Alocação de Recursos Financeiros no NHS

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Financial Resource Allocation
Health Economics: 3 - Financial Resource Allocation
 
This section discusses the way in which National Health Service (NHS) funding is
allocated from the NHS England to Clinical Commissioning Groups (CCGs) in
England. It does not cover any other means by which financial resources are
allocated, for example from parliament to the Department of Health, from the
Department of Health to NHS England or from CCGs to providers. It also does not
cover the NHS financial resource allocation mechanisms in Scotland, Wales or
Northern Ireland, which are different to that of England, although some principles
remain the same.
NHS England allocates financial resources directly to CCGs for them to spend on
health care. The allocation for each CCG is a share of the resources available
nationally, which is decided during the Treasury’s annual Spending Review. Each
CCG’s share is determined by a process that includes a needs-based formula. This
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formula calculates what funding CCGs should receive so that they are all able to
commission the same level of services for a given level of need.
The government has allocated resources to different areas of England using a
formula since 1971, and has used a needs-based formula since 1976. It is worth
noting that as well as being a means of distributing resources, it is also a means of
redistributing resources, since allocations to different areas are not equal with
respect to need. The resource allocation process does not aim to achieve such
equality every year; rather it seeks to get closer to equality. Historic inequalities
between areas that the NHS inherited when it was founded in 1948 remain, though
of course they are not as large as they were and have continued to diminish over
time.
The resource allocation process starts with a calculation, using the national resource
allocation formula described below, of what the CCG should receive given the size of
its population, the age and sex distribution of its population, any additional need
factors, unmet need and health inequalities, and unavoidable variations in the cost of
providing services. This is referred to as the target allocation. This is then
compared with the CCG’s current funding, called the recurrent baseline, to see if
the CCG is above target or below target. Depending on the outcome of the spending
review and therefore how much is available for the NHS in total, the next year’s
allocation is calculated from the recurrent baseline. All CCGs will get a percentage
increase, though CCGs that are below target may get an additional percentage
amount. The extent to which under-target CCGs get extra funding, and therefore
inequalities are reduced, will depend on several factors, including how much of the
additional funding available should be given to all CCGs because of national priority
spending commitments. The precise details of these changes are called the pace of
change policy. They may include aims such as ensuring that CCGs do not go
further above or below their targets, or that there will be a minimum increase for all.
The targets are derived from a weighted capitation formula. CCGs get a certain
amount of funding for each member of their population. However that amount will
vary depending on the characteristics of that population and of the area in which the
CCG is based. The formula calculates a weight for each CCG that determines the
actual amount.
There are three separate formulae for each type of service that the CCGs are
responsible for: CCGs core responsibilities, specialised services and primary medical
care. The core responsibilities element is by far the largest; for 2016-17 was £70.54
billion, compared with £7.34 billion for primary medical care and £14.51 billion for
specialised services. For the core responsibilities formula, services are divided into
Acute, Maternity, Mental Health, and prescribing. These are combined according to
weights reflecting shares in national expenditure – in 2016-17, 72.3% for Acute,
3.7% for Maternity, 11% for Mental Health and 13.1% for prescribing.
Each formula has the same structure, but has different weights. They start with the
resident population in the CCG area, calculated as the sum of the numbers on the
registered lists of all member GP practices of the CCG, and adjust this for six factors,
which are the age and sex distribution, other need factors, unmet needs and health
inequalities, unavoidable costs and, for the core responsibilities formula only, two
‘remoteness’ factors, emergency ambulance costs and unavoidable smallness. 
 
The age and sex distribution
The rationale for this is that different ages and sexes have different needs and
therefore demands for health care. In particular, if there are many older or very
young people then needs and demands will be high. 
 
Other need factors
The rationale for this is that in addition to age, socioeconomic factors may affect the
need and demand for health care. 
 
Unmet need and health inequalities
The rationale for this is that the age and sex distribution and other need factors
assess currently met need and may not capture unmet need or inappropriately met
need. One of the responsibilities of NHS England is also to reduce health
inequalities. The specific indicator used is the standardised mortality ratio for those
under 75 years of age. 
 
Unavoidable costs
The rationale for this is that even if the same amount of funding is given for equal
need, this may not enable CCGs to purchase as much care for their population if the
costs of providing care are higher in their geographical area. This therefore attempts
to even out the different purchasing power in different CCGs. It is referred to as
‘unavoidable’ costs because not all differences in costs are out of the control of
CCGs. If costs are higher because of inefficiency, then there is no justification for
compensating for them; in fact this gives an incentive to be inefficient. Unavoidable
costs are mainly dealt with by the Market Forces Factor (MFF), which takes account
of geographical differences in factors such as wages in the private sector and land
and buildings valuations. 
 
Emergency ambulance cost adjustment
The core responsibilities formula has an emergency ambulance cost adjustment
(EACA) to take account of geographical variations in the cost of delivering
Systems of Health and Social Care
and the Role of Incentives to Achieve
Desired End-points ›
emergency ambulance services. The rationale is that sparsely populated areas may
result longer distances being travelled and therefore unavoidably higher costs. 
 
Costs of unavoidable smallness
The core responsibilities formula also adjusts for the fact that larger hospitals can
achieve economies of scale with respect to A&E departments, but in remote areas it
may be necessary to provide 24-hour A&E coverage in small hospitals, leading to
unavoidably higher costs.
The index numbers that are derived from this weighted capitation formula are, of
course, expressed in terms of populations, not funding. However, the index numbers
are then used to calculate target allocations using informationon the total resources
that are available for spending on the NHS nationally.
This resource allocation process has been subject to much debate. One view is that it
has been one of the most long-lasting and consistently successful policy initiatives
that UK governments have ever produced in terms of distributing and redistributing
public funds. It has certainly reduced geographical inequalities and, just as
importantly, may have prevented greater inequalities from developing. However, the
formula has been heavily criticised, not always simply by those who believe that they
lose out because of it, on the technical grounds that the data within the formula are
not always appropriate for the purpose for which they are used and that the weights
are not based on sound statistical principles. Unfortunately, because data are never
perfect, it is probably the case that it is not possible to create a perfect formula, so
that there will always be grounds for criticism. Unless a viable alternative to the
formula approach is developed, it is likely that it will continue, and continue to
attract criticism.
 
© David Parkin 2017
 
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