Adjustments for Age-sex and MLC NRAC 29 March 2007

Age-sex cost weights (paper 16) Morbidity and Life Circumstances (paper 17a) Unmet Need (paper 17b) Contents

Combined Mental Illness & Learning Difficulties Adjustments produced at data zones level Community data sources (PTI outstanding) Overall Age-sex indices Age-sex Cost weights - update

Option 1 (needs indices) preferable to Option 2 (needs indices + supplementary variables Flat funding not necessary (coefficients significant) Maternity index – birth rate Combine Mental illness and Learning Difficulties MLC – Last Meeting

Combined Mental illness and Learning Difficulties Included Maternity outpatients Analysis of options for: –Mental Illness & Learning Difficulties –Prescribing –Community Completed rurality & ethnicity analyses Updated Draft technical addendum Further work on unmet need MLC – Further work since meeting

Option 1 or Option 2 ? Recommendation – In a straight choice between Option 1 and Option 2, Option 1, the use of needs indices without supplementary variables, should be adopted. MLC – Recommendations

Acute care programme Recommendation – To adopt the Acute needs index for the diagnostic groups in the Acute care programme and Care of the Elderly programmes as recommended in the original research report. all-cause standardised mortality rate ages 0-74 limiting long term illness rate (age/sex standardised) MLC – Recommendations

Mental Illness care programme Recommendation – To adopt the Mental Health index as proposed in Option 1 but excluding the urbanity index. % claiming severe disability allowance, % of people in one person households % social rented housing MLC – Recommendations

Figure 6 – Out of sample regression fits (Updated cost ratios)

Learning Difficulties care programme Recommendation – To amalgamate the Learning Difficulties and Mental Illness care programmes and predict needs for the aggregated costs using the Mental Health index recommended above (i.e. excluding urbanity index). % claiming severe disability allowance, % of people in one person households % social rented housing MLC – Recommendations

Maternity care programme Recommendation – To adopt birth rate as the index for Maternity. MLC – Recommendations

Figure 7 Average maternity cost ratios by Board

Prescribing care programme Recommendation – To adopt the Acute index, as described above, to predict needs for each of the diagnostic groups in the Prescribing care programme. MLC – Recommendations

Table 6 Significance of component variables

Figure 6 – Out of sample regression fits (Updated cost ratios)

Community care programme Option 1 index: proportion unemployed, on benefits or low paid proportion in South Asian ethnic minorities MLC – Recommendations

Community care programme Limited coverage nationally (around 6% of the population) Lack of representation of all Boards (making Board level adjustments difficult) Wrong geography for resource allocation (so data is practice based so the benefits of data zone geography are lost and results have to be mapped back from practices to intermediate data zones using averaging) MLC – Recommendations

Community care programme Data are for district nurses and health visitors only and therefore cover only around a quarter of all activity in this care programme Data are face-to-face contact rates with patients and so do not necessarily reflect the true cost. The PTI dataset is currently undergoing a revision to historical data that will revise previous contact rates. MLC – Recommendations

Community care programme Tribal concerns about representativeness and index Replication of results not possible Non-significant index and variables Proportion South Asian negative coefficient MLC – Recommendations

Community care programme - options 1.Option 1 index described above 2.Another proxy index, e.g. Acute 3.Current Arbuthnott index 4.Flat funding (no needs adjustment other than population and age-sex costs) 5.GMS index as a proxy 6.Further work to establish an better Option 1 index MLC – Recommendations

Table 13 Community regression model coefficients

Community care programme Recommendation – that NRAC notes the lack of adequate data to produce a robust MLC indicator for Community. It is unlikely that further work on currently available data within the NRAC project would be fruitful. Therefore it is recommended that the Acute index, with a coefficient specific to Community services, be used as a proxy MLC index for Community. MLC – Recommendations

Flat Funding Recommendation – that the original proposal for flat funding is not adopted and that the coefficient for each diagnostic group is retained within the formula as estimated. MLC – Recommendations

Ethnic Minorities Recommendation – the original proposal for no specific ethnic minority adjustment is carried forward. MLC – Recommendations

Table 14 Coefficients for % Black & ethnic minority populations when included in option 1 models

Asylum Seekers No further work Rurality Indices generally good predictors across rural and urban areas. Lower utilisation in rural areas often. MLC – Recommendations

Comparison with Arbuthnott Formula Better geographical basis (data zones) Updated coefficients (frozen since ) Recommended indices better predictors Arbuthnott index variables require updating MLC – Recommendations

Updating the formula - currently Needs index values (yearly) Needs index coefficients (frozen) Care programme weights (yearly) Expected costs based on age-sex cost weights (yearly) MLC – Recommendations

Updating the formula Recommendation - Needs index values should not be updated without also updating the index coefficients. Based on evidence in this report updating both needs indices and coefficients every 3 years should be sufficient. MLC – Recommendations

1.Shortfall method 2.Variations method 3.Shortfall tested using disease prevalence data Unmet Need

Shortfall Method Needs index utilisation Regression slope Actual trend

Shortfall Method (2) Needs index utilisation Regression slope Adjusted slope

Variations Method Needs index utilisation Board B Board A Board C

Shortfall - deprivation Table 17 – Shortfall method – Coefficients for least deprived populations

Shortfall – ethnic minorities Table 19 – Shortfall method – Coefficients for areas of lower ethnic minority population

Shortfall – remoteness & rurality Table 21 – Shortfall method – Coefficients for non-urban and non-remote & rural areas

Disease prevalence (Health Survey)

Shortfall Method Needs index utilisation rurality deprivation ethnicity

Prevalence of disease = Predicted needs (based on age-sex + MLC) + Deprivation shortfall + ethnicity shortfall + rurality shortall Linking predicted needs and disease prevalence

Decide needs indices Calculate predicted needs Link to disease prevalence Evidence of shortfall ? If yes, use shortfall methods Calculate predicted needs using adjusted coefficient Proposed analysis