Attempt at deriving a formula for setting general practitioner fundholding budgets.

OBJECTIVE--To explore the possibility of using routine Hospital Episode Statistics, census data, and vital statistics to derive weights for an equitable capitation formula for setting general practitioner fundholding budgets for buying acute hospital services. DESIGN--Analysis of a routine dataset of 9 million hospital episodes in 1991-2, extracting elective general practitioner fundholding procedures, combined with 1991 census variables, vital statistics, and data on supply of health care at ward level. Costs were attached to each procedure according to the average cost of the relevant "Mersey" band category. MAIN OUTCOME MEASURES--Variation in age and sex adjusted expenditure per head on fundholding procedures across wards modelled for the impact of health and social needs variables after adjusting for variations in supply. RESULTS--No sensible simple model including determinants of use other than age and sex could be derived. The most parsimonious but statistically acceptable model showed that though standardised mortality ratio and self reported illness and several social class variables were associated with utilisation, the signs and the size of the coefficients were contradictory. The most important explanation of variation was provided by age and sex differences between wards. CONCLUSIONS--An equitable system of setting general practitioner fundholders'' budgets is needed. In the short term age and sex weighted capitation should form the principal basis of fundholder budgets. Utilisation data at ward level are inadequate for developing a formula which adequately adjusts for the differences in the health care needs of populations. A capitation formula based on information derived from individual cohort data may be the only means of promoting equity and efficiency and of avoiding discriminating against patients with known high cost health problems.     

Financial incentives of subregional RAWP.

Accounting for the cross boundary flows of residents from one health authority treated by another has been considered by the review of the Resource Allocation Working Party (RAWP) formula by the National Health Service Management Board. A common concern is that the approximate costs used are unfair to those authorities (typically those with teaching hospitals) that are likely to treat more complex cases. This paper argues that when spending exceeds the target allowance for acute services this is more likely to be due to district residents using services at a high rate than to inadequate compensation for inflows. Districts where residents make a high use of services are often those where there are large flows across district boundaries. Since authorities cannot control outflows there is little they can do to reduce their residents'' high use of services. Furthermore, curious financial incentives can be inferred for clinicians in these districts if they were to take effective action to bring their district''s spending to target levels. These problems are discussed to illuminate problems of accounting for cross boundary flows that alternatives to current practice must resolve.     

Allocating resources for health and social care in England.

The fair allocation of resources for health and social care in relation to the needs of the population in different parts of the United Kingdom has become particularly important since the implementation of the new arrangements for community care in April 1993. These depend on close collaboration between health authorities and local authority social services departments. Yet funding reaches these authorities by different means and according to different criteria. Most health authority funds come through a weighted capitation formula that overemphasises the effects of age, while family health services funding is largely not cash limited and hence demand led. Funds to local authorities for community care are being transferred from the social security budget but on a basis that partly reflects past provision of residential and nursing home care. None of these mechanisms responds to underlying needs that give rise to demands on the health and social care system as a whole, and none makes any attempt to compensate for defects in the others. The solution includes better research and a unified weighted capitation system for all sources of funding.     

Mortality,morbidity, resource allocation,and planning: a consideration of disease classification.

The report of the Resource Allocation Working Party recommended that revenue allocations to health authorities should be based, in part, on national patterns of bed usage and local standardised mortality ratios for conditions aggregated according to the chapters of the International Classification of Diseases (ICD). Similar criteria are now being considered for planning purposes by regions. The extent to which diseases which commonly result in the use of hospital care are also common causes of deaths within their ICD chapter was studied. National utilisation figures show that most beds in ophthalmology, ear, nose, and throat surgery, gynaecology, and consultant dentistry, and an estimated one-third or more of the beds used in general surgery, neurosurgery, and plastic surgery, are used for the treatment of conditions which are uncommon causes of death, both in absolute terms and relative to their ICD chapters. It seems unlikely that the requirements for care of patients with these diseases can be measured simply, either by all-causes mortality statistics, or by the use of mortality statistics ascribed to the ICD chapter which such diseases share with other, more common, causes of death. Consideration needs to be given to the diseases treated by each specialty in deciding whether and how to apply mortality statistics in planning for and funding the specialty.     

Milk sharing: from private practice to public pursuit

After only six months, a commerce-free internet-based milk-sharing model is operating in nearly 50 countries, connecting mothers who are able to donate breast milk with the caregivers of babies who need breast milk. Some public health authorities have condemned this initiative out of hand. Although women have always shared their milk, in many settings infant formula has become the "obvious" alternative to a mother's own milk. Yet an internationally endorsed recommendation supports mother-to-mother milk sharing as the best option in place of a birth mother's milk. Why then this rejection? Several possibilities come to mind: 1) ignorance and prejudice surrounding shared breast milk; 2) a perceived challenge to the medical establishment of a system where mothers exercise independent control; and 3) concern that mother-to-mother milk sharing threatens donor milk banks. We are not saying that milk sharing is risk-free or that the internet is an ideal platform for promoting it. Rather, we are encouraging health authorities to examine this initiative closely, determine what is happening, and provide resources to make mother-to-mother milk sharing as safe as possible. Health authorities readily concede that life is fraught with risk; accordingly, they promote risk-reduction and harm-minimisation strategies. Why should it be any different for babies lacking their own mothers' milk? The more that is known about the risks of substituting for breast milk, the more reasonable parental choice to use donor milk becomes. We believe that the level of intrinsic risk is manageable through informed sharing. If undertaken, managed and evaluated appropriately, this made-by-mothers model shows considerable potential for expanding the world's supply of human milk and improving the health of children.     

Diagnostic dilatation and curettage: is it used appropriately?

OBJECTIVE--To determine patterns of use of dilatation and curettage in Britain as compared with those in the United States; to examine variations in utilisation rates within one regional health authority. DESIGN--Analysis of routinely collected hospital inpatient statistics. SETTING--Statistics for England, Scotland, and the United States; local statistics for Oxford region. SUBJECTS--All inpatient episodes in which dilatation and curettage was performed but excluding those related to pregnancy. RESULTS--Dilatation and curettage rates remained stable in Britain between 1977 and 1990, whereas in the United States they declined dramatically. In 1989-90 the rate was 71.1 per 10,000 women in England as compared with only 10.8 per 10,000 in America. In 1989, 6936 women underwent diagnostic dilatation and curettage in the Oxford region, making it the most common elective operation. A total of 2726 (39%) of these women were under 40. There was a more than twofold variation in usage of the procedure among district health authorities within the region and even greater variation in rates in women under 40. The proportion of patients treated as day cases in the district general hospitals ranged from 22% to 82%. CONCLUSIONS--Dilatation and curettage may frequently be used inappropriately. The considerable variations in usage of dilatation and curettage internationally and nationally indicate differences in clinical perception of its appropriateness. This makes it suitable for audit. In developing guidelines it will be important to agree on the most appropriate patients and the relative merits of alternative methods of endometrial sampling. Probably this could result in considerable cost savings at no risk and possibly some benefit to patients.     

Regional variations in need for and provision and use of child health services in England and Wales.

An analysis of indicators of the need for and provision and use of child health services in the 15 pre- 1974 hospital board regions in England and Wales showed that need and provisions were badly matched. There was a high degree of correlation between the indices within each of the three groups, indicating that a region with a small provision in one area of child health services would tend to have few resources in other areas also. Statistics on the use of services relate more to the provision of those services than to the need for them. Regions with large resources will justify these resources by claiming that their use statistics indicate needs, whereas they really indicate met demands. It is more important to identify demands and needs that are not being met.     

Grampian Health Board's joint drug formulary.

OBJECTIVE--To develop a model for creating a joint general practice-hospital formulary, using the example of ulcer healing drugs. DESIGN--A joint formulary development group produced draft guidelines based on an earlier hospital formulary, which were sent to interested local general practitioners for consultation. Revised guidelines were then drawn up and forwarded to the health board''s medicines committee for approval and distribution. SETTING--Grampian Health Board. SUBJECTS--Nine members of joint formulary development group plus local general practitioners who were invited to comment on a list of 11 ulcer healing drugs. MAIN OUTCOME MEASURE--Degree of coincidence of drugs selected by hospital doctors and general practitioners. RESULTS--The ulcer healing drugs selected by the panel of general practitioners and by hospital doctors were highly coincident. The cost of one day''s treatment with drugs varied considerably between hospital and general practice--for example, one drug cost 46p in hospital and 1 pounds in general practice and another cost 1.26 pounds in hospital and 1.01 pounds in general practice. Overall, six drugs cost more in hospital and five cost more in general practice. CONCLUSIONS--A joint formulary for use in hospitals and general practice in a health board can be devised fairly simply by consultation as virtually the same drugs are used in both types of practice. It should influence the health board''s expenditure on drugs and affect the choice of drugs when a patient is discharged from hospital or is referred to any hospital in the region.     

Emergency preparedness for those who care for infants in developed country contexts

Emergency management organisations recognise the vulnerability of infants in emergencies, even in developed countries. However, thus far, those who care for infants have not been provided with detailed information on what emergency preparedness entails. Emergency management authorities should provide those who care for infants with accurate and detailed information on the supplies necessary to care for them in an emergency, distinguishing between the needs of breastfed infants and the needs of formula fed infants. Those who care for formula fed infants should be provided with detailed information on the supplies necessary for an emergency preparedness kit and with information on how to prepare formula feeds in an emergency. An emergency preparedness kit for exclusively breastfed infants should include 100 nappies and 200 nappy wipes. The contents of an emergency preparedness for formula fed infants will vary depending upon whether ready-to-use liquid infant formula or powdered infant formula is used. If ready-to-use liquid infant formula is used, an emergency kit should include: 56 serves of ready-to-use liquid infant formula, 84 L water, storage container, metal knife, small bowl, 56 feeding bottles and teats/cups, 56 zip-lock plastic bags, 220 paper towels, detergent, 120 antiseptic wipes, 100 nappies and 200 nappy wipes. If powdered infant formula is used, an emergency preparedness kit should include: two 900 g tins powdered infant formula, 170 L drinking water, storage container, large cooking pot with lid, kettle, gas stove, box of matches/lighter, 14 kg liquid petroleum gas, measuring container, metal knife, metal tongs, feeding cup, 300 large sheets paper towel, detergent, 100 nappies and 200 nappy wipes. Great care with regards hygiene should be taken in the preparation of formula feeds. Child protection organisations should ensure that foster carers responsible for infants have the resources necessary to formula feed in the event of an emergency. Exclusive and continued breastfeeding should be promoted as an emergency preparedness activity by emergency management organisations as well as health authorities. The greater the proportion of infants exclusively breastfed when an emergency occurs, the more resilient the community, and the easier it will be to provide effective aid to the caregivers of formula fed infants.     

Commentary: educational initiatives deserve randomised controlled trials.

The media have been full of reports of crisis in the NHS. Although national analyses suggest that the NHS should be able to cope within the increases in spending it has been given, local pressures can leave parts of the service struggling. Firstly, the change to allocation of funds on the basis of population needs has meant that some authorities and trusts have had effective cuts in their budgets, requiring them to trim services. Secondly, the government''s insistence on an annual 3% increase in efficiency may have resulted in authorities taking short term measures that actually decrease efficiency in the long term. Thirdly, health authorities have had to bear the costs of national targets such as reducing waiting lists and junior doctors'' hours as well as local problems such as higher numbers of mentally disordered offenders. However, all these factors can be controlled by national or local management and so their impact is not inevitable.     

Making access to health care more equal: the role of general medical services.

The Resource Allocation Working Party (RAWP) recognised the need to consider both health authority and primary care services in achieving its objective. RAWP and the subsequent Advisory Group on Resource Allocation (AGRA) found (but did not publish) considerable variation in resources used by both services but could not find a clear relation between them. Statistics provided by the DHSS were used to compare spending by 80 area health authorities in 1980-1 with expenditure per head on general medical services by their corresponding family practitioner committees. There was considerable variation in the provision of resources for both services and no clear relation between the variations in spending on each service. Only 40 of the 80 areas had both health authority and family practitioner committee spending levels within 10% of "target." Subregional inequalities in resources tend to be related to variations in admission rates, which in turn are related to general practitioners'' referral behaviour. These results emphasise the importance of finding out more about inequalities in the provision of general medical services and their relation to the use of hospital services. They also suggest that RAWP''s aim of equality of opportunity of access to health care resources may be achieved only if general medical services are brought into the equation as well.     

Devolving authority for health care in Canada's provinces: 2. Backgrounds,resources and activities of board members

OBJECTIVE: To obtain information from the members of the boards of devolved health care authorities and evaluate their orientations in meeting the expectations of provincial governments, local providers and community members. DESIGN: Mail survey, conducted in cooperation with the devolved authorities, in the summer of 1995. SETTING: Three provinces (Alberta, Saskatchewan and Prince Edward Island) with established boards and 2 (British Columbia and Nova Scotia) with immature boards. PARTICIPANTS: All 791 members of boards of devolved authorities in the 5 provinces, of whom 514 (65%) responded. OUTCOME MEASURES: Sociodemographic background, training, experience and activities of board members as well as their use of information. RESULTS: There were systematic differences between established and immature boards in regard to training, information use and actual and desired activities. Members spent 35 hours per month, on average, on work for their board. Members were largely middle-aged, well educated and well off. Only 36% were employed full time. Nine out of 10 had previous experience on boards, more often in health care than in social services. They were least pleased with their training in setting priorities and assessing health care needs and most pleased with their training in participating effectively in meetings and understanding their roles and responsibilities. The information for decision-making most available to them was information on service costs (68% said it was available "most of the time" or "always") and utilization (64%); the least available information was that on key informants'' opinions (47%), service benefits (37%) and citizens'' preferences (28%). Board activity was dominated by setting priorities and assessing needs, secondarily occupied with ensuring the effectiveness and efficiency of services and allocating funds, and least concerned with delivering services and raising revenue. The match between activities desired by members and actual activities was significantly poorer for members of immature boards than for those of established boards. CONCLUSIONS: The responses concerning these structural variables suggest that board members are most likely to meet the expectations of provincial governments. Fewer appear well equipped to accommodate the views of their providers and even fewer to incorporate the perspectives of their community.     

Weighting in the dark: resource allocation in the new NHS.

National allocation of resources to regional health authorities and by them to districts is now determined by a weighted capitation formula. The national formula was derived from regression analysis, with hospital utilisation as an index of need for health care--a method which has fundamental limitations. This paper argues that the search for an empirically based resource allocation formula of high precision in the name of promotion of equity is largely fruitless given the impossibility of measuring the true need for, and costs of, providing health care, especially with the limited data available. The inclusion of measures of social deprivation is also poorly thought out. The availability of data from the 1991 census, which included a question regarding long-standing illness, together with the intention of the Department of Health to review the weighted capitation formula using this information may stimulate much work but little light. It is essential that the impact of resource allocation formulas is justifiable on grounds other than the composition of any particular formula.     

National survey of current arrangements for diversion from custody in England and Wales.

OBJECTIVES--To assess the extent and nature of psychiatric assessment schemes based at magistrates'' courts in England and Wales for the early diversion of mentally disordered offenders from custody and to determine the response of the NHS to new initiatives concerning alternatives to custody for this group. DESIGN--Postal survey of the probation service, petty sessional divisions, mental health provider units, and district purchasing authorities in England and Wales. SUBJECTS--All chief probation officers (n = 55), clerks to the justices (n = 284), managers of mental health provider units (n = 190), and purchasers of mental health services (n = 190) in each of the district health authorities. MAIN OUTCOME MEASURES--Number of psychiatric assessment schemes, practical difficulties in their operation, extent of regular liaison with health and social services; current and future intentions to purchase or provide services for diversion from custody. RESULTS--Data were obtained from every magistrates'' court. Forty eight psychiatric assessment schemes were identified with another 34 under development. Particular problems were lack of adequate transport arrangements, difficulties with hospital admissions, and overdependence on key people. There was little liaison between health, social services, and members of the criminal justice system. Twenty five of the 106 purchasers who responded had a policy dealing with diversion, and 39 had a scheme under development; 56 purchasers had no current or future plans about diversion. Sixty nine of the 150 providers who responded reported that diversion was included in their current or next business plan. CONCLUSION--Schemes to divert mentally disordered offenders from the criminal justice system are often hampered by lack of adequate transport arrangements, difficulties in hospital admissions, and overdependence on key people.     

The Bradford community stroke trial: results at six months.

OBJECTIVE--Comparison of day hospital attendance and home physiotherapy for stroke patients leaving hospital to determine which service produces greater functional and social improvement for the patient, reduces emotional stress for the care giver, and lessens the need for community support. DESIGN--Stratified, randomised trial of stroke patients attending day hospital two days a week or receiving home treatment from a community physiotherapist. The six month assessment results are reported in this paper. SUBJECTS--Patients over 60 years old resident within the Bradford metropolitan district discharged home after a new stroke with residual disability. SETTING--Four day hospitals in two health authorities and domiciliary work undertaken by experienced community physiotherapists. MAIN OUTCOME MEASURES--Barthel index, functional ambulatory categories, Motor Club assessment, Frenchay activities index, and Nottingham health profile were used. Carers'' stress was indicated by the general health questionnaire. Treatment given and community care provided were recorded. RESULTS--Of 124 patients recruited, 108 were available for reassessment at six months. Both treatment groups had significantly improved in functional abilities between discharge and six months. The improvements were significantly greater for patients treated at home (Mann-Whitney test; Barthel index, median difference 2 (95% confidence interval 0 to 3) p = 0.01; Motor Club assessment, median difference 2 (1 to 5), p = 0.01). The home treated patients received less treatment (median difference 16 (11 to 21) treatments, p less than 0.001). More than a third of patients in both groups showed depressed mood, and a quarter of care givers were emotionally distressed. CONCLUSIONS--Home physiotherapy seems to be slightly more effective and more resource efficient than day hospital attendance and should be the preferred rehabilitation method for aftercare of stroke patients. New strategies are needed to address psychosocial function for both patients and care givers.     

Can there be fair funding for fundholding practices?

Most regional health authorities set budgets for fundholding practices according to the amount of care used by the practice population. This article explains why this funding method can only lead to an inequitable allocation of resources between fundholding and non-fundholding practices. Using the experience of North West Thames region, the efforts made to make funding fairer are discussed. The steps that health authorities could take to investigate and reduce the problem are also outlined. In the absence of a capitation formula for funding fundholding practices, the paper suggests that health authorities should do much more to investigate the amount of money they spend on non-fundholding practices. Regions could develop and use other methods to set budgets rather than rely on activity recorded by practices. Regions and the Department of Health should resolve urgently if and how far the budgets for fundholders should be compensated for increases in provider prices.     

Prescribing at the hospital-general practice interface. I: Hospital outpatient dispensing policies in England.

OBJECTIVE--To describe the outpatient dispensing policies of major acute hospitals in England. DESIGN--Postal questionnaire survey in November 1990. SETTING--All (278) major acute hospitals in England with more than 250 beds, excluding maternity, paediatric, or psychiatric hospitals; nine hospitals declined. PARTICIPANTS--Hospital chief pharmacists. MAIN OUTCOME MEASURES--Current dispensing policy and exceptions to it; when the policy was formed; and who was involved in its formation. RESULTS--Completed questionnaires were received from 200 (72%) of the hospitals approached. The quantities of drugs dispensed to outpatients ranged from zero in 12 hospitals to unlimited amounts in nine; nearly half (92) dispensed a 14 days'' supply of drugs. The greater the restriction on outpatient dispensing, the more recently the policy had been introduced (chi 2 for trend = 7.15; df = 1; p less than 0.01). Permissible exceptions to the policy included the consultant''s specific request (134 hospitals), difficulty in obtaining drugs in the community (102), urgent need for start of treatment (49), and certain types of patients (41) or drugs or their regimens (104). Groups who were neither represented on the hospital committee concerned with policy formation nor consulted before policy changes included regional health authorities in 122 hospitals, district health authorities in 101 hospitals, and general practitioners in 32 hospitals. CONCLUSIONS--Outpatient dispensing policies varied considerably among the hospitals surveyed, but they seemed to be moving towards greater restrictions on the supply of drugs given to outpatients.     

Hospital and community health service costs: England and Scotland compared.

In publications which have compared the health expenditure in the component parts of the United Kingdom by applying the Resource Allocation Working Party (RAWP) formula to the health budget of England, Scotland, Wales, and Northern Ireland it has been previously concluded that Scotland''s hospital and community health services expenditure is more than 19% above what would be a fair distribution. It has also been implied that Scotland''s allocation should be cut substantially to improve services in England. On the assumption that the purpose of examining the distribution of the health and community health service budget is to ensure "equal opportunity of access to health care for people at equal risk" it is concluded that simple RAWPing of the United Kingdom budget is flawed and a conclusion based on this is therefore untenable.     

Area disease estimation based on sentinel hospital records

Background

Population health attributes (such as disease incidence and prevalence) are often estimated using sentinel hospital records, which are subject to multiple sources of uncertainty. When applied to these health attributes, commonly used biased estimation techniques can lead to false conclusions and ineffective disease intervention and control. Although some estimators can account for measurement error (in the form of white noise, usually after de-trending), most mainstream health statistics techniques cannot generate unbiased and minimum error variance estimates when the available data are biased.

Methods and Findings

A new technique, called the Biased Sample Hospital-based Area Disease Estimation (B-SHADE), is introduced that generates space-time population disease estimates using biased hospital records. The effectiveness of the technique is empirically evaluated in terms of hospital records of disease incidence (for hand-foot-mouth disease and fever syndrome cases) in Shanghai (China) during a two-year period. The B-SHADE technique uses a weighted summation of sentinel hospital records to derive unbiased and minimum error variance estimates of area incidence. The calculation of these weights is the outcome of a process that combines: the available space-time information; a rigorous assessment of both, the horizontal relationships between hospital records and the vertical links between each hospital''s records and the overall disease situation in the region. In this way, the representativeness of the sentinel hospital records was improved, the possible biases of these records were corrected, and the generated area incidence estimates were best linear unbiased estimates (BLUE). Using the same hospital records, the performance of the B-SHADE technique was compared against two mainstream estimators.

Conclusions

The B-SHADE technique involves a hospital network-based model that blends the optimal estimation features of the Block Kriging method and the sample bias correction efficiency of the ratio estimator method. In this way, B-SHADE can overcome the limitations of both methods: Block Kriging''s inadequacy concerning the correction of sample bias and spatial clustering; and the ratio estimator''s limitation as regards error minimization. The generality of the B-SHADE technique is further demonstrated by the fact that it reduces to Block Kriging in the case of unbiased samples; to ratio estimator if there is no correlation between hospitals; and to simple statistic if the hospital records are neither biased nor space-time correlated. In addition to the theoretical advantages of the B-SHADE technique over the two other methods above, two real world case studies (hand-foot-mouth disease and fever syndrome cases) demonstrated its empirical superiority, as well.     

Quantitative ecological risk assessment of accidental oil spills on ship routes nearby a marine national park in Brazil

Fernando de Noronha (FN) is a marine protected area off the coast of Brazil. The study of risks caused by nearby ship routes is new to authorities concerned with preserving FN. We identify nearby ship routes that cause FN to be potentially exposed to oil spills from tankers. A coral species is chosen as a bioindicator of the ecosystem's health, which aids quantitative approaches. We simulate oil leakage scenarios with pessimistic occurrence frequencies and corals' mortality in case of accident. A metapopulation coral model is integrated to quantify measures of ecological risk under the potential occurrence of accidental scenarios. The categorization of risk results according to the International Union for the Conservation of Nature quantitative criteria shows that risks are negligible. Due to the considerable uncertainty in the results, we propose a more conservative categorization of risks based not on total metapopulation extinction, but on half loss. As a result, risks were considered not acceptable. The presented methodology and results are useful in supporting authorities in their preservation efforts such as the prioritization of sources of hazard as well as selection of the best cost-effective conservation measures for maintaining good environmental health on a realistic budget, using this methodology as an exploratory tool.