D-PACT: Carer guiding elderly woman with remote interaction.

Professor of Health Policy, Sheena Asthana has worked for nearly two decades, studying the funding models and policies of the NHS in England. Her body of research informed the setting of practice-level budgets in the NHS from 2009-11, accounting for approximately £8 billion of funding and paved the way for a more equitable allocation of NHS resource that can still be seen today.

Professor Asthana’s work has been crucial to informing Parliamentary debate around the allocations of health and local government funding from central government.

Disease prevalence in rural and coastal communities

Professor Sheena Asthana started her investigation into coronary heart disease prevalence in 1999, following funding from the Economic and Social Research Council. Professor Asthana investigated estimates of coronary heart disease in Primary Care Trusts in England, comparing them to actual rates of surgical interventions – like bypass operations.

Her results revealed that although the burden of the disease was highest in areas with older populations – even if those populations were relatively affluent – hospitalisation and surgery rates were highest in socially disadvantaged areas, usually with younger populations.

The results demonstrated that the higher levels of need were in rural and coastal communities but the underlying driver for NHS resources was that those suffering from urban deprivation were assumed to have a greater need.

Ageing, rural and coastal populations were not being given appropriate weighting in the allocation formulae used to distribute NHS resources.

Allocating national resource for public health services

Professor Asthana with Research Fellow, Dr Alex Gibson investigated the formula used to allocate budgets to Primary Care Trusts in England following concerns that rural and coastal Trusts were showing signs of organisational stress due to high budget deficits.

The found in 2004-5, only 7 per cent of Trusts in derived urban areas were running a deficit, compared to 70 per cent in more affluent rural areas signalling an underlying flaw in resource allocation and the huge variations in per capita expenditure on critical healthcare. In 2010, approximately £4,000 was spent on each cancer patient in Dorset, compared to £15,000 in some areas of London.

The funding model was introducing circularity – areas that were well funded, used more services and then were shown to have higher level of needs.

Related publications: 

  • Asthana, S. Gibson, A., Halliday, J. The medicalisation of health inequalities and the English NHS: the role of resource allocation. Health Economics, Policy and Law. DOI
  • Asthana S & Gibson A 2006 'A formula for unfairness' Health Serv J 116, (6032) 18-19 Author Site
  • Asthana S & Gibson A 2005 'Rationing in response to NHS deficits: rural patients are likely to be affected most' BRITISH MEDICAL JOURNAL 331, (7530) 1472-1472 Author Site , DOI

The feasibility of developing a need-based approach to PBRA

The Department of Health and NIHR-funded feasibility study investigated a different approach to NHS funding and resource allocation. It used health surveys to estimate the prevalence of various illness across different population cohorts, defined by factors including: age, sex, ethnicity, educational status and location. Sheena and her team applied these to local areas using census data and drawing upon national cost data. These estimates could then be used to allocate resources in a way to best reflect the healthcare needs of the populations.

Professor Trevor Bailey, Dr Paul Hewson and Dr Alex Gibson applied Bayesian statistical methods to ensure the team were able to capture and describe all uncertainty around the ‘risk-adjusted resource need’ estimates which allowed them to communicate to policy makers the problems with allocating fixed budgets to small populations.

This supported their claims that the existing funding formula wasn’t fit for purpose.

Related publications:

  • Asthana S, Gibson AJS, Bailey T, Dibben C, Hewson P, Economou T, Batchelor D, Eastham J, Craig R & Scholes S 2008 Person Based Resource Allocation (PBRA): The Feasibility of Developing a Need-Based Approach to PBRA. Department of Health, Policy Research Programme
  • Gibson, A, and Asthana, S. (2012): A Tangled Web: Complexity and Inequality in the English Local Government Finance Settlement, Local Government Studies, 38(3): 301-19. DOI:10.1080/03003930.2011.642947
  • Asthana, S. and Gibson, A. (2011). Setting health care capitations through diagnosis-based risk adjustment: a suitable model for the English NHS? Health Policy 101(2): 133-39
  • Asthana, S., Gibson, A., Hewson, P., Bailey, T., Dibben, C. (2011). Devolved commissioning, population size and budgetary risk: evidence from the modelling of `fair share' practice budgets for mental health. Journal of Health Services Research and Policy 16(2): 95-101.

Developing a person based resource allocation formula for setting practice-level mental health budgets 

Using the ‘casemix-based modelling approach, the research team led by Professor Asthana looked at several factors in distributing the then £8 billion mental health budget. Factors including age, sex, ethnicity, tenure, employment status were used to predict the likelihood that different ‘person-types’ would fall into each of the casemix categories.

They then combined these likelihood estimates with NHS administrative and census data to predict the number of people in each practice falling into each casemix category. Using treatment costs attached to all patients included in the original casemix study, they then applied casemix cost distributions to patient counts to generate an overall estimate of the resource needed to meet the mental healthcare needs of each practice population.

The evidence pointed to a complex relationship between mental health needs, age and deprivation. Needs were generally higher in northern England, especially major cities but there was a notable coastal fringe of ‘high-need’ practices which reflected the high proportion of elderly people in retirement hot-spots.

The research informed practice-level indicative budgets from 2009-11 following the restructuring of Primary Care Trusts. Professor Asthana continues to advise the Government on fairer distribution of NHS funding.

Related publications: 

  • Asthana S, Bailey T, Gibson AJS, Hewson P & Dibben C 2009 Developing a Person Based Resource Allocation Formula for Setting Practice-Level Mental Health Budgets: 2009/10 and 2010/11. Department of Health, Policy Research Programme
  • Asthana S, Gibson A, Bailey T, Moon G, Hewson P & Dibben C 2016 'Equity of utilisation of cardiovascular care and mental health services in England: a cohort-based cross-sectional study using small-area estimation' Health Services and Delivery Research 4, (14) 1-712 , DOI Open access
  • Asthana S, Gibson A, Hewson P, Bailey T & Dibben C 2011 'Devolved commissioning, population size and budgetary risk: evidence from the modelling of ‘fair share’ practice budgets for mental health' Journal of Health Services Research and Policy
  • Asthana S, Gibson A, Hewson P, Bailey T & Dibben C 2011 'General practitioner commissioning consortia and budgetary risk: evidence from the modelling of 'fair share' practice budgets for mental health' J Health Serv Res Policy 16, (2) 95-101 Author Site , DOI

Resource Allocation Using the Four-Block Model

Professor Sheena Asthana and Dr Alex Gibson
Following Professor Asthana’s success in identifying better funder models for NHS resource allocation, she, along with Dr Alex Gibson took this experience to look at other public service funding models. Together they demonstrated that the model was deeply flawed and generated inequitable allocation of a major source of local authority revenue. 
Nurse comforting patient