.8370.39 1.09 43 95195143 5.565.56 Bexley and Greenwich 30 43731 91670.08 73.4873.48 1.05 1479 3.40 Bromley 21 10913 29771.91 45.30 0.63 7778127812 7726.6126.61 Croydon 20 29720297 19 20220219 60.90 57.61 0.95 771095 773.283.28 East Kent 33 39530 344 56.1556.1551.02 0.91 773051 775.135.13 East Surrey 26 16133 31663.46 80.82 1.27 7155 17.36 East Sussex46Sussex 028 46 02844 64162.61 60.72 0.97 7713871387 771.89 Kingston and Richmond 19 831 27 83783727 62.0962.0987.16 1.40 8006 25.0725.07 Lambeth, Southwark and Lewisham79 03397 389 106.86106.86131.68 1.231.23 18 356 24.82 Merton, Sutton and Wandsworth48 92949 35378.29 78.97 1.01.01 1 424 0.68 West Kent 45 24846 06246.80 47.64 1.02 814 0.84 West Surrey 29 23143 124 45.8645.8667.65 1.48 13 893 21.79 West Sussex39Sussex 080 39 08046 24852.97 62.68 1.18 7168 9.71 South WestWestSouth 322 827354 199 49.1249.1253.92 1.10 31 372 4.80 Avon 49 9264992651 61650.50 52.21 1.03 1690 1.71 Cornwall and Isles of Scilly 24 085 26 04326043 49.1149.1153.10 1.08 19581958 3.99 Dorset 35 913 32 89689632 52.07 47.70 0.92 773017 774.37 Gloucestershire 26 54925 35247.44 45.31 0.95 7711971197 772.14 Isle of Wight 7507762 59.78 60.7060.70 1.02 115 0.92 North and East Devon 23 481 25 70170125 49.35 54.0254.02 1.09 22202220 4.67 North and Mid Hampshire 22 50222502 28 5832858341.02 52.11 1.27 6081 11.09 Portsmouth and SE Hampshire27 750 31 95195131 51.5851.5859.39 1.15 42014201 7.81 SomersetSomerset 21 52624 30744.09 49.79 1.13 2781 5.70 South and West Devon 31 33839 47752.72 66.41 1.261.26 8139 13.69 Southampton and SW Hampshire26 08829 02948.23 53.67 1.11 2941 5.44 Wiltshire 26 16231 62243.52 52.6052.60 1.21 5460 9.08 West Midlands 299 290276 49554.96 49.87 0.93 7722 79522795 775.09 75 238 68 07007068 74.04 66.99 0.90 7771687168 777.05 20 2602026017 05167.27 56.62 0.84 7732093209 7710.66 Dudley 15 44615 13549.15 48.1648.16 0.98 77311 770.99 Herefordshire 71997215 43.2443.24 43.3443.34 1.00 16 0.10 North Staffordshire 27 49627496 28 1222812257.83 59.15 1.02 626 1.32 20 36715 47769.49 52.81 0.760.76 7748904890 7716.68 Shropshire 19 18718 454 44.9744.97 43.2543.25 0.96 77733733 771.72 Solihull 92299884 45.35 48.5848.58 1.07 655 3.223.22 South Staffordshire 24 420 26 5272652741.55 45.13 1.09 2107 3.58 Walsall 15 61412 40401 159.44 47.21 0.79 7732133213 7712.23 Warwickshire 24 489 24 03903924 48.75 47.85 0.98 77450450 770.90 16 94011 38769.83 46.94 0.67 775553 7722.8922.89 Worcestershire 23 40522 733 43.5743.57 42.3242.32 0.97 77672672 771.25 North West 441 516 384 874874384 66.0466.04 56.6256.62 0.87 7756 64256642 779.429.42 Bury and Rochdale 25 5522555216 27765.02 41.42 0.64 7792759275 7723.60 East Lancashire 37 116 27 75975927 72.4572.4554.18 0.75 7793579357 7718.2618.26 Liverpool 39 11034 63783.60 74.04 0.89 774473 779.569.56 Manchester 45 14837 023104.78 85.92 0.82 778125 7718.8618.86

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TaTable b l e 1 continued)continued)

Health authority or regionAllocation Expenditure Per capita Per capita RatioRatio Expenditure, Per capita expenditure, »$000)»$000) $»000)$»000) allocation expenditure expenditure:allocation excess $+) or excess $+) $»)$») $»)$») deficit $77)) or deficit $77)) $»000) $»)

Morecambe Bay 18 90324 88360.75 79.97 1.32 5980 19.22 North Cheshire 18 63023 12859.72 74.14 1.241.24 4498 14.42 North West Lancashire 32 25532 24468.62 68.6068.60 1.00 771111 770.02 Salford and 32 99228 054 73.6873.6862.65 0.85 774938 7711.0311.03 Sefton 18 86511 55064.94 39.76 0.61 777314 7725.18 South Cheshire 32 701 45 64745647 48.5148.5167.71 1.40 12 946 19.20 South Lancashire 15 3458888 49.2949.29 28.5528.55 0.580.58 7764576457 7702.7402.74 St Helens and Knowsley 20 32516 92561.03 50.82 0.83 7734003400 7710.2110.21 Stockport 14 95412 04051.41 41.39 0.81 772914 7710.02 West Pennine 31 84023 27966.88 48.90 0.73 778561 7717.9817.98 Wigan and Bolton 37 47031 32764.66 54.06 0.84 7761436143 7710.60 Wirral 20 31020310 11 21321311 61.2861.28 33.8333.83 0.55 779097 7727.4527.45 England $total) 2 910 6912930103 2 930 103 59.19 59.84 1.01.01 1 19 412 0.39

of resources, nor can it be assumed that health allocation from the total, and that Underspending in areas equitable expenditure would guarantee that the result is the level of resources needed of greater need the ultimate goal ± equal access to services to achieve equity. The possibility of doing The results of this study show that at the for individuals with equal needs ± would so appears to have been recognised by the level of health authorities, the relation of be achieved. The study takes as its starting Yorkteam, who wrote that ``use of the in- expenditure on mental health to the psy- point the assumption that the YorkPsychi- dex implies a considerable redistribution chiatric allocation varies, but declines atric Index accurately reflects the need for of resources towards deprived areas ....it . . it significantly as the level of socio-economic psychiatric services in each area. Although is to be hoped that the psychiatric index deprivation increases, in areas outside this assumption is to some extent justified we have developed will be the first step inner London. Subject to the assumptions by the use of the index in the allocation towards a more equitable distribution of described above, this does appear to suggest process, its limitations have been acknowl- resources'' Smith et aletal, 1996). A further that expenditure is inequitable, and that the edged by the Yorkteam which devised it limitation of the study is the failure to take effect of this inequity is to cause further Carr-HillCarr-Hill et aletal, 1994,1994aa,,bb; Smith;Smith et aletal,, into account the level of social services disadvantage to areas with high levels of 1994, 1996) and it has also been criticised spending on community mental health care socio-economic deprivation. This probably by other commentators on the grounds that in each area, which may exacerbate or al- arises because the Yorkindices, which it is based on inappropriate measures of the leviate any apparent deficiencies in health identify psychiatric and general medical utilisation and the supply of mental health spending; however, this cannot easily be needs separately, were only introduced into care Glover, 1996; Jarman & Bajekal, considered because directly comparable the allocation process from 1995±1996 1996; Lelliott, 1996). We also assume that data are not available Judge & Mays, onwards. As a consequence of the more it is appropriate to disaggregate the mental 1994).1994). redistributive nature of the new psychiatric index, compared with the general index, the allocation based on it contains the TaTable b l e 2 Regression analyses of expenditure:allocation ratio in health authorities in England onYork assumption that a greater proportion of Psychiatric Need Index, inner-London status and service activity purchased the total resources for health care should be spent on mental health in more deprived VariableCoefficient 95% CI PP areas, a proportion which, using the meth- od described by Glover 1999), doubles Model 11Model from 8 to 16% from the least to the most Psychiatric Need Index 774.264.26 775.66 to 772.842.84 550.001 deprived health authorities. However, this Inner-London health authority 0.530.33 to 0.72 550.001 assumption, which could not have been $For model: FF$2,97)$2,97)ˆ2.13,2.13, PP550.0001, adjusted RR22ˆ0.2906) made prior to the introduction of the York Model 22Model formula, has never been drawn to the atten- Psychiatric Need Index 774.73 776.37 to 773.083.08 550.001 tion of health authorities. They may fail to spend resources in line with the York Per capita secure occupied bed-days 6.94 3.89 to 9.999.993.89 550.001 formula simply because it has never been $For model: FF$2,97)$2,97)ˆ16.8,16.8, PP550.001, adjusted RR22ˆ0.2421)0.2421) suggested that they should do so. Even if

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kind advocated by Sheldon suggests that the implications of the Yorkformula are not being translated into practice, and that current mental health spending is failing to rectify past inequities. The first step towards addressing this would be to make explicit to each health authority the implications of the allocation formula for the resourcing of particular clinical areas Glover, 1999). Where there are substantial shortfalls of mental health expenditure in relation to allocation, local health authorities should be called upon to justify them, particularly where we have found this to be a systematic effect: in de- prived areas outside London. This might prompt a gradual shift in expenditure, to approach the allocation more closely over time. However, it may become apparent that there are good local justifications for current spending patterns, and if so, those would need to be considered in any future re-examination of the allocation formula.

ACKNOWLEDGEMENTS

We are grateful to the Regional Office staff who provided OLS data, and to Colin Sanderson for his comments on the manuscript.

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