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.     

Reviewing RAWP. Variations in admission rates: implications for equitable allocation of resources.

The review of the Resource Allocation Working Party (RAWP) formula by the National Health Service Management Board has considered the method used to account for cross boundary flows between health authorities. There is no consensus on how this should be done subregionally, as it raises the unresolved problem of the best method of estimating the size of catchment populations. Different methods produce different population sizes when the admission rates of individuals living in different districts vary. The National Health Service/Department of Health and Social Security acute services working group on performance indicators recently considered the assumptions made by different methods in terms of admission thresholds set by hospital clinicians. More complicated methods of assessing catchment areas seem to offer little advantage over the simplest method, but none of the methods answer the underlying questions of what truly determines admission rates and whether higher admission rates are better than lower ones. Empirical research into variations in admission rates and their relation to outcomes is important for determining the fair allocation of resources in future.     

What are health authorities doing about the health problems caused by unemployment?

Unemployment is over three million in Britain, and unemployment is known to be associated with poor health. It has been suggested that health authorities should produce a comprehensive response to the health problems caused by unemployment, and a survey was undertaken to find how many had done so. All the regional and district health authorities in England, the health boards of Wales, Scotland, and Northern Ireland, and the family practitioner committees of England and Wales were asked by letter what they were doing to respond to the health problems of unemployment. A list of suggestions of what they might be doing was enclosed. The overall response rate was 77% (255/331), and 50% (127/255) of the respondents were doing something--33.3% (3/9) of the regional health authorities, 64% (101/158) of the district health authorities and health boards, and 26% (23/88) of the family practitioner committees. The paper describes what they were doing. A relation was sought between the level of unemployment in an area and the extent of the response, and a significant association was found. Half of Britain''s health authorities are now responding in some way to the health problems associated with unemployment.     

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.     

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.     

Analysing spatio-temporal clustering of meningococcal meningitis outbreaks in Niger reveals opportunities for improved disease control

Background

Meningococcal meningitis is a major health problem in the “African Meningitis Belt” where recurrent epidemics occur during the hot, dry season. In Niger, a central country belonging to the Meningitis Belt, reported meningitis cases varied between 1,000 and 13,000 from 2003 to 2009, with a case-fatality rate of 5–15%.

Methodology/Principal Findings

In order to gain insight in the epidemiology of meningococcal meningitis in Niger and to improve control strategies, the emergence of the epidemics and their diffusion patterns at a fine spatial scale have been investigated. A statistical analysis of the spatio-temporal distribution of confirmed meningococcal meningitis cases was performed between 2002 and 2009, based on health centre catchment areas (HCCAs) as spatial units. Anselin''s local Moran''s I test for spatial autocorrelation and Kulldorff''s spatial scan statistic were used to identify spatial and spatio-temporal clusters of cases. Spatial clusters were detected every year and most frequently occurred within nine southern districts. Clusters most often encompassed few HCCAs within a district, without expanding to the entire district. Besides, strong intra-district heterogeneity and inter-annual variability in the spatio-temporal epidemic patterns were observed. To further investigate the benefit of using a finer spatial scale for surveillance and disease control, we compared timeliness of epidemic detection at the HCCA level versus district level and showed that a decision based on threshold estimated at the HCCA level may lead to earlier detection of outbreaks.

Conclusions/Significance

Our findings provide an evidence-based approach to improve control of meningitis in sub-Saharan Africa. First, they can assist public health authorities in Niger to better adjust allocation of resources (antibiotics, rapid diagnostic tests and medical staff). Then, this spatio-temporal analysis showed that surveillance at a finer spatial scale (HCCA) would be more efficient for public health response: outbreaks would be detected earlier and reactive vaccination would be better targeted.     

Uptake of immunisation in district health authorities in England

The uptakes of immunisation in the district health authorities in England were studied for the years 1983-5. Multiple regression analysis showed that the factors significantly associated with a low uptake of immunisation were mainly related to social conditions, particularly overcrowding of households and population density. Of the service factors, high proportions of elderly and singlehanded general practitioners and high average list sizes were also associated with a low uptake of immunisation in some of the analyses.The results suggest that the measures outlined in the government''s white paper on improving primary health care services are likely to lead to improved uptakes of immunisation. If, however, the uptakes of immunisation are used as a measure of standards of the services provided they should first be adjusted to control for variations in social conditions, and the quality of vaccination data would have to be improved.     

Predicting psychiatric admission rates.

OBJECTIVE--To determine the numbers of actual and expected psychiatric admissions for the residents of the district health authorities of England and to develop a model to indicate which social, health status, and service provision factors best explain the variation of the actual from the expected psychiatric admissions; to use this model to predict psychiatric admission for district health authorities as an aid to resource allocation. DESIGN--The actual psychiatric admission for district health authority residents were extracted from data of the 1986 Mental Health Enquiry. Expected admissions were calculated using the age, sex, and marital status structure of each district health authority and the national psychiatric admission rates related to age, sex, and marital status. Standardised psychiatric admission ratios were calculated as the ratios of the numbers of actual to expected psychiatric admissions. A wide range of social, health status, and service provision data were used as the explanatory variables in regression analyses to determine which combination of factors best explained the variation between districts of standardised psychiatric admission ratios. SETTING--The 168,652 psychiatric admissions recorded for the 1986 Mental Health Enquiry, after exclusion of mental handicap and psychogeriatric admissions. RESULTS--The actual number of psychiatric admissions varied from 79% above to 54% below the expected number of admissions from age, sex, and marital status for the districts of England. The most powerful variables to explain this variation were the rate of notification of drug misusers, standardised mortality ratios, and levels of illegitimacy in each district. A complex model was developed which could be used to predict district psychiatric admissions as an aid to resource allocation. A simpler model was also developed (which was less powerful than the more complex model) based on the underprivileged area score. One advantage of this model was that it could be used at the level of electoral wards as well as district health authorities.     

Unemployment rates: an alternative to the Jarman index?

OBJECTIVE--To compare the Jarman index with alternative deprivation measures with regard to its usefulness to district health authorities as an indicator of need at small area level. DESIGN--The Jarman index (UPA (8)), Townsend''s index of material deprivation, the Scottish Development Department''s index, the Department of the Environment''s basic index, and unemployment rates were compared in respect of their correlation with measures of morbidity by electoral ward in a typical English district health authority. Measures of morbidity comprised standardised mortality ratios, admission rates (standardised and non-standardised), and permanent sickness rates. Spearman rank correlation coefficients were calculated for each combination of measures and were then ranked for each of the deprivation indices. SETTING--The 59 electoral wards of the Central Nottinghamshire Health Authority. RESULTS--The Jarman index consistently ranked lower in respect of its correlation with measures of morbidity than did the other deprivation measures. Current unemployment rates correlated well with morbidity measures, in particular with hospital admission rates, with correlations ranging from 0.669 to 0.830 for average and standardised all age admission rates. CONCLUSIONS--The Jarman index seems to be the least appropriate of these indices for health authority use. Unemployment rate merits further consideration as a simple, up to date marker for deprivation and consequent need for health service provision.     

Empowering GPs as purchasers.

FHSAs have defined their role in purchasing primary care FHSAs have also found themselves intermediaries between district health authorities and general practitioners All of the purchasing authorities recognise the need to educate general practitioners on how to use their influence in the purchasing process General practitioners should be involved in the purchasing process as they purchase the bulk of health care; are the first point of contact for the users of the health service; need to have input on what is purchased; and need to be able to manage the changes resulting from the shift in the balance of power towards primary care The involvement of general practitioners in the purchasing process at present varies considerably among health authorities. Several district health authorities have developed models of purchasing that enable different levels of involvement     

Utilisation by homeless people of acute hospital services in London.

OBJECTIVES--To estimate the numbers and distribution of homeless people in London; to quantify the utilisation of acute inpatient services by homeless people in two health authorities; and to predict the total numbers of admissions in homeless people in district health authorities across London. DESIGN--Data were collected from various sources on the distribution of homeless people across London boroughs. All unplanned acute inpatient admissions during November 1990 to relevant hospitals were identified. SETTING--Bloomsbury and Paddington and North Kensington, two former inner London district health authorities. SUBJECTS--Homeless people in London residing in bed and breakfast and private sector leased accommodation, residing in hostels, and of no fixed abode. MAIN OUTCOME MEASURES--Number and cost of acute unplanned admissions in homeless people in two health authorities in November 1990; predicted number of such admissions each year in district health authorities in London. RESULTS--There were at least 60,000 homeless people in London in March 1990. The majority were housed in temporary accommodation (55,412). There were at least 3295 hostel dwellers and 651 people sleeping rough. Homeless people accounted for 105 (8%) of the 1256 acute unbooked admissions in residents of Bloomsbury and Paddington and North Kensington health authorities in November 1990. Considerable variations in the pattern of acute unplanned admissions in homeless people were observed in the two districts with respect to housing status and specialty of admission. The total number of acute unplanned admissions in homeless people across London each year was estimated at 7598, ranging from 38 in Bexley to 1515 in Parkside. CONCLUSIONS--The results have fundamental implications for resource allocation across London. Allocation must take better account of the heterogeneity, uneven distribution, and extra health needs of homeless people.     

Lessons from the outbreak of food poisoning at Stanley Royd Hospital: what are health authorities doing now?

The committee of inquiry into the outbreak of food poisoning at Stanley Royd Hospital identified serious deficiencies in the management of the outbreak and urged all health authorities to learn from the incident and prepare adequate plans for dealing with any future outbreaks. A survey of district health authorities in England showed that most authorities do not yet have a written plan or that their plans are incomplete and inadequate. The appreciable resistance to such planning suggests that most health authorities would be unable to deal with outbreaks of food poisoning effectively and efficiently.     

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.     

Radio‐tracking three Sugar Gliders using forested highway median strips at Bongil Bongil National Park,north‐east New South Wales

Major roads and highways disrupt ecological flows and create barriers or filters to the movement of many species of wildlife, including gliding mammals. Mitigating these impacts presents major challenges for road authorities. One approach has been the retention of forest vegetation in median strips to serve as ‘stepping stones’ for gliding mammals to cross road gaps otherwise beyond their glide capacity. A recently upgraded section of the Pacific Highway through tall open forest near Bonville in north‐east New South Wales retained forest within two 10‐ to 45‐m‐wide median strips separating each carriageway and a service road. We investigated whether Sugar Gliders (Petaurus breviceps) used these median strips to cross an 85 to 135 m‐wide road corridor. Three radio‐collared Sugar Gliders (one male and two females) moved between both highway medians and forest on either side of the road corridor during 32 days of radio‐tracking. Although the sample size is small, these results suggest that highway median strips, featuring mature vegetation with a major den tree, can provide ‘stepping stones’ for gliding mammals to cross a highway that would otherwise function as a movement barrier or filter. Longer‐term research with greater numbers of animals at this and other sites is required to determine whether such strips would be commonly used when den trees are absent and whether gliding via median strips may also increase road mortality of the species.     

Survey of health visiting in antenatal care.

The range of the health visitor''s work is expanding. To find out what antenatal work health visitors actually carry out and what their attitudes towards such work are we surveyed general practitioners, midwives, and health visitors in three district health authorities. The results indicate that health visitors are qualified and willing to work with women in the antenatal period.     

Cost of achieving a balance in the anaesthetic department of a district general hospital.

In Achieving a Balance the Department of Health published requirements for medical staffing in hospitals. To review the effect that these would be likely to have a study was undertaken in the anaesthetic department of a district general hospital. The results were then validated with staffing levels in a new district general hospital with only one tier of junior staff. It was found that over the next 10 years a massive expansion in the numbers of consultants would be needed at a cost of 108,000 pounds in salaries and employer''s contributions alone.     

Organisation of primary care services outside normal working hours.

OBJECTIVE--To determine the use and organisation of out of hours services in primary care. DESIGN--Telephone survey. SETTING--Family health services authorities in England and Wales. MAIN OUTCOME MEASURES--Rate of use of out of hours care, methods of provision, and role of authorities. RESULTS--12-25% of authorities were unable to answer one or more key questions in the survey because of insufficient information. The mean number of night visits made per unrestricted principal per 1000 patients per year was 35.3. 13 of the 19 authorities with averages above 40 covered large towns or cities. 81 authorities had at least one commercial deputising service. In 46 metropolitan districts and one other district over 75% of general practitioners had consent to use a deputising service, although not all did so. Information on cooperation between practices was limited. 22 cooperatives were recognised by the authorities, nine were not officially recognised, and a further 13 were nearing institution. Only two cooperatives were in areas with extensive use of deputising services. CONCLUSION--Methods of providing out of hours care are changing, and without good information systems family health services authorities will not be able to monitor the effect on quality and cost effectiveness of care.     

Funding the NHS. Is the NHS sustainable?

The survival of the NHS lies largely in the hands of government, and this article suggests steps that it should take to deal with pressures on the NHS in terms of funding, managing efficiency, and demands. Changes to the system of funding may be unfeasible, but management could be improved by research to allow greater understanding of the local effects of national policies. Alternatively health authorities could be given more freedom to manage funds, although this would have to be accompanied by stiff sanctions for those who failed. Demand could be contained by strengthening policies to ensure that new technologies are cost effective. The government could try to reduce demands arising from increased expectations by encouraging informed public debate about priorities and influencing the availability of private health care. All these efforts should be guided by the values underpinning the NHS, which should be debated and decided collectively and confirmed in a new charter for NHS''s 50th anniversary in 1998.     

Costs and Cost-Effectiveness of a Mobile Phone Text-Message Reminder Programmes to Improve Health Workers' Adherence to Malaria Guidelines in Kenya

Background

Simple interventions for improving health workers'' adherence to malaria case-management guidelines are urgently required across Africa. A recent trial in Kenya showed that text-message reminders sent to health workers'' mobile phones improved management of pediatric outpatients by 25 percentage points. In this paper we examine costs and cost-effectiveness of this intervention.

Methods/Findings

We evaluate costs and cost-effectiveness in 2010 USD under three implementation scenarios: (1) as implemented under study conditions in study areas; (2) if the intervention was routinely implemented by the Ministry of Health (MoH) in the same areas; and (3) if the intervention was scaled up nationally. Under study conditions, intervention costs were 19,342 USD, of which 45% were for developing and pretesting text-messages, 12% for developing text-message distribution system, 29% for collecting health workers'' phone numbers, and 13% were costs of sending text-messages and monitoring of the system. If the intervention was implemented in the same areas by the MoH, the costs would be 28% lower (13,920 USD) due to lower costs of collecting health workers'' numbers. The cost of national scale-up would be 97,350 USD, and the majority of these costs (66%) would be for sending text-messages. The cost per additional child correctly managed was 0.50 USD under study conditions, 0.36 USD if implemented by the MoH in the same area, and estimated at only 0.03 USD if implemented nationally. Even if the effect size was only 5% or the cost on the national scale was 400% higher than estimated, the cost per additional child correctly managed would be only 0.16 USD.

Conclusions

A simple text-messaging intervention improving health worker adherence to malaria guidelines is effective and inexpensive. Further research is justified to optimize delivery of the intervention and expand targets beyond children and malaria disease.