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(Health & Social Services Committee \
HSS-03-02\(p.2\) )Tj
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( )Tj
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(Date: )Tj
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(23 January 2002 )Tj
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(Venue: )Tj
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(Committee Room 1, National Assembly for Wales )Tj
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(Title: )Tj
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(NHS Resource Allocation Review - Townsend Report )Tj
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( )Tj
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(1. Purpose )Tj
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(1.1 The Committee is asked to consider Professor Townsend\222s report )Tj
/T1_2 1 Tf
(Targeting Poor Health: Next Steps )Tj
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0 -1.2 TD
(on the NHS Resource Allocation Review and to agree the actions to be tak\
en. The report is attached at )Tj
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(Appendix 1 )Tj
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(. )Tj
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(2. Background )Tj
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(2.1 The Committee commissioned the Resource Allocation Review in Februar\
y 2000. The Review is )Tj
T*
(headed by Professor Peter Townsend of the London School of Economics and\
Bristol University who )Tj
T*
(chairs the National Steering Group convened by the Assembly to oversee t\
he Review. The participative )Tj
T*
(review structure included the Project Review Group and a series of Task \
Groups. Several workshops were )Tj
T*
(held with the research team to agree a way forward. Professor Townsend e\
ncouraged and welcomed )Tj
T*
(contributions and participation from all sources. His report )Tj
/T1_2 1 Tf
(Targeting Poor Health )Tj
/T1_1 1 Tf
(was considered by the )Tj
T*
(Committee on 4 July 2001. At the Committee it was agreed to use the repo\
rt as the basis of consultation )Tj
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(together with other supplementary work. )Tj
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(2.2 Between July and September supplementary work was completed on rural\
and urban issues. A rural )Tj
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(adjustment for community nursing services was agreed following recommend\
ations from Task Group C )Tj
T*
(and an "age adjustment" reflecting the weightings of different age group\
s was also agreed by the Project )Tj
T*
(Review Group. These adjustments, together with comparisons of the propos\
ed new formula at Local )Tj
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(Health Group level with population shares, were reflected in tables acco\
mpanying the consultation letter )Tj
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(from the Minister for Health and Social Services. )Tj
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(2.3 Professor Townsend\222s Report drew heavily from the independent rep\
ort from the research team and )Tj
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(the executive summaries of the Review\222s Task Groups. Consultation end\
ed on 30 November. )Tj
T*
(Approximately 700 copies of the Report were distributed to approximately\
300 organisations. A total of )Tj
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(47 responses were received. )Tj
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(2.4 Professor Townsend\221s report )Tj
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(Targeting Poor Health: Next Steps )Tj
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(details the issues raised during )Tj
0 -1.2 TD
(consultation, the response by the National Steering Group, and the way f\
orward. The report incorporates )Tj
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(the comments of the National Steering Group which met on 9 January 2002.\
)Tj
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(3. Consultation Issues Raised )Tj
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(3.1 Many of the comments picked up concerns and issues raised during the\
Review process - concerns )Tj
T*
(over the information about the distribution of existing resources accord\
ing to need, the reliability of )Tj
T*
(statistics on expenditure and costs, the use of the Welsh Health Survey \
\(WHS\) for resource allocation )Tj
T*
(purposes, some aspects of the proposed "direct method" formula \(particu\
larly the GMS and prescribing )Tj
T*
(elements\), and the implementation and phasing of the proposed new metho\
d of allocation. There were also )Tj
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(a number of issues which required further explanation and clarification.\
An analysis of the key )Tj
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(consultation issues raised is set out in )Tj
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(Annex B )Tj
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(. )Tj
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(3.2 The use of the Welsh Health Survey for resource allocation purposes \
has attracted particular attention. )Tj
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(Dr Gordon, head of the independent research team, has responded to the k\
ey issues raised relating to the )Tj
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(Welsh Health Survey and its use for resource allocation purposes - )Tj
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(Annex C )Tj
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(refers. The Office for )Tj
-30.744 -1.34286 Td
(National Statistics were also commissioned to evaluate the reliability o\
f estimates from the WHS with a )Tj
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(view to advising on their suitability for use in resource allocation. Th\
e report from the Office for National )Tj
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(Statistics is set out in )Tj
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(Annex D )Tj
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(. The Office for National Statistics confirmed that the survey methodolo\
gy )Tj
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(was found to be sound and contained no substantial flaws. )Tj
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(3.3 The National Steering Group responses to the issues raised during co\
nsultation have been set out in )Tj
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(section 2, analysed by chapters in the 4 July Report )Tj
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(Targeting Poor Health )Tj
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(. )Tj
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(4. Way Forward )Tj
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(4.1 The way forward is set out in section 3 of the report. In making the\
recommendations - which change, )Tj
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(add to or confirm the recommendations in the original report itself - th\
e National Steering Group wishes to )Tj
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(remind readers of the original framework of the report. The steps that h\
ave to be planned and then put in )Tj
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(place will apply to each of the three areas of work singled out in the r\
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(the dual strategy \(of policy measures to be taken, and monitored, insid\
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(1. In its review of the allocation of NHS resources the National Assembl\
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(Committee approved a searching consideration of the report. This process\
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(3. Inevitably a succession of planned steps will have to be taken in the\
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(4. The steps that have to be planned and put in place will apply to each\
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(undesirability of using SMRs as an indirect measure of health need. )Tj
ET
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(7. The recommended strategy of adopting the direct method of measuring n\
eed for health care attracted )Tj
T*
(many comments. Gwent Health Authority offered the strongest level of sup\
port at health authority level )Tj
T*
(welcoming an early move towards the new formula target shares. The remai\
ning four health authorities )Tj
T*
(support the view that further development work is required before implem\
entation or that implementation )Tj
T*
(of the formula had to be introduced by stages for different groups of se\
rvices. Much of this was )Tj
T*
(concentrated on the coverage, representativeness and reliability of the \
Welsh Health Survey. )Tj
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/P <>BDC
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(8. Speed of implementation was of concern. Seven out of the eight NHS tr\
usts who responded took the )Tj
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(view that further development work is required. Gwent Healthcare NHS Tru\
st offers support for )Tj
T*
(implementation in 2003. )Tj
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(9. Several health authorities and trusts imply a trade-off between "impl\
ementation" and "equalisation." )Tj
T*
(Thus, the North Wales Health Authority suggests that a seven years equal\
isation period "may well be )Tj
T*
(required" but welcomed the aim to apply a formula " built upon a compreh\
ensive, direct assessment of the )Tj
T*
(health needs of the population." The Health Authority continue " the inn\
ovative approach proposed has the )Tj
T*
(potential to form the foundation of a direct needs methodology provided \
it is significantly developed, )Tj
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(supported by further research and innovation." )Tj
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/P <>BDC
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(Section 1: Review background, structure and process )Tj
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(Introduction )Tj
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(1.1 As a result of discussions within the Health and Social Services Com\
mittee on the distribution of )Tj
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(money to the NHS Wales a major resource allocation review was commission\
ed in February 2000, with )Tj
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(the objective of ensuring more equitable access for the entire populatio\
n of Wales in accordance with their )Tj
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(1.2 The Review is an important strand of )Tj
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(Improving Health in Wales, )Tj
/T1_0 1 Tf
(a plan for the NHS and its partners, )Tj
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(which was launched in February 2001. The plan sets the policy agenda for\
the next five to ten years and )Tj
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(outlines the commitment to rebuild, renew, and improve the National Heal\
th Services in Wales. )Tj
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(1.3 The Review is headed by Professor Peter Townsend of the London Schoo\
l of Economics and Bristol )Tj
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(University who chairs a National Steering Group convened by the Assembly\
to oversee the Review. )Tj
T*
(Professor Townsend is an international authority on poverty and inequali\
ty. His report - )Tj
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("Targeting Poor )Tj
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(Health )Tj
/T1_0 1 Tf
("- was considered by the National Assembly\222s Health and Social Servic\
es Committee on 4 July )Tj
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(2001. At the Committee it was agreed to use the report as the basis of c\
onsultation together with other )Tj
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(supplementary work. )Tj
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(1.4 Views and comments were sought on the proposals contained in the fol\
lowing documents which )Tj
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(incorporated the supplementary work undertaken following the 4 July Heal\
th and Social Services )Tj
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(Committee meeting. )Tj
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(\( a \) Targeting Poor Health : Professor Townsend\222s Report of the We\
lsh Assembly\222s National Steering )Tj
T*
(Group on the Allocation of NHS Resources \(Volume1\) Volume 1 drew on th\
e Independent Report of the )Tj
T*
(Research Team \(Volume 2 \) and the Executive Summaries of the Review\222\
s Task Groups \(Volume 3 \) )Tj
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(\( b \) Supplementary tables :- )Tj
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(Table 1 updated Table 2 \( Chapter 5, page 72 \) in the Townsend Report \
\( Volume 1 \). This table )Tj
T*
(compared the allocation of \2431.356 billion, at health authority level,\
using the current formula with )Tj
T*
(the new formula proposed by the research team. The new formula proposed \
by the research team )Tj
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(had been supplemented to take into account issues of rurality. )Tj
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(Tables 2, 3, and 4 detailed the allocations, at Local Health Group level\
, using the new formula )Tj
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(proposed by the research team for Hospital and Community Services, Presc\
ribing, and General )Tj
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(Medical Services respectively, compared with population shares. )Tj
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(Table 5. Provisional Age Adjustment - The provisional effects of an age \
adjustment were included. )Tj
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(These provisional effects are illustrative, and will require further ref\
inement. )Tj
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(1.5 The National Assembly will need to agree the implementation plan and\
analysis is being undertaken to )Tj
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(see how these changes could be absorbed through differential growth with\
in current resource planning )Tj
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(assumptions. On implementation the Townsend Report recommends that the t\
ransition to new target )Tj
T*
(shares should be achieved through annual differential growth in NHS reso\
urces. This will result in a )Tj
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(redistribution of resources over a period of time. No area will receive \
less than their current level of )Tj
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(resources \(including cost inflation \) and those areas which are furthe\
st from their target share will receive )Tj
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(the highest rate of growth. )Tj
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(1.6 The Townsend Report also envisages the need for an on - going formul\
a refinement process which )Tj
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(1.7 Consultation on Professor Townsend\222s Report "Targeting Poor Healt\
h" ended on 30 November 2001. )Tj
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("Targeting Poor Health : Next Steps " details the issues raised during c\
onsultation, the response by the )Tj
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(National Steering Group, and the way forward. )Tj
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(Review Structure )Tj
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(1.8. The Review was headed by Professor Peter Townsend of the London Sch\
ool of Economics and )Tj
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(Bristol University who is an international authority on poverty and ineq\
uality and chairs the National )Tj
T*
(Steering Group. )Tj
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(1.9. The research input on area inequalities in health was provided by a\
team headed by Dr David Gordon )Tj
T*
(of Bristol University. The team produced an independent report looking i\
n detail at issues of poor health )Tj
T*
(and inequalities in health, as well as making recommendations for a new \
resource allocation mechanism. )Tj
T*
(Their report forms volume 2 of Professor Townsend\222s Report. )Tj
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(1.10. The service input, prepared on the basis of research information a\
s well as administrative and )Tj
T*
(professional experience, was provided by a series of Task Groups respons\
ible for addressing each of the )Tj
T*
(requirements of the terms of reference. The Task Group review process ha\
d been set up to ensure full )Tj
T*
(participation across Wales underpinned by evidence based research work l\
ed by expert research team. The )Tj
T*
(reports of the Task Groups form Volume 3 of Professor Townsend\222s the \
Report. )Tj
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(1.11. To take forward the Review at the working level a Project Review G\
roup \(PRG\) was set up to )Tj
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(consider the outcomes of the Task Groups and identify issues for conside\
ration by the National Steering )Tj
T*
(Group \( NSG \). )Tj
ET
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(Review Process )Tj
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(1.12. The research team issued an Emerging Findings Report in early Janu\
ary 2001 which was discussed )Tj
T*
(at a workshop in late January 2001. Positive support for the "direct" re\
source allocation approach emerged )Tj
T*
(from the workshop but there were also concerns raised over the use of th\
e Welsh Health Survey \(WHS \) )Tj
T*
(for resource allocation purposes. Given the complexity of the issues inv\
olved the Office for National )Tj
T*
(Statistics \( ONS \) was commissioned to carry out work to evaluate the \
reliability of estimates from the )Tj
T*
(Welsh Health Survey with a view to advising on their suitability for use\
in resource allocation. The ONS )Tj
T*
(report is detailed at Annex D. The Emerging Findings Report was consider\
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(Health and Social Services Committee in February 2001. )Tj
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(1.13. The final research team report was issued in early May 2001. A wor\
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(discuss the findings of the final research team report. The outcome of t\
he workshop was reported to the )Tj
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(research team and had formed the agenda for a meeting with stakeholders \
in early June. The consensus of )Tj
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subject to the completion of work )Tj
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(1.14. Between July and September supplementary work was completed on rur\
al and urban issues. A rural )Tj
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ations from Task Group C )Tj
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(Section 2: Consultation process and response )Tj
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(Consultation Process )Tj
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(2.1 Consultation commenced on 12 October 2001. Following a press confere\
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Cardiff on the 12 October. )Tj
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(2.2 Approximately 700 copies of the Report have been distributed to appr\
oximately 300 organisations, )Tj
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(individuals, and working groups , including Health Authorities, NHS trus\
ts, Community Health Councils, )Tj
T*
(Local Health Groups, Local Authorities and Welsh representative medical \
bodies, Assembly Members, )Tj
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(Welsh Members of Parliament, prominent UK academics, voluntary action gr\
oups, various minority )Tj
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(groups and interested members of the public. The Report has also been po\
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(2.3 Consultation ended on 30 November . A total of 47 consultation respo\
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(2.4 The key issues raised during consultation on "Targeting Poor Health"\
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(Chapter 1 summarised the problem of poor health and inequalities in heal\
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(underlying socio-economic determinants of health status and action in ar\
eas not delegated to the National )Tj
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(2.6 )Tj
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(Chapter 2: Policies relevant to action: a dual strategy for action withi\
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(Chapter 2 outlined the dual strategy for action necessary to address poo\
r health in Wales and tackle )Tj
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(inequalities in health. Chapter 2 indicates that action is needed to tac\
kle inequities in access to health care )Tj
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(services - which is the particular role of the NHS - in Wales as in othe\
r regions of the UK, and is also )Tj
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(needed to tackle the underlying socio-economic determinants of poor heal\
th - which is the role of the )Tj
T*
(Assembly corporately as outlined in the Assembly\222s Better Wales strat\
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(Assembly\222s departments working in partnership with local government a\
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(\( a \) A dual strategy of measures to be taken within the NHS in Wales,\
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(should be examined in turn and their contribution monitored and assessed\
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(strategic potentialities for equity in health within Wales. )Tj
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(\( b \) Specific recommendations for training grants for \221equity in p\
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(the proposals, the strategic fit of these grants with primary care, part\
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(effectiveness of dual strategies, the need for a narrowing of strategies\
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(The National Steering Group welcomes the supportive comments and conside\
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T*
(illustration of wider organisational and professional action needed to a\
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(and health care. The Report \(page 15 para 2.9\) recommends the provisio\
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(either in the general NHS budget or through instruments such as the Heal\
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T*
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(weaken overall outcome. In relation to the request for a strategic frame\
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T*
(reduce deprivation among low-income families including , for example, po\
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(consider the preparation of statements about the development of cross-de\
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(agreement on a common approach to the analysis of HA/LHG expenditure inf\
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(more reliable and comprehensive inputting of coding data by trusts on in\
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(2. Equivalent data to be collected on activity undertaken within a prima\
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(Paragraph 3.75 recommends that an indispensable step in tackling inequal\
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(4. Appropriate linkage to equivalent data collected about social service\
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(of the operation in the existing formula and provide a necessary baselin\
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(The National Steering Group will also ensure that where further explanat\
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(2.8 )Tj
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a basis for shifting resources )Tj
T*
(between LHGs." Until detailed financial information could be mapped at c\
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T*
(LHG levels for the previous three years or for the present year "there w\
ill continue to be significant )Tj
T*
(uncertainty about how the existing distribution of expenditure compares \
with either the existing formula )Tj
T*
(or a new formula distribution." Recommended was the need for urgent step\
s to be taken to produce good )Tj
T*
(information about the trends in costs of each component of healthcare se\
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(relation to specific changes in policy and thereby get into a position o\
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T*
(effectiveness of particular expenditure on the NHS. Before devoting effo\
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(There were two limitations in proceeding with a new formula: )Tj
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(therefore be used only as a measure of financial equity - it does not ad\
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(limitations of information: there is very limited financial information \
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(Chapter 4 recommends that priority needs to be given to: )Tj
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(\( a \) Collecting information which will allow systematic and consisten\
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(resources being spent on Local Health Group populations \(and subsets of\
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(\( b \) Improving as a matter of urgency the quality of the information \
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(through the implementation of the new financial information strategy rec\
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(The issues raised during consultation are set out in Annex B \(4\). They\
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T*
(existing distribution of resources. There were a number of comments on t\
he lack or inconsistency of )Tj
T*
(financial information for the purposes of allocating resources according\
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T*
(and local or Trust levels. Some NHS trusts referred specifically to "poo\
r" information in Wales on costs )Tj
T*
(and expenditure and also on the utilisation of services. The Audit Commi\
ssion reports "an almost )Tj
T*
(universal finding is the lack of meaningful information with which to pl\
an and manage services. )Tj
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(Typically, data is missing or of a poor enough quality to question its u\
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(urgent attention \(our emphasis\). )Tj
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(We take seriously the concerns that have been expressed by a number of o\
rganisations consulted about the )Tj
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(report of the review, and accept the Audit Commission's view that "meani\
ngful information" about )Tj
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(financial distribution the NHS budget "requires urgent attention." The C\
ommission has said it welcomes )Tj
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(in particular two messages in the report, namely )Tj
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(1\) "How expenditure in relation to the objective of reducing inequitabl\
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(2\) "How statistical information for the purposes of improved public inf\
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(progress year on year towards greater equity, might be standardised." )Tj
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(The Audit Commission explains that problems with financial and clinical \
information "have contributed to )Tj
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(the inability to trace money through the system and to demonstrate that \
additional funds have had a )Tj
ET
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(measurable impact in terms of improving the quality of services and outc\
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(The National Steering Group believes that a new allocation formula is of\
equal importance to the "urgent )Tj
0 -1.2 TD
("need to put in place a baseline of information about financial distribu\
tion and expenditure upon which all )Tj
T*
(can build. This means giving priority to information for the present fin\
ancial year - but also for 2000-01 )Tj
T*
(using the new costing methodology issued in October following a major re\
view \(referred to in Chapter 3 )Tj
T*
(of the report\). As a corollary, The NSG, underlines the importance of t\
he baseline review of current )Tj
T*
(expenditure to LHB \( LHG \) level which is being undertaken for 2000-01\
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T*
(under the auspices of the Financial Information Strategy Group on which \
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T*
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and advice the Audit Commission )Tj
T*
(should additionally be invited to embark on the longer-term work identif\
ied in its submission. Drawing on )Tj
T*
(sources of advice established during the Review process to date the plan\
ned steps for the development and )Tj
T*
(implementation of both the urgent and longer-term programmes of work sho\
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(and Social Services Committee )Tj
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(The proposed "direct" resource allocation formula allocates resources ba\
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(health at Local Health Group level. The question of needs index validati\
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T*
(- the use of the Welsh Health Survey for resource allocation. As the Rep\
ort indicates \( para 4.9 page 63 \) )Tj
T*
(resource mapping determines what share of the total resources allocated \
to health authorities is being spent )Tj
T*
(on each local health group population within its share. This is needed a\
s a benchmark for comparing )Tj
T*
(existing expenditure shares with the share indicated by the existing or \
proposed population formula. )Tj
T*
(Transparency will be crucial to the acceptance of an All Wales resource \
mapping system )Tj
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(. )Tj
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(2.9. )Tj
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(Chapter 5 : A new model of allocating resources by area to health care s\
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(Summary of Chapter 5 )Tj
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(Chapter 5 explains the way in which a direct measurement of health need,\
using the Welsh Health Survey, )Tj
T*
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of health and to form the basis of )Tj
T*
(resource allocation. Chapter 5 also outlines the disadvantages of an ind\
irect measure of health need )Tj
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(resource allocation approach and illustrates the impact of the new propo\
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(Chapter 5 recommends that: )Tj
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(\( a \) The National Assembly for Wales adopts the direct model of measu\
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(\( b \) Steps are taken to confirm but also improve the value of the WHS\
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(\( c \) Links between resource management, measurement of local health c\
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(\( d \) The direct method of measuring area needs for health care should\
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(\( e \) The transition to new target shares should be achieved through r\
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T*
(resources. Thus no area will receive less than their current level of re\
sources and those areas which are furthest )Tj
T*
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(\( f \) The change should be achieved as rapidly as is possible consiste\
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(which the Assembly considers necessary to ensure a planned transition to\
the new shares. We consider the )Tj
T*
(change could be effected in three years - but at most five years. )Tj
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(\( g \) The scope for continued interim action through the Health Inequa\
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T*
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(The key issues raised during consultation are set out at Annex B \(5.1- \
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(Issues raised during consultation relating to the use of the Welsh Healt\
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(purposes )Tj
ET
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(Issues raised during consultation relating to the use of the Welsh Healt\
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T*
(purposes are set out in Annex B \(5.1\) A number of common themes of con\
cern were apparent: )Tj
ET
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(Concerns over the sample size of the survey )Tj
ET
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(Concerns over under- reporting and response rates )Tj
ET
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(l)Tj
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( )Tj
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(Concerns over the ability to measure the health needs of the elderly )Tj
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(Concerns whether the health indicators are a broad enough measure of rel\
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ET
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(Doubts have been expressed about the use of the Welsh Health Survey for \
resource allocation purposes )Tj
T*
(without confirmation of the value of some elements of the Survey, and it\
s further improvement. )Tj
ET
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(National Steering Group Response )Tj
ET
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(Dr Gordon\222s report is at Annex \(C \). The use of the Welsh Health Su\
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0 -1.2 TD
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T*
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T*
(Statistics \(ONS\) were commissioned to evaluate the reliability of esti\
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(with a view to advising on their suitability for use in resource allocat\
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(Annex D. )Tj
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(The ONS has concluded that in general the survey methodology was found t\
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nst Welsh Public Health )Tj
T*
(Dataset \( PHCD \). Comparisons of estimates for individual unitary auth\
orities for seven types of illnesses )Tj
T*
(were made. The ONS reported that significant positive correlations were \
found with at least one )Tj
T*
(comparative administrative data source for five of these. This provided \
evidence of reliability in the )Tj
T*
(survey estimates for relative prevalence. There was, however, no correla\
tion with administrative sources )Tj
T*
(for mental illnesses leading to concern that the WHS estimates for menta\
l illness may not be directly )Tj
T*
(related to the need for treatment. Mental illness represents approximate\
ly 18% of the hospital and )Tj
T*
(community service share. )Tj
ET
EMC
/P <>BDC
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(The ONS also undertook work to validate estimates against NOP non- respo\
nse survey, General Practice )Tj
T*
(Research Database \(GPRD\) and Census Long Term Limiting Disease. The ON\
S reported that the non- )Tj
T*
(response surveys were biased upwards but that the correlation between th\
e age- standardised 1991 Census )Tj
T*
(rates for individual authorities and age standardised estimates from the\
WHS is high \(0.96\). The results )Tj
T*
(indicate that the survey may over- estimate absolute prevalence as a who\
le but is reliable in terms of )Tj
T*
(estimating relative prevalence across unitary authorities. The ONS concl\
ude that as it is the latter that )Tj
T*
(determines resource allocation in the proposed formula upward bias does \
not invalidate the survey for use )Tj
T*
(in the proposed formula. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 287.64722 Tm
(The ONS also assessed the potential impact of sampling errors on the WHS\
survey and indicated that it )Tj
T*
(was not possible to be confident in correctly ranking all authorities in\
terms of prevalence for any )Tj
ET
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591.30804 252.50945 l
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BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 254.59192 Tm
(individual illness using the WHS but that there was little evidence that\
alternative sources of information )Tj
ET
9.83789 235.9818 m
225.17935 235.9818 l
S
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 238.06427 Tm
(would provide more accurate rankings \( our emphasis \) . The ONS estima\
te that the maximum difference )Tj
T*
(between "true" allocations for any authority and one of the five simulat\
ed allocations was less than 0.5% )Tj
T*
(of total resources allocated but that three authorities gained or lost m\
ore than 5% of their "true" allocation. )Tj
T*
(\( see Table 4 ONS report \) . )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(The National Steering Group considers the findings of the ONS provide re\
asonable assurance on the use )Tj
T*
(of the survey for resource allocation purposes. Further work undertaken \
by the Health Statistics and )Tj
T*
(Analysis Unit, National Assembly, indicates that the resource allocation\
change derived from the WHS is )Tj
T*
(in the same direction at health authority level, ie the same authorities\
are "gainers" or "losers", as the )Tj
T*
(changes that would arise from using distributions based on the Resource \
Allocation Working Group's )Tj
T*
(1998 recommendations or a simple distribution based on 1991 Census Limit\
ing Long-Term Illness. )Tj
T*
(Additionally, an initial calculation of an age adjustment, which however\
needs further development to )Tj
T*
(include the effects of increased length of stay, has been incorporated i\
nto the formula. The age adjustment )Tj
ET
EMC
Q
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(has been applied to 65% of expenditure corresponding to hospital in-pati\
ent services. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 716.82602 Tm
(The National Steering Group is aware that, as with all approaches that i\
ntroduce a new method of )Tj
0 -1.2 TD
(allocation, there will be a number of areas which will require improveme\
nt and refinement and the issues )Tj
T*
(raised in the consultation responses provide a strong focus. The Nationa\
l Steering Group is also aware that )Tj
T*
(the results of a WHS for resource allocation can be improved if a new WH\
S can be undertaken which )Tj
T*
(incorporates questions to address some of the concerns raised during con\
sultation. It is proposed that work )Tj
T*
(on enhancing the WHS is completed in 2002 /03 for incorporation into a n\
ew WHS to be undertaken in )Tj
T*
(2003. )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 582.44051 Tm
(Issues raised during consultation relating to the proposed formula for h\
ospital and community services )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 547.22087 Tm
(The issues raised during consultation relating to the proposed formula f\
or hospital and community )Tj
T*
(services are set out in Annex B \( 5.2 \). Key issues raised were: )Tj
ET
EMC
/Lbl <>BDC
BT
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(l)Tj
/T1_0 1 Tf
( )Tj
ET
EMC
/LBody <>BDC
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/T1_0 1 Tf
13.77304 0 0 13.77304 49.18942 495.4736 Tm
(The expenditure block groupings )Tj
ET
EMC
/Lbl <>BDC
BT
/T1_2 1 Tf
6.88652 0 0 6.88652 35.13403 478.94595 Tm
(l)Tj
/T1_0 1 Tf
( )Tj
ET
EMC
/LBody <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 49.18942 478.94595 Tm
(Costing issues )Tj
ET
EMC
/Lbl <>BDC
BT
/T1_2 1 Tf
6.88652 0 0 6.88652 35.13403 462.4183 Tm
(l)Tj
/T1_0 1 Tf
( )Tj
ET
EMC
/LBody <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 49.18942 462.4183 Tm
(Application of the formula at LHG level )Tj
ET
EMC
/Lbl <>BDC
BT
/T1_2 1 Tf
6.88652 0 0 6.88652 35.13403 445.89066 Tm
(l)Tj
/T1_0 1 Tf
( )Tj
ET
EMC
/LBody <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 49.18942 445.89066 Tm
(Data updating )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 410.67102 Tm
(Key concerns on expenditure block groupings relate to health need indica\
tors for arthritis, diabetes, back )Tj
T*
(pain, varicose veins and dental records where patients have less than 20\
teeth. Concerns on costing issues )Tj
T*
(focus on current developments in costing systems and the analysing of co\
sts by HRG to support future )Tj
T*
(commissioning needs which represent a mismatch with the formula which an\
alyses costs by DRG. Other )Tj
T*
(costing concerns relate to the Trust Returns \(TFR2\) and the failure of\
these returns to account for )Tj
T*
(expenditure in England, particularly specialised services. Other formula\
concerns focus on disparities )Tj
T*
(between current funding and those proposed by the new formula at LHG lev\
el, the way in which )Tj
T*
(population changes are included in the formula and the need for the form\
ula to reflect socio- economic )Tj
T*
(factors. The problem is to distinguish the preparation of accounts of mo\
nies expended for Treasury )Tj
T*
(purposes and the preparation of accounts for purposes of managing and pl\
anning expenditures for social )Tj
T*
(distribution. )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
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(National Steering Group Response )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 174.95531 Tm
(Many of the issues raised have been highlighted in the Report for furthe\
r development work \(para 5.11 )Tj
T*
(and 5.14 page 68 and page 69\). The Report makes specific reference to t\
he connections between WHS )Tj
T*
(health condition indicators and the expenditure blocks and the need to m\
odify aspects of the methodology. )Tj
ET
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BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 125.37236 Tm
(The Report also recognises the concerns over the accuracy and reliabilit\
y of existing budgetary returns. )Tj
T*
(\( our emphasis \). Further development work has been highlighted to est\
ablish whether the use of average )Tj
T*
(costs for each condition needs to be refined to allow for the additional\
costs of treating older people. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 57.09744 Tm
(The National Steering Group also recognises that costing systems are cur\
rently being developed and that )Tj
T*
(the move towards HRG analysis from DGR analysis will have a shares distr\
ibution impact. The National )Tj
ET
EMC
Q
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(Steering Group is aware that review and refinement of the costing system\
will be both time consuming )Tj
0 -1.2 TD
(and complex. The National Steering Group proposes first, that a costing \
review timetable and action plan )Tj
T*
(is agreed and second, that a corresponding timetable for the completion \
of a revised budgetary account at )Tj
T*
(central and local levels of the distribution of 2000 - 01 health expendi\
tures and also for the present )Tj
T*
(financial year. )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 653.26176 Tm
(Issues raised during consultation relating to the rural needs adjustment\
)Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 618.04214 Tm
(The issues raised during consultation relating to the rural needs adjust\
ment are set out in Annex B \(5.3 \). )Tj
T*
(Comments focus on why the rural cost adjustment has only been applied to\
7.5% of expenditure \( the % of )Tj
T*
(the travel element of community health services of total hospital and co\
mmunity services\), the need for )Tj
T*
(supporting evidence for the adjustment, the need not to dismiss the Scot\
tish model for hospital service and )Tj
T*
(GMS and an explanation why ambulance services have been removed. )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 516.71193 Tm
(National Steering Group Response )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 481.49229 Tm
(Welsh data have been used in replicating the Scottish model for rurality\
. The outcome of that work was )Tj
T*
(reported to Task Group C who agreed with the findings that there was suf\
ficient evidence to support an )Tj
T*
(adjustment for community nursing services but that there was not current\
ly evidence to support a rural )Tj
T*
(cost adjustment for hospital services. Further work on GMS has been unde\
rtaken and is detailed in Annex )Tj
T*
(E. The feasibility of using Welsh data to replicate the Scottish GMS rur\
al adjustment has been addressed. )Tj
T*
(There have been representations that the Scottish model would be inappro\
priate for Wales and that a )Tj
T*
(special model for Wales would have to be introduced and separately asses\
sed. Further work on this area )Tj
T*
(will need to be progressed and a firm timetable and action plan agreed )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 330.57915 Tm
(The new formula did not include ambulance services and for the purposes \
of comparison, tables )Tj
T*
(comparing formula shares excluded ambulance services -Table 1 note \(iii\
\) refers. The treatment of )Tj
T*
(ambulance services will be agreed when the new structures arising from t\
he NHS Plan become clearer. In )Tj
T*
(the meantime it is proposed that the existing rural cost adjustment for \
ambulance services will be )Tj
T*
(maintained. )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 229.24892 Tm
(Issues raised during consultation relating to urban issues )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 194.0293 Tm
(The issues raised during consultation relating to urban issues are set o\
ut in Annex B \(5.4\). Comments )Tj
T*
(focus on the need to complete further work on urban issues and cover are\
as such as asylum seekers, ethnic )Tj
T*
(minority groups, prisoners, children with complex and high cost medical \
conditions, student populations, )Tj
T*
(HIV, mental health problems and those with generic disorders, market for\
ces for GMS, responsibilities for )Tj
T*
(emergency planning and outbreak control. There is also need to monitor e\
thnic minority utilisation. )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 92.69908 Tm
(National Steering Group Response )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 57.47945 Tm
(Task Group A has completed further work on urban issues following the 4 \
July Health and Social Services )Tj
T*
(Committee and this is reflected in volume 3 of the Report \(Task Group E\
xecutive Summaries\). The results )Tj
ET
EMC
Q
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(of the review of urban issues indicate that there is currently no eviden\
ce to support an urban issues cost )Tj
0 -1.2 TD
(adjustment. The scope of the work undertaken covered almost all the issu\
es raised in consultation. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 702.84471 Tm
(A key constraint in the review of urban issues has been the lack of avai\
lable data which has precluded )Tj
T*
(further investigative work being undertaken on a number of issues such a\
s AIDS/HIV, ethnic minorities, )Tj
T*
(drugs and alcohol abuse. Work should be undertaken to look at a cost dis\
tribution for HIV/AIDS and )Tj
T*
(ethnic minorities based on the resource allocation formula in England, w\
hich incorporates cost premiums )Tj
T*
(reflecting additional costs of providing these services. The NSG recomme\
nds that every effort should be )Tj
T*
(made to relate such work to the use of the WHS as a standard guide to re\
source allocation, and therefore to )Tj
T*
(isolate what case is made out in these specialist inquiries for "additio\
nal" and not just total costs. )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 568.4592 Tm
(Issues raised during consultation relating to GMS )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 533.23958 Tm
(The issues raised during consultation relating to GMS are set out in Ann\
ex B \(5.5\). Consultation )Tj
T*
(comments focused on clarification whether non -cash limited services ove\
r time would become cash )Tj
T*
(limited, the need for further clarity on the proposals for GMS given tha\
t the work being undertaken in )Tj
T*
(England needs is to be considered before deciding on a way forward, and \
the need to take account of nurse )Tj
T*
(activity e.g smears, vaccinations, and health promotion activities and r\
urality which impacts on branch )Tj
T*
(surgeries and on-call arrangements. There were doubts whether the propos\
ed GMS formula could be part )Tj
T*
(of the early introduction of the direct method of allocation. )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 398.85406 Tm
(National Steering Group Response )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 363.63443 Tm
(As indicated by the research team, the GMS formula was a "notional" or i\
ndicative amount and served to )Tj
T*
(illustrate the share of resources if GMS was to be solely formula based.\
)Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 311.88716 Tm
(The National Steering Group has recognised for some time that deriving a\
formula distribution for GMS )Tj
T*
(would be difficult given the demand led nature of the expenditure. It wa\
s for this reason that the National )Tj
T*
(Steering Group took the decision to review the work undertaken in Englan\
d to ensure that the method )Tj
T*
(finally adopted in Wales was able to benefit not only from the work bein\
g undertaken by the research )Tj
T*
(team on Bristol but also research undertaken to derive a formula for GMS\
in England. A review of the )Tj
T*
(English GMS formula has been undertaken by Dr Martyn Senior \226 his rep\
ort is at Annex E. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(The National Steering Group proposes that a GMS formula approach based o\
n the direct measurement of )Tj
T*
(health need be progressed but subject to the further data refinements as\
set out in Dr Senior\222s report \226 )Tj
T*
(incorporation of children and pregnant women into the GMS formula, recor\
ding of consultations and )Tj
T*
(home visits, unavoidable costs of rurality, a market forces factor for G\
P\222s, temporary residents )Tj
T*
(consultation rate. The level of work to address these issues will be con\
siderable and it may be necessary to )Tj
T*
(take account of the new GP contract. )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 76.17143 Tm
(Issues raised during consultation relating to Prescribing )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 40.9518 Tm
(The issues raised during consultation relating to Prescribing are set ou\
t in Annex B \( 5.6\). There are )Tj
ET
EMC
Q
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(particular concerns over the use of the General Practice Morbidity Datab\
ase \( GPMD \) as a key data )Tj
0 -1.2 TD
(source. This concern is supported also by Health Solution Wales \( the o\
rganisation which maintains the )Tj
T*
(database\) which has indicated that the prescribing data from the GPMD i\
s not of a high enough quality for )Tj
T*
(resource allocation purposes. There is also a need to take into account \
the large variations in prescribing )Tj
T*
(practice. )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 653.26176 Tm
(National Steering Group Response )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 618.04214 Tm
(The National Steering Group agrees that some doubts about the reliabilit\
y of the GPMD need to be met. It )Tj
T*
(would be possible to check the use of the of the GPMD in Wales using alt\
ernative data sources like the )Tj
T*
(General Practice Research Database \( GPRD \) used previously by the ONS\
. This could be done quickly, )Tj
T*
(especially with the help of the ONS. It is proposed that the direct meas\
urement of prescription expenditure )Tj
T*
(using GPMD be implemented only if its provisional use is confirmed by fu\
rther enquiries in the next 6 )Tj
T*
(months. It is also proposed that an action plan and timetable is put in \
place to begin to bring the data )Tj
T*
(quality up to an acceptable level with the distributive effect of existi\
ng practices. )Tj
ET
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(Issues raised during consultation relating to formula implementation )Tj
ET
EMC
/P <>BDC
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/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 448.437 Tm
(The issues raised during consultation relating to formula implementation\
are set out in Annex B \( 5.7 \). )Tj
T*
(There is concern over the proposed implementation timetable, particularl\
y in relation to the allocation )Tj
T*
(change coinciding with organisational change and statutory financial cha\
nge. Concern was also expressed )Tj
T*
(at the equalisation period and the concept of differential growth. It is\
suggested that growth must be )Tj
T*
(calculated after allowing for NHS pay awards and core inflationary costs\
plus the cost of sustaining core )Tj
T*
(services. There is also a need to take into account cross - border flows\
, to develop a strategy for )Tj
T*
(information to support the directional change, the impact of disaggregat\
ion of existing Health Authority )Tj
T*
(LTAs and other expenditures to LHGs which has the potential to enhance a\
ny imbalance with the )Tj
T*
(proposed funding flows , and the impact on Trust and Health Authority re\
covery plans. The detailed )Tj
T*
(response of the Finance and Assets Task Group which comments on structur\
al change issues and pace of )Tj
T*
(change issues is also noted. )Tj
ET
EMC
/P <>BDC
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/T1_1 1 Tf
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(National Steering Group Response )Tj
ET
EMC
/P <>BDC
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/T1_0 1 Tf
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(The implementation plan will be finally agreed by the National Assembly \
and the concerns raised in )Tj
T*
(consultation about the implementation timescales / equalisation and grow\
th will be considered at that )Tj
T*
(stage. )Tj
ET
EMC
/P <>BDC
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/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 144.44635 Tm
(Issues raised during consultation relating to the Inequality Fund )Tj
ET
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/P <>BDC
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(The key issues raised during consultation relating to the Inequality Fun\
d are set out in Annex B \( 5.8\). )Tj
T*
(Comments focus on the need to agree a measure for the Inequalities Fund,\
that there is a need for a )Tj
T*
(recurrent fund to target interventions which allow the Acheson Report re\
commendations to be addressed, )Tj
T*
(that the inequalities fund should continue to be linked to other resourc\
es that tackle the determinants of )Tj
T*
(health and the size of any inequalities fund. )Tj
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(National Steering Group Response )Tj
ET
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(The implementation plan will be finally agreed by the National Assembly \
and the comments raised in )Tj
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(consultation about the inequalities fund will be considered at that stag\
e. )Tj
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(General \(Chapter 5\) )Tj
/T1_0 1 Tf
(National Steering Group Response )Tj
ET
EMC
/P <>BDC
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/T1_1 1 Tf
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(The responses during the consultation process have been refreshingly ful\
l and rewarding, and show the )Tj
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(level of commitment in Wales to transparency and to the sophisticated wo\
rk that will be necessary to )Tj
T*
(achieve equity in health. )Tj
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/T1_1 1 Tf
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(The NSG notes strong support for proceeding with the direct method in th\
e allocation of NHS resources in )Tj
T*
(Wales. Important concerns have been raised about issues to do with healt\
h need and with the extent and )Tj
T*
(quality of financial information. The NSG notes that the research team b\
elieves it has used "the most valid )Tj
T*
(and reliable health and financial information currently available" in th\
e proposed new formulae for GMS, )Tj
T*
(prescribing and TFR2 resource allocations. This belief is sustained in t\
he reports below by the team as a )Tj
T*
(whole, under the direction of Dr Gordon, and by Dr Martyn Senior. The pr\
oposed new formulae are )Tj
T*
(designed to be open and transparent. It is argued that they can easily b\
e updated if and when better data )Tj
T*
(about health need and about expenditure or costs become available. In th\
e absence of a transparent )Tj
T*
(existing formula the data used in the proposed new health resource alloc\
ation formulae seem to be of )Tj
T*
(sufficient quality to allow rapid implementation. This is not to deny th\
at there is time in the ensuing )Tj
T*
(months to strengthen the plans for the WHS, for prescribing data in the \
GPMD and for costing data from )Tj
T*
(the TFR2 returns )Tj
ET
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/P <>BDC
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/T1_1 1 Tf
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(On the basis of the ONS evidence the NSG accepts that it is unlikely tha\
t further improvements in the )Tj
T*
(health needs data quality, though of course desirable, would result in s\
ignificant changes to the resource )Tj
T*
(allocations. The statistical modelling carried out by ONS \(see Annex D\)\
has demonstrated that "the )Tj
T*
(maximum expected absolute difference between the proposed allocations an\
d the \221true\222 allocations at )Tj
T*
(LHG area level range from just 0.06% to 0.31%, )Tj
/T1_0 1 Tf
(ie )Tj
/T1_1 1 Tf
(less than half of one percent of the total Wales NHS )Tj
T*
(allocation "\(see Table 4 in Appendix D\). )Tj
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(The NSG also accepts that although not yet ideal the proposed formulae f\
or GMS, prescribing and TFR2 )Tj
T*
(health resource allocations are much more scientifically valid and relia\
ble than the current allocations in )Tj
T*
(Wales. The implementation of the new formulae result in a much fairer al\
location of health resources )Tj
T*
(according to need for health care and the \221poorest\222 areas in Wales\
will receive significant additional )Tj
T*
(resources which should help them to meet their much higher relative leve\
ls of health need. If this step is )Tj
T*
(not taken and the old health resource allocations are retained, then the\
\221poorest\222 areas will not receive the )Tj
T*
(additional monies they need to meet the health needs of their population\
s. This would contradict the )Tj
T*
(expressed aims of the review when set up and would almost certainly resu\
lt in a continued widening of the )Tj
T*
(health gap between the \221richest\222 and \221poorest\222 areas in Wale\
s. )Tj
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(2.10 )Tj
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(Chapter 6: A review of existing methods of allocating resources using in\
direct models )Tj
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(Summary of Chapter 6 )Tj
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(Chapter 6 sets out how the current population formula methodology operat\
es, how the process in Wales )Tj
0 -1.2 TD
(compares with alternative approaches in the other countries of the UK an\
d what is its impact on the )Tj
T*
(current distribution of resources to health authorities in Wales. )Tj
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(Chapter 6 recommends that the work to develop the indirect approach be p\
ut on hold for two years until the )Tj
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(early promise of the direct model can be fully confirmed )Tj
ET
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(Issues raised during Consultation )Tj
ET
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(The key issues raised during consultation are set out in Annex B \( 6 \)\
. The comments focus on the need to )Tj
T*
(develop an indirect needs based approach. In general correspondents were\
aware of the unreliability of the )Tj
T*
(statistics of the utilisation of services in Wales as well as of the lim\
itations of SMRs \( under 75 \) as )Tj
T*
(surrogate indicators of health. )Tj
ET
EMC
/P <>BDC
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(National Steering Group Response )Tj
ET
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(There is a need to enhance aspects of the direct resource allocation for\
mula and to enhance the Welsh )Tj
T*
(Health Survey . However, especially since there is an absence of data ab\
out the workings of the existing )Tj
T*
(formula the proposed formula provides a more than adequate basis as a fi\
rst step in distributing resources. )Tj
T*
(During its implementation it will be possible to check some aspects of i\
ts applicability as well as introduce )Tj
T*
(certain refinements. )Tj
ET
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(2.11 )Tj
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(Chapter 7: Conclusions and Recommendations )Tj
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(Summary of Chapter 7 )Tj
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(This chapter summarised the conclusions and recommendations of the previ\
ous chapters. Chapter 7 also )Tj
T*
(emphasis that the role of a resource allocation formula in reducing ineq\
ualities of health and health care is )Tj
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(certainly smaller than the contribution that can be made to equity of ac\
cess and outcome : )Tj
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(by carefully investigating carefully investigating and revising, where n\
ecessary, the sums going to )Tj
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(particular service uses and )Tj
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/Lbl <>BDC
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/T1_3 1 Tf
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(tracking expenditure to the poorest and least healthy in rich and poor a\
reas alike; and )Tj
ET
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(l)Tj
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13.77304 0 0 13.77304 49.18942 124.65919 Tm
(adopting the "dual strategy" to develop appropriate action outside the h\
ealth services )Tj
/T1_2 1 Tf
(. )Tj
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(Chapter 7 concludes that these three measures would have a substantial i\
mpact on the growing inequalities )Tj
T*
(of health, and the likely growing inequalities of health care and recomm\
ends to the Committee that having )Tj
T*
(set in train a more equitable and transparent process of resource alloca\
tion, these three measures should )Tj
T*
(now be priorities for the NHS and the Assembly corporately. )Tj
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(Section 3 : Way Forward )Tj
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(3.1 The National Steering Group is grateful for the considered comments \
on the report of July 2001 on the )Tj
0 -1.2 TD
(Review of the Allocation of NHS Resources that have been received. A lar\
ge number of organisations and )Tj
T*
(individuals have made representations which the NSG has found instructiv\
e. These have been summarised )Tj
T*
(above, with notes of the reactions of the NSG, and described in greater \
detail in annexes below. )Tj
ET
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(3.2 Commentators have naturally tended to concentrate their attention se\
lectively on particular issues of )Tj
T*
(concern to them rather than all the issues covered by the report. In mak\
ing the recommendations that )Tj
T*
(follow \(and which change, add to or confirm the recommendations in the \
original report itself\), the NSG )Tj
T*
(wishes to remind readers of the original framework of the report. The st\
eps that have to be planned and )Tj
T*
(then put in place will apply to each of the three areas of work singled \
out in the report of the Review - 1\) )Tj
T*
(the dual strategy \(of policy measures to be taken, and monitored, insid\
e and outside the NHS\); 2\) reliable )Tj
T*
(financial information on a year to year basis about actual NHS and non-N\
HS expenditure per person in )Tj
T*
(deprived and non-deprived groups, as well as by unit of service and dise\
ase category; and 3\) the )Tj
T*
(development of a resource allocation formula according to the direct mea\
sured health care needs of the )Tj
T*
(population. )Tj
ET
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/T1_1 1 Tf
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(3.3 Many of the comments picked up concerns and issues raised and discus\
sed with NHS participants in )Tj
T*
(during the Review proces. In particular, these included concerns over th\
e information about the )Tj
T*
(distribution of existing resources according to need, the reliability of\
statistics on expenditure and costs, )Tj
T*
(the use of the Welsh Health Survey for resource allocation purposes, som\
e aspects of the proposed "direct )Tj
T*
(method" formula \( particularly the GMS and prescribing elements \). Imp\
lementation and phasing of the )Tj
T*
(proposed new method of allocation were also raised. There were, addition\
ally, a number of issues which )Tj
T*
(required further explanation and clarification. )Tj
ET
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/T1_1 1 Tf
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(3.4 These concerns have been discussed with the Office of National Stati\
stics \( ONS \) and the review )Tj
T*
(team. The reports detailed at Annex C \( Research Team response to consu\
ltation \) and Annex D \( ONS )Tj
T*
(report \) therefore comprise new information for many correspondents and\
may help to answer some of )Tj
T*
(their concerns. The NSG recognises that action to remedy the state of fi\
nancial information about )Tj
T*
(distribution of NHS resources has become urgent. The Group also recognis\
es that further work on the )Tj
T*
(Welsh Health Survey is required if it is to be used at LHG level and tha\
t much further work on the GMS )Tj
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(and Prescribing elements of the formula is required . )Tj
ET
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(Further steps recommended )Tj
ET
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/T1_1 1 Tf
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(3.5 Given the above the National Steering Group proposes the following: \
)Tj
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(1\) The Dual Strategy. )Tj
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(The need for measures external as well as internal to the NHS has been w\
elcomed. The NSG )Tj
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(recommends: )Tj
ET
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(a\) that the "dual" strategy is confirmed in principle but needs to be d\
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(b\) that the proposals for "equity" and "advocacy" grants should be conf\
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(that they should be considered for mainstream funding and that the strat\
egic fit of these grants with )Tj
T*
(primary care and partnership funding and as illustrative models of other\
measures affecting primary and )Tj
T*
(secondary treatment should be investigated - to enhance the effectivenes\
s of the dual strategy approach; )Tj
ET
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(c\) that strategic framework and policy measures to reduce deprivation \
among low-income families, )Tj
T*
(including, for example, policies on free school meals and nutrition, sho\
uld be drawn up urgently - with the )Tj
T*
(participation of all relevant departments within the Assembly )Tj
ET
EMC
/P <>BDC
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/T1_0 1 Tf
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(d \) that special consideration be given to the need for new and improve\
d statistics about equity of access to )Tj
T*
(high quality health care for all including individuals in households exp\
eriencing deprivation. )Tj
ET
EMC
/P <>BDC
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/T1_1 1 Tf
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(2\) Improving Information about the Distribution of NHS Expenditure. )Tj
ET
EMC
/P <>BDC
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/T1_0 1 Tf
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(The NSG accepts the Audit Commission's view that "meaningful information\
" about financial distribution )Tj
T*
(of the NHS budget "requires urgent attention." As the Commission has sai\
d, the problems of financial and )Tj
T*
(clinical information "have contributed to the inability to trace money t\
hrough the system and to )Tj
T*
(demonstrate that additional funds have had a measurable impact in terms \
of improving the quality of )Tj
T*
(services and outcomes for patients." Two messages of the NSG\222s report\
were particularly welcomed, )Tj
T*
(namely )Tj
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( )Tj
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(How expenditure in relation to the objective of reducing inequitable acc\
ess to health care can be )Tj
T*
(tracked consistently at central and local levels; )Tj
ET
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/Lbl <>BDC
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(l)Tj
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( )Tj
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/LBody <>BDC
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/T1_0 1 Tf
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(How statistical information for the purposes of improved public informat\
ion, and the monitoring of )Tj
T*
(progress year on year towards greater equity, might be standardised. )Tj
ET
EMC
/P <>BDC
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/T1_0 1 Tf
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(a\) The National Steering Group believes that a new allocation formula i\
s of equal importance to the )Tj
T*
("urgent "need - as expressed by the Audit Commission - to put in place a\
baseline of information about )Tj
T*
(financial distribution and expenditure upon which all can build. Priorit\
y might be given to information for )Tj
T*
(the present financial year - but also for 2000-01 using the new costing \
methodology issued in October )Tj
T*
(following a major review \(referred to in Chapter 3 of the report\). Thi\
s would be a welcome start in putting )Tj
T*
(a new financial strategy into place. )Tj
/T1_1 1 Tf
(The NSG recommends accordingly. )Tj
ET
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(b\) The NSG also underlines the importance of the baseline review of cur\
rent expenditure to LHB level )Tj
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(which is being undertaken for 2000-01\(to be completed by July 2002\) un\
der the auspices of the Financial )Tj
T*
(Information Strategy Group on which the Audit Commission and National Au\
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ET
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/T1_0 1 Tf
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(c\) In view of its recent experience and advice the Audit Commission sho\
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(embark on the longer-term work identified in its submission. )Tj
ET
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(d \) Drawing on sources of advice established during the Review process \
to date the planned steps for the )Tj
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(development and implementation of both the urgent and longer-term progra\
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(These four recommendations set out above are new. They build on the conc\
lusion drawn in the report that )Tj
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(to tackle inequalities in health in Wales an information system about tr\
ends in access to, and outcome of, )Tj
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(health care must be put in place jointly by finance, health care and soc\
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(centrally, regionally and at local Trust and LHG levels. )Tj
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(In building an effective financial information strategy the Assembly wil\
l necessarily need to set up a )Tj
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(complex programme that is parallel to, or interdependent with, existing \
methods of financial )Tj
T*
(administration and accountability. During the consultation process, and \
the review process itself, various )Tj
T*
(illustrations of what needs to be included have been given . For example\
, )Tj
ET
EMC
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(the issue of clear guidance on the methodology to be employed in compili\
ng costings \226to reflect )Tj
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(the outcome of the work of the Costing Working Group \( now achieved \) \
)Tj
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/Lbl <>BDC
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(agreement on a common approach to the analysis of HA/LHG expenditure inf\
ormation, both )Tj
T*
(planned and actual, so that it meets both local management information r\
equirements and wider )Tj
T*
(national requirements for the analysis of expenditure in relation to are\
a and, possibly, specific )Tj
T*
(population groups; )Tj
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(more reliable and comprehensive inputting of coding data by trusts on in\
dividual patients, )Tj
T*
(including postcode and practice details, to enable expenditure to be ana\
lysed at LHG, electoral )Tj
T*
(ward, and practice level. The National Assembly is currently funding the\
Information Quality )Tj
T*
(Programme which includes Data Accreditation across NHS Wales. \(These da\
ta are not currently )Tj
T*
(comprehensively collected for outpatients and the postcode data will be \
important for equity to be )Tj
T*
(monitored within LHG areas.\) )Tj
ET
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(Equivalent data to be collected on activity undertaken within a primary \
or community care setting )Tj
T*
(\226 this will be increasingly important as and when activity traditiona\
lly undertaken in a secondary )Tj
T*
(care setting is undertaken in a primary or community care setting. \( A \
project \( I3PC\) taking )Tj
T*
(forward data quality issues in primary care anda National Information De\
velopment Plan is due for )Tj
T*
(publication in February 2002 which will present a strategy to meet the i\
nformation needs of NHS )Tj
T*
(Wales in delivering )Tj
/T1_2 1 Tf
(" Improving Health in Wales )Tj
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(An agreed set of financial management information data, rather than just\
the data required to )Tj
T*
(satisfy statutory financial reporting requirements, to be subject to ext\
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T*
(England; and )Tj
ET
EMC
/Lbl <>BDC
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/T1_1 1 Tf
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(l)Tj
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( )Tj
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(Appropriate linkage to equivalent data collected about social services e\
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(3\) A New "Direct" Formula )Tj
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(The National Steering Group welcomes the elaborate comments that have be\
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T*
(recommendation for the introduction of a formula of allocation whereby t\
he need for health care is )Tj
T*
(assessed by direct rather than indirect methods. It finds necessary the \
reminder that it is impossible to )Tj
ET
EMC
Q
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(trace how the existing formula of allocation works in any detail at loca\
l level. Commentators have been )Tj
0 -1.2 TD
(unable to compare the merits and demerits of the existing formula with t\
he proposed formula at local )Tj
T*
(level. Nonetheless the NSG wish to put on record their gratitude for sug\
gestions from many with )Tj
T*
(considerable experience and expertise about the ways in which the propos\
ed formula could be assessed or )Tj
T*
(improved. The comments are not criticisms of a new formula so much as su\
ggestions for possible )Tj
T*
(improvement that deserve close attention and investigation for early res\
olution. The NSG has )Tj
T*
(recommended implementation of the formula in 2003-4. This means that the\
re are 10 months for )Tj
T*
(refinement and improvement of the proposed course of action. )Tj
ET
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(After studying the comments the NSG recommends that: )Tj
ET
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(a\) the National Assembly for Wales adopts the direct model of measuring\
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ET
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(b\) steps are taken immediately to confirm but also improve the value of\
the WHS. The NSG notes that )Tj
T*
(monies have been allocated for a repeat survey. )Tj
ET
EMC
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(c\) links between resource allocation t, measurement of local health car\
e needs, and expenditure on those )Tj
T*
(needs at LHG and Trust level be established organisationally during the \
early months of 2002 and )Tj
T*
(monitored annually; )Tj
ET
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(d\) appreciating that there remain 10 months for development the direct \
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ET
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(e\) the transition to new target shares should be achieved through annua\
l differential growth in NHS )Tj
T*
(resources. This will result in a redistribution of resources over a peri\
od of time. Thus no area will receive )Tj
T*
(less than its current level of resources \( including cost inflation \) \
and an allowance for funding of agreed )Tj
T*
(priorities and development e.g. standard driven initiatives such as impr\
ovement in treatment of CHD and )Tj
T*
(Cancer. Those areas which are furthest from their target share will rece\
ive the highest rate of growth. The )Tj
T*
(estimates of the research team, supported by ONS, is that these areas in\
clude those with disproportionately )Tj
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(high numbers of deprived and low-income groups; )Tj
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(f\) the change should be achieved as rapidly as is possible consistent w\
ith an acceptable level of growth for )Tj
T*
(all - which the Assembly considers necessary to ensure a planned transit\
ion to the new shares. )Tj
T*
(Implementation of the formula after further development work in the next\
10 months will produce target )Tj
T*
(shares \( based on the latest financial information\) close to the relat\
ive percentage shares anticipated in the )Tj
T*
(Consultation Letter. The NSG expects the formula to be then refined year\
by year. This means that the )Tj
T*
(Welsh Assembly Government will necessarily determine the pace of impleme\
ntation. Although the NSG )Tj
T*
(has recommended implementation in three years \226 and at most 5 years \226\
the Minister will of course take a )Tj
T*
(decision in the first year about the pace of redistribution during that \
year, and will need to take a similar )Tj
T*
(decision in the succeeding years. Whether full implementation can be ach\
ieved after three years, or has to )Tj
T*
(be extended, will of course depend on both modifications of the formula \
as well as the rate of growth of )Tj
T*
(NHS resources in the interim; )Tj
ET
EMC
Q
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(g\) the scope for continued interim action through the Health Inequaliti\
es Fund should be considered by the )Tj
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(Committee as an alternative route for achieving the aim of targeting res\
ources on those in greatest need; )Tj
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(h\) consequentially that the work to develop an indirect approach be put\
on hold for two years until the )Tj
T*
(early promise of the direct model can be fully confirmed. This is not to\
say that the NSG object to research )Tj
T*
(designed to improve existing statistics of the utilisation of health car\
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T*
(compare indirect with direct methods of measuring need; )Tj
ET
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(i\) in preparing for the implementation of the direct model further work\
should be undertaken as soon as )Tj
T*
(possible on the following in particular: )Tj
ET
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/T1_1 1 Tf
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(l)Tj
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(GMS - undertake further formula refinement on GMS to address issues such\
as incorporation of )Tj
T*
(children and pregnant women into the GMS formula, recording of consultat\
ions and home visits, )Tj
T*
(unavoidable costs of rurality, a market forces factor for GP\222s, tempo\
rary residents consultation rate. )Tj
T*
(The level of work to address these issues will be considerable. Any form\
ula must take into account )Tj
T*
(the implementation of the new GP contract. )Tj
ET
EMC
/Lbl <>BDC
BT
/T1_1 1 Tf
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(l)Tj
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( )Tj
ET
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/LBody <>BDC
BT
/T1_0 1 Tf
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(Prescribing - agree an action plan and timetable to bring the GPMD data \
quality up to an )Tj
T*
(acceptable level and /or to investigate alternative sources of data. )Tj
ET
EMC
/Lbl <>BDC
BT
/T1_1 1 Tf
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(l)Tj
/T1_0 1 Tf
( )Tj
ET
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/LBody <>BDC
BT
/T1_0 1 Tf
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(WHS - a review of the use of the Welsh Health Survey for resource alloca\
tion should be completed )Tj
T*
(in 2002 /03 before a new survey is carried out. )Tj
ET
EMC
/Lbl <>BDC
BT
/T1_1 1 Tf
6.88652 0 0 6.88652 35.13403 417.54605 Tm
(l)Tj
/T1_0 1 Tf
( )Tj
ET
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/LBody <>BDC
BT
/T1_0 1 Tf
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(The NSG underlines the need for the allocations for mental health servic\
es, including forensic )Tj
T*
(psychiatry \(which is likely to require a different approach such as top\
-slicing\), to be discussed with )Tj
T*
(the Mental Health Strategy Implementation Team. )Tj
ET
EMC
/Lbl <>BDC
BT
/T1_1 1 Tf
6.88652 0 0 6.88652 35.13403 367.9631 Tm
(l)Tj
/T1_0 1 Tf
( )Tj
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/LBody <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 49.18942 367.9631 Tm
(Urban issues - develop allocations for HIV/AIDS and allowances for costs\
particular to ethnic )Tj
T*
(minorities based on the formula in England, which incorporates cost prem\
iums reflecting )Tj
T*
(additional costs of providing these services. )Tj
ET
EMC
/Lbl <>BDC
BT
/T1_1 1 Tf
6.88652 0 0 6.88652 35.13403 318.38016 Tm
(l)Tj
/T1_0 1 Tf
( )Tj
ET
EMC
/LBody <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 49.18942 318.38016 Tm
(Rural Issues - ongoing work to investigate the evidence for additional c\
osts, including work on )Tj
T*
(GMS rurality. )Tj
ET
EMC
/Lbl <>BDC
BT
/T1_1 1 Tf
6.88652 0 0 6.88652 35.13403 285.32487 Tm
(l)Tj
/T1_0 1 Tf
( )Tj
ET
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/LBody <>BDC
BT
/T1_0 1 Tf
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(Costing - A costing review timetable and action plan to be agreed )Tj
ET
EMC
/Lbl <>BDC
BT
/T1_1 1 Tf
6.88652 0 0 6.88652 35.13403 268.79723 Tm
(l)Tj
/T1_0 1 Tf
( )Tj
ET
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/LBody <>BDC
BT
/T1_0 1 Tf
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(Financial strategy - Integration of the financial information strategy w\
ith the All Wales Information )Tj
T*
(Management and Technology Strategy to be achieved within 2002/03 )Tj
ET
EMC
/Lbl <>BDC
BT
/T1_1 1 Tf
6.88652 0 0 6.88652 35.13403 235.74193 Tm
(l)Tj
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( )Tj
ET
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/T1_0 1 Tf
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(Assess the implications of funding of rare and expensive interventions a\
nd drugs which cannot be )Tj
T*
(adequately identified by formula based allocations. )Tj
ET
EMC
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/T1_0 1 Tf
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(j\) The NSG also propose that a Standing Group be set up to oversee the \
development of the allocation )Tj
T*
(formula and ensure that progress on the outstanding work is made. )Tj
ET
EMC
/P <>BDC
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(7. Professor Michael A Crawford Head of the Institute of Brain Chemistry\
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(1. The Audit Commission commented " An almost universal finding is the l\
ack of meaningful information )Tj
0 -1.2 TD
(with which to plan and manage services . Typically, data is missing or o\
f a poor enough quality to )Tj
T*
(question its usefulness. This is an area that requires urgent attention.\
Problems with financial and clinical )Tj
T*
(information have contributed to the inability to trace money through the\
system and to demonstrate that )Tj
T*
(additional funds have had a measurable impact in terms of improving the \
quality of services and outcomes )Tj
T*
(for patients. We believe that mechanisms need to be put in place to prov\
ide assurance that the sizeable )Tj
T*
(amounts of additional monies that are now being invested in the NHS resu\
lt in tangible improvements to )Tj
T*
(patient services. " )Tj
ET
EMC
/P <>BDC
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(The Audit Commission has indicated that it has held preliminary discussi\
ons with the National Assembly )Tj
T*
(on a potential programme of work. Key areas of work being proposed are :\
)Tj
ET
EMC
/Lbl <>BDC
BT
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(l)Tj
/T1_0 1 Tf
( )Tj
ET
EMC
/LBody <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 49.18942 534.07686 Tm
(Tracking new funds which will seek to provide an independent and transpa\
rent assessment of the )Tj
T*
(impact of new funding. )Tj
ET
EMC
/Lbl <>BDC
BT
/T1_1 1 Tf
6.88652 0 0 6.88652 35.13403 501.02156 Tm
(l)Tj
/T1_0 1 Tf
( )Tj
ET
EMC
/LBody <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 49.18942 501.02156 Tm
(Reviews of data quality which will form part of a broader programme to d\
rive up the data quality )Tj
T*
(in the NHS. )Tj
ET
EMC
/Lbl <>BDC
BT
/T1_1 1 Tf
6.88652 0 0 6.88652 35.13403 467.96626 Tm
(l)Tj
/T1_0 1 Tf
( )Tj
ET
EMC
/LBody <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 49.18942 467.96626 Tm
(Abolition of health authorities which will involve supporting organisati\
ons through structural )Tj
T*
(change. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 416.21899 Tm
(The Audit Commission is also continuing to develop a series of initiativ\
es in response to the NHS Plan in )Tj
T*
(England and include work on local commentaries on NHS Performance and NH\
S Plan Implementation )Tj
T*
(Review which will have relevance in Wales. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 347.94406 Tm
(2. Iechyd Morganng Health Authority supports the recommendation on devel\
oping a comprehensive )Tj
T*
(financial information strategy. The key elements which are around the ne\
ed to identify health care activity )Tj
T*
(to individual GP practice level and to develop and standardise costing o\
f services, require time and )Tj
T*
(financial support. The requirements must be integrated into the All Wale\
s IM&T strategy and the )Tj
T*
(timescales for delivery need to be considered in the light of the fact t\
hat without progress in this area, the )Tj
T*
(detailed refinement required prior to implementation of the new proposed\
formula cannot be undertaken )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(3. The Vale of Glamorgan Community Health Council strongly supports the \
recommendations in respect )Tj
T*
(of improving the quality and consistency of information on expenditure, \
access and outcomes in health )Tj
T*
(care and inequalities and tracking expenditure to the poorest and least \
healthy in rich and poor areas. )Tj
T*
(Concerns were expressed that the resources required in equipment and sta\
ffing to achieve this are, within )Tj
T*
(Trusts, expected to be achieved within their overall budgets and would w\
ant the Assembly to consider a )Tj
T*
(separate budget which is supplementary to existing budgets in secondary \
and primary care. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(4. Conwy and Denbighshire NHS Trust comment that costing systems within \
NHS Wales are poor and )Tj
T*
(under-developed and using average specialty costs within disease groups \
could present significant )Tj
T*
(problems. The same point is also made by North West Wales NHS Trust, Dyf\
ed Powys Health Authority, )Tj
T*
(Specialised Health Services Commission for Wales , Iechyd Morgannwg Heal\
th Authority, and Cardiff )Tj
T*
(and Vale NHS Trust, Bro Taf Health Authority, on costing issues. The hos\
pital and community services )Tj
ET
EMC
Q
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(formula resource distributions are determined by reference to average sp\
ecialty cost costs within disease )Tj
0 -1.2 TD
(groups. Current developments in costing systems in wales are seeking to \
further analyse costs by HRG to )Tj
T*
(support future commissioning needs. This represents a fundamental mis-ma\
tch between the formula basis )Tj
T*
(and the charging basis within North Wales. These must be aligned as part\
of a clear financial strategy )Tj
/T1_1 1 Tf
(. )Tj
ET
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/P <>BDC
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/T1_0 1 Tf
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(5. North Glamorgan NHS Trust commented that the resource mapping methodo\
logy needs to ensure that )Tj
T*
(alternative sources of data are used to validate the index and outcome s\
ince the needs index, on which the )Tj
T*
(LHG shares derive, takes as its starting point the Welsh Health Survey l\
inked in with specialty / DRG )Tj
T*
(spending information from summarised Trust Financial Returns. )Tj
ET
EMC
/P <>BDC
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/T1_0 1 Tf
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(6. The Vale of Glamorgan Community Health Council also comment that the \
overall increase in local )Tj
T*
(authority expenditure is 1% per annum \( average \) and for servicse to \
the elderly 2% per annum average. )Tj
T*
(A substantial component of health expenditure relates to elderly people \
and they have serious doubts )Tj
T*
(about local authorities ability to play a full part in strengthening com\
munity services and promoting health )Tj
T*
(without additional funding. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 483.65663 Tm
(7. Clwyd Community Health Council commented that : )Tj
ET
EMC
/Lbl <>BDC
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(l)Tj
/T1_0 1 Tf
( )Tj
ET
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/LBody <>BDC
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/T1_0 1 Tf
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(the increase in community expenditure in North Wales Health Authority ov\
er the period 1998/99 to )Tj
T*
(1999/2000 is almost 35% and that a similar increase occurred also for Br\
o Taf Health Authority but )Tj
T*
(not for the other three health authorities but that there does not appea\
r to have been any change to )Tj
T*
(the formula for identifying expenditure in this area during the period. \
)Tj
ET
EMC
/Lbl <>BDC
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/T1_2 1 Tf
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(l)Tj
/T1_0 1 Tf
( )Tj
ET
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/LBody <>BDC
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/T1_0 1 Tf
13.77304 0 0 13.77304 49.18942 363.63443 Tm
(there does not appear to be any reason for the change in the expenditure\
figures for North Wales )Tj
T*
(Health Authority between 1998/99 and 1999/2000. )Tj
ET
EMC
/Lbl <>BDC
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/T1_2 1 Tf
6.88652 0 0 6.88652 35.13403 311.88716 Tm
(l)Tj
/T1_0 1 Tf
( )Tj
ET
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/LBody <>BDC
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/T1_0 1 Tf
13.77304 0 0 13.77304 49.18942 311.88716 Tm
(There is a clear need to ensure that a reconciliation is audited between\
the annual accounts and new )Tj
T*
(costing formula. )Tj
ET
EMC
/P <>BDC
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/T1_1 1 Tf
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(Annex B \( 4 \) )Tj
ET
EMC
/P <>BDC
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/T1_1 1 Tf
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(Consultation Response )Tj
ET
EMC
/P <>BDC
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/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 189.70062 Tm
(Chapter 4 : Limits of analysis and action )Tj
ET
EMC
/P <>BDC
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/T1_0 1 Tf
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(1. Clwyd Community Health Council commented that in relation resource ma\
pping there is a need to )Tj
T*
(ensure that LHG\222s / LHB\222s are adequately funded and a transparent \
formula used for resourcing )Tj
ET
EMC
/P <>BDC
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/T1_0 1 Tf
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(2. North Glamorgan NHS Trust commented that the resource mapping methodo\
logy needs to ensure that )Tj
T*
(alternative sources of data are used to validate the index and outcome s\
ince the needs index, on which the )Tj
T*
(LHG shares derive, takes as its starting point the Welsh Health Survey l\
inked in with specialty / DRG )Tj
T*
(spending information from summarised Trust Financial Returns. )Tj
ET
EMC
Q
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(Annex B \( 5.1 \) )Tj
ET
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/P <>BDC
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/T1_0 1 Tf
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(Chapter 5: A new model of allocating resources by area to health care se\
rvices )Tj
ET
EMC
/P <>BDC
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(Consultation Responses relating to the use of the Welsh Health Survey fo\
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(purposes )Tj
ET
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(In relation to responses relating to the use of the Welsh Health Survey \
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T*
(number of common themes were apparent : )Tj
ET
EMC
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(l)Tj
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( )Tj
ET
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/LBody <>BDC
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13.77304 0 0 13.77304 49.18942 575.00246 Tm
(Concerns over the sample size of the survey )Tj
ET
EMC
/Lbl <>BDC
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/T1_2 1 Tf
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(l)Tj
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( )Tj
ET
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/LBody <>BDC
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/T1_1 1 Tf
13.77304 0 0 13.77304 49.18942 558.47481 Tm
(Concerns over self- reporting )Tj
ET
EMC
/Lbl <>BDC
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/T1_2 1 Tf
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(l)Tj
/T1_1 1 Tf
( )Tj
ET
EMC
/LBody <>BDC
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/T1_1 1 Tf
13.77304 0 0 13.77304 49.18942 541.94716 Tm
(Concerns over under- reporting and response rates )Tj
ET
EMC
/Lbl <>BDC
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/T1_2 1 Tf
6.88652 0 0 6.88652 35.13403 525.41951 Tm
(l)Tj
/T1_1 1 Tf
( )Tj
ET
EMC
/LBody <>BDC
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/T1_1 1 Tf
13.77304 0 0 13.77304 49.18942 525.41951 Tm
(Concerns over the ability to measure the health needs of the elderly )Tj
ET
EMC
/Lbl <>BDC
BT
/T1_2 1 Tf
6.88652 0 0 6.88652 35.13403 508.89186 Tm
(l)Tj
/T1_1 1 Tf
( )Tj
ET
EMC
/LBody <>BDC
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/T1_1 1 Tf
13.77304 0 0 13.77304 49.18942 508.89186 Tm
(Concerns whether the health indicators are a broad enough measure of rel\
ative health need )Tj
ET
EMC
/P <>BDC
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/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 473.67224 Tm
(Concerns over the sample size of the survey )Tj
ET
EMC
/P <>BDC
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/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 438.45261 Tm
(Bro Taf Health Authority, Bro Taf Health Authority Directorate of Public\
Health Policy, Ian Lucas MP, )Tj
T*
(North East Wales NHS Trust and North West NHS Trust raised comments on t\
he sample size. For )Tj
T*
(example : )Tj
ET
EMC
/P <>BDC
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/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 370.17769 Tm
(1. The sample size for each unitary authority was small. The survey repr\
esented little over 1% of the adult )Tj
T*
(population of Wales. )Tj
ET
EMC
/P <>BDC
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/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 318.4304 Tm
(2. Reassurance is sought that the sample on which the statistics are bas\
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ET
EMC
/P <>BDC
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/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 283.21078 Tm
(3. Support the funding of a new WHS, possibly over a larger sample size \
to be the basis of any new )Tj
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(formula )Tj
ET
EMC
/P <>BDC
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/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 231.4635 Tm
(Concerns over self reporting and Perceived Need )Tj
ET
EMC
/P <>BDC
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/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 196.24388 Tm
(Concerns over self reporting and perceived need were raised by Lynne Nea\
gle AM, The Welsh NHS )Tj
T*
(Confederation , North Wales Health Authority, Iechyd Morgannwg Health Au\
thority, Bro Taf Health )Tj
T*
(Authority Directorate of Public Health and Policy, and Bro Taf Health Au\
thority. For example : )Tj
ET
EMC
/P <>BDC
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/T1_1 1 Tf
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(1. The WHS as a self reporting survey will not prove to be a robust and \
adequate measurement of health )Tj
T*
(need )Tj
ET
EMC
/P <>BDC
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/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 76.22168 Tm
(2. Self reported health status data can contain an intrinsic risk of unr\
eliability. The dangers are the varying )Tj
T*
(ability within the population to complete the questionnaire, an individu\
al\222s perception of illness whilst a )Tj
T*
(factor for demand is a less robust basis for measurement in relation to \
secondary and specialists services )Tj
ET
EMC
Q
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(where actual demand is filtered through clinical assessment. )Tj
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(3. The inherent risk of self reported health status would not appear to \
have been appropriately recognised. )Tj
0 -1.2 TD
(Such risks include the varying ability within the population to complete\
the questionnaire, particularly )Tj
T*
(those in vulnerable groups such as the elderly, those with a poor standa\
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T*
(ethnic minorities etc. The survey must be robust in relation to these gr\
oups if it is to represent health need )Tj
T*
(in a comprehensive manner. Additionally, the survey should be free from \
any potential bias caused by, for )Tj
T*
(example, differentials in the proportion of respondents claiming non mea\
ns tested ill health related )Tj
T*
(benefits where responses may be influenced by prevailing social security\
incentive structures and the lack )Tj
T*
(of employment opportunities )Tj
ET
EMC
/P <>BDC
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/T1_0 1 Tf
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(4. Self reporting relies on the individual\222s perception of illness wh\
ich whilst being a major factor for )Tj
T*
(demand in primary care is less robust in relation to secondary and speci\
alist services where actual demand )Tj
T*
(is filtered through clinical assessment. )Tj
ET
EMC
/P <>BDC
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/T1_0 1 Tf
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(5. Perceived health need may be a reasonable measure of need for general\
medical services which )Tj
T*
(represent only 2% of finances allocated by formula. The measure is inapp\
ropriate for secondary care, )Tj
T*
(which consumes the larger part of the NHS budget )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 431.90936 Tm
(Concerns over under- reporting and response rates )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 396.68973 Tm
(Huw Lewis AM, Lynne Neagle AM, Bro Taf Health Authority and Bro Taf Heal\
th Authority Directorate )Tj
T*
(of Public Health and Policy, Iechyd Morgannwg Health Authority and Dyfed\
Powys Health Authority )Tj
T*
(comment on under- reporting and response rates. For example : )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 328.41481 Tm
(1. There is a clear concern that under- reporting from key sections of t\
he community and particular areas )Tj
T*
(of Wales will lead to a distorted picture on the level of need. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 276.66753 Tm
(2. Serious mental illness is likely to be under- reported. Reporting of \
back pain and rheumatism are )Tj
T*
(subjective and unlikely to relate to treatment costs. Similarly with var\
icose veins surgery no longer offered )Tj
T*
(except in sever cases. Having less than 20 teeth is a fairly good marker\
for general poor health in children )Tj
T*
(but it is of less value in older people. Ethnic minorities may also have\
difficulty in assessing health need. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 191.86496 Tm
(3. Health service utilisation does not depend entirely on disease or sev\
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T*
(socio - economic circumstances )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 140.11769 Tm
(4. The surveys of 1995 and 1996 both had a response rate of around 60% a\
nd this may present a biased )Tj
T*
(picture . A follow up of non responders reported that 9% had been too il\
l or disabled to respond. It is )Tj
T*
(asserted by the research team that under representation of black and eth\
nic minorities those with low level )Tj
T*
(of literacy , the sick , the elderly, young single and those disabled is\
" not so problematic when comparing )Tj
T*
(areas ". This is not supported by the evidence. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 38.78748 Tm
(5. The 1998 WHS survey used suggests higher response amongst deprived ar\
eas. There is a need to )Tj
ET
EMC
Q
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(demonstrate that the amount of reallocation of resources is reasonable g\
iven the needs across all areas and )Tj
0 -1.2 TD
(that the particular answer on one year is repeatable. Further work is re\
quired to validate the results of one )Tj
T*
(years survey. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 684.99001 Tm
(6. Independently review the effectiveness and validity of using WHS as a\
proxy for actual health need as )Tj
T*
(the WHS is self completed and is therefore a measure of perceived need r\
ather than actual need )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 633.24274 Tm
(Concerns over the ability to measure the health needs of the elderly )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 598.0231 Tm
(1. North Wales Health Authority\222s view is that the WHS is not sophist\
icated enough to measure the )Tj
T*
(general health needs of an increasingly elderly population . There is mu\
ch research evidence that the use )Tj
T*
(of health services by the elderly in society is significantly greater th\
an other elements of the population. )Tj
T*
(Without such demand being reflected in the survey results areas such as \
North Wales will be unfairly )Tj
T*
(disadvantaged. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(2. North East Wales NHS Trust comments that the formula does not appear \
to give an appropriate )Tj
T*
(weighting to the higher cost of treating the elderly nor are the specifi\
c conditions of the elderly included in )Tj
T*
(the health measures )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 428.41797 Tm
(3. North West Wales NHS Trust commented that there is evidence quoted in\
the report that the 1991 )Tj
T*
(census probably under estimated the prevalence of limiting long term ill\
ness particularly amongst the )Tj
T*
(elderly. There was a poorer response to the WHS survey by the elderly, a\
nd therefore the formula might )Tj
T*
(well under estimate the prevalence of need among the elderly - which cou\
ld disadvantage areas with a )Tj
T*
(higher proportion of +75 population )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 327.08775 Tm
(4. Conway and Denbighshire NHS Trust also comment that there is a need t\
o adddress the health needs of )Tj
T*
(the elderly )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 275.34047 Tm
(Concerns whether the health indicators are a broad enough measure of rel\
ative health need )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 240.12085 Tm
(North East Wales NHS Trust , Welsh NHS Confederation, Bro Taf Health Aut\
hority, North Wales Health )Tj
T*
(Authority, Iechyd Morgannwg Health Authority, the Welsh NHS Confederatio\
n comment on the health )Tj
T*
(indicators. For example: )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 171.84592 Tm
(1. There are concerns as to whether the limited number of health indicat\
ors covered by the WHS give a )Tj
T*
(broad enough measure of relative health need to form the basis of resour\
ce allocation. Within each )Tj
T*
(condition area e.g. heart disease, the range of questions asked give a s\
implistic analysis of the spectrum of )Tj
T*
(health need . )Tj
ET
EMC
/P <>BDC
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(2. The subjective definition of ill health, as defined by the WHS, does \
not appear to us to be an adequate )Tj
T*
(or accurate direct measure of health care need. The excellent work in Sc\
otland on the Scottish \221Fair )Tj
T*
(Shares\222 formula would seem highly relevant to Wales, and we recommend\
that work on this is not )Tj
T*
(abandoned. )Tj
ET
EMC
Q
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(3. The assumption is all respondents have an average severity of health \
condition )Tj
ET
EMC
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BT
/T1_1 1 Tf
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(Other comments and issues raised )Tj
ET
EMC
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BT
/T1_0 1 Tf
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(1. Specialised Health Services Commission for Wales comment that the val\
idity of the WHS as a )Tj
0 -1.2 TD
(morbidity indicator is unproven in comparison with the obvious first cho\
ice of using the census morbidity )Tj
T*
(indicator. The inadequate reliability of sampled data is a further probl\
em with the WHS because of the )Tj
T*
(volatile allocations which will result. Some of the other sources of dat\
a used to derive morbidity indicators )Tj
T*
(also suffer from similar concerns. A radical change should not be made t\
wo years before the new )Tj
T*
(expanded census morbidity data will require us to reconsider. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(2. Both North West Wales NHS Trust and North East Wales NHS Trust commen\
t that the similarity of )Tj
T*
(results for LLTI in the 1998 WHS and the 1991 census does not prove the \
robustness of the data since the )Tj
T*
(results are more a function of size of the authority )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 476.67386 Tm
(3. Bro Taf Health Authority, Directorate of Public Health and Policy, co\
mments that the use of )Tj
T*
(Cronbach\222s Co-efficient Alpha and KR-20 are not appropriate in the co\
ntext in which they have been )Tj
T*
(used. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(4. Specialised Health Services Commission for Wales comment that no cons\
ideration has been given to )Tj
T*
(averaging the two WHS surveys. Specialised Health Services Commission fo\
r Wales also comment that )Tj
T*
(the instability of the WHS measures is indicated by comparison between 1\
995 and 1998 WHS SF 36 )Tj
T*
(measure \( correlation 0.86 \). Not good enough for resource allocation.\
)Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 323.59636 Tm
(5. Dyfed Powys Health Authority comment that the effectiveness and valid\
ity of using the WHS as a )Tj
T*
(proxy for actual health need as the WHS is self completed and is therefo\
re a measure of perceived need )Tj
T*
(rather than actual need. This would appear to be valid as a proxy for ac\
tual need for GP and A & E )Tj
T*
(services but less so for hospital and community health services. GP and \
A & E services act as filters of )Tj
T*
(perceived need with only a proportion actually requiring to utilise hosp\
ital and / or community health )Tj
T*
(services. )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
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(Annex B \( 5.2 \) )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
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(Chapter 5: A new model of allocating resources by area to health care se\
rvices )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
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(Consultation Responses Relating to the Elements of the Hospital and Comm\
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ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(Comments and issues relating to the Elements of the Hospital and Communi\
ty Services formula can be )Tj
T*
(grouped as follows: )Tj
ET
EMC
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(Expenditure blocks )Tj
ET
EMC
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( )Tj
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(Costing issues )Tj
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EMC
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(l)Tj
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( )Tj
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EMC
/LBody <>BDC
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(Application at LHG level )Tj
ET
EMC
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BT
/T1_0 1 Tf
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(l)Tj
/T1_1 1 Tf
( )Tj
ET
EMC
/LBody <>BDC
BT
/T1_1 1 Tf
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(Formula Updating )Tj
ET
EMC
/P <>BDC
BT
/T1_2 1 Tf
13.77304 0 0 13.77304 9.83789 686.31706 Tm
(Expenditure blocks )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 651.09744 Tm
(North Wales Health Authority, Iechyd Morgannwg Health Authority )Tj
/T1_2 1 Tf
(, )Tj
/T1_1 1 Tf
(North West Wales NHS Trust, and )Tj
0 -1.2 TD
(North East Wales NHS Trust commented on expenditure blocks. For example,\
: )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 599.35016 Tm
(1. A more detailed review of the expenditure blocks in the hospital inpa\
tient formula and the )Tj
T*
(appropriateness of the indicators is required. The incidence of health d\
isease/cancer are reasonable )Tj
T*
(measures to identify need for inpatient facilities but that it is not cl\
ear what is included in the following )Tj
T*
(expenditure block. )Tj
ET
EMC
/P <>BDC
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16.72441 506.64874 m
65.7988 506.64874 l
S
BT
/T1_1 1 Tf
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(Indicator )Tj
ET
EMC
/P <>BDC
235.88437 506.64874 m
334.75784 506.64874 l
S
BT
/T1_1 1 Tf
12.71358 0 0 12.71358 235.88437 508.57103 Tm
(Expenditure Block )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
12.71358 0 0 12.71358 16.72441 479.5417 Tm
(Arthritis )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
12.71358 0 0 12.71358 235.88437 479.5417 Tm
(\24320m )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
12.71358 0 0 12.71358 16.72441 450.51237 Tm
(Diabetes )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
12.71358 0 0 12.71358 235.88437 450.51237 Tm
(\243 7m )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
12.71358 0 0 12.71358 16.72441 421.48305 Tm
(Back Pain )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
12.71358 0 0 12.71358 235.88437 421.48305 Tm
(\243 7m )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
12.71358 0 0 12.71358 16.72441 392.45372 Tm
(Varicose Veins )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
12.71358 0 0 12.71358 235.88437 392.45372 Tm
(\243 3m )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
12.71358 0 0 12.71358 16.72441 363.42439 Tm
(<20 teeth )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
12.71358 0 0 12.71358 235.88437 363.42439 Tm
(\243 5m )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
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(but these do not appear to be good indicators of the need for a general \
in-patient service formula. )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 286.46001 Tm
(2. The full logic behind the outpatient, district nurse & chiropody form\
ula is difficult to support. For )Tj
T*
(example, as 42% of those with heart disease reported they had attended o\
utpatients \(although it is not clear )Tj
T*
(if it is for that condition\) this is used to determine need across Wale\
s. As across Wales 23% of those with )Tj
T*
(less than 20 teeth also saw a chiropodist, therefore of the 185 people f\
rom Ynys M\364n with less than 20 )Tj
T*
(teeth, 42.5 were estimated to "need" chiropody \226 with no regard to th\
e prevalence of foot problems. )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 185.12979 Tm
(3. The use of the formula to allocate community nursing costs is not sup\
ported. A high percentage of the )Tj
T*
(District Nursing caseload relates to the elderly. Social/economic needs \
are also a factor. A weighted )Tj
T*
(population capitation formula with a social/economic need measure would \
be more appropriate for these )Tj
T*
(costs )Tj
/T1_2 1 Tf
(. )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 100.32722 Tm
(4. The formula for accidents/A&E services does not reflect the current f\
unding arrangements. A&E )Tj
T*
(services are "outside the market" and the Health Authority is responsibl\
e to fund services to meet the )Tj
T*
(needs of all accidents in the catchment area, \(rather than the need for\
A&E services for its population, )Tj
T*
(wherever the accident occurs\). This formula will not provide the fundin\
g for an A&E department in a )Tj
ET
EMC
Q
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(tourist area. North West Wales have 7% of A&E attendance but would only \
get 6% of funding \(using )Tj
0 -1.2 TD
(Ynys M\364n and Gwynedd Local Health Groups as proxy\). )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(5. The use of A&E in the previous three months to the survey also does n\
ot capture the seasonal impact. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 667.62509 Tm
(6. The splitting of the allocation into 8 categories before allocation w\
ould appear to be driven by data )Tj
T*
(availability rather than robust analysis of the key components of the he\
althcare system e.g. the )Tj
T*
(identification of the chiropody as an expenditure category )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 599.35016 Tm
(Costing issues )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 564.13054 Tm
(North West Wales NHS Trust, Dyfed Powys Health Authority, Specialised He\
alth Services Commission )Tj
T*
(for Wales , Iechyd Morgannwg Health Authority, and Cardiff and Vale NHS \
Trust, Bro Taf Health )Tj
T*
(Authority, commented on costing issues. For example: )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 495.85561 Tm
(1. The hospital and community services formula resource distributions ar\
e determined by reference to )Tj
T*
(average specialty cost costs within disease groups. Current developments\
in costing systems in wales are )Tj
T*
(seeking to further analyse costs by HRG to support future commissioning \
needs. This represents a )Tj
T*
(fundamental mis-match between the formula basis and the charging basis w\
ithin North Wales. These must )Tj
T*
(be aligned as part of a clear financial strategy )Tj
/T1_1 1 Tf
(. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 394.52539 Tm
(2. The Welsh Trust returns do not account for substantial expenditure in\
England , particularly for )Tj
T*
(specialised services. As a result the allocation between programme headi\
ngs may be biased \226 the share on )Tj
T*
(mental health does not include forensic expenditure in England. A reconc\
iliation of health authority )Tj
T*
(expenditure is required against trust expenditure to identify any furthe\
r anomolies. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 309.72282 Tm
(3. There is a need to go beyond Welsh Trust TFR2 returns in order to inc\
orporate the considerable )Tj
T*
(expenditure on services in England. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 257.97556 Tm
(4. The draft formula is calculated on the 1998/99 Trust speciality costi\
ng return \(TFR2\), with cost )Tj
T*
(analysed by DRG. There have been various all Wales professional groups l\
ooking at improving the )Tj
T*
(finance costing data, and more up to date returns will reflect in initia\
l outcomes of this work. From )Tj
T*
(2000/01 costing is provided by HRG \(not DRG\). Given the significant in\
vestment in health in the last 2 )Tj
T*
(years, it is important that more up to date data is used \226 although t\
he full effect of the 2001/02 investment )Tj
T*
(will not be evident until the 2002/03 returns \(likely to be available i\
n September 2003\). )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 140.11769 Tm
(5. It is vital to appropriately cost services. This will involve identif\
ying costs as a minimum to the HRG )Tj
T*
(levels. It is felt amongst clinicians that even this will not properly a\
ttribute the full costs to growing flows )Tj
T*
(of tertiary referrals as part of the growing clinical network. This has \
to be overcome, but in the meantime )Tj
T*
(as with all Trusts, significantly increased resources are required to es\
tablish appropriate costing systems )Tj
T*
(which has the full involvement of clinicians. These resources do not exi\
st as was evident )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 38.78748 Tm
(Application at LHG Level )Tj
ET
EMC
Q
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/T1_0 1 Tf
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(1. Iechyd Morgannwg Health Authority and The Welsh NHS Confederation com\
ment that the application )Tj
0 -1.2 TD
(of the WHS at an LHG level presents risks in relation to stability of th\
e formula over time. Iechyd )Tj
T*
(Morgannwg Health Authority comments further that evidence will be requir\
ed regarding stability or )Tj
T*
(alternatively dampening measures will have to be introduced to moderate \
data changes. It should be )Tj
T*
(recognised that a shift of less than 1% in the all Wales position in cer\
tain indicators could be dramatically )Tj
T*
(magnified at local level due to the small population bases of LHG\222s. \
)Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 616.71509 Tm
(2. The proposed new formulae is intended to operate at LHG level and the\
likely disparity between current )Tj
T*
(funding and those proposed by the new formulae is likely to be relativel\
y greater at LHG level than HA )Tj
T*
(level. )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 548.44017 Tm
(Formula Updating )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 513.22054 Tm
(Pembrokeshire and Derwen NHS Trust , Conwy and Denbighshire NHS Trust, )Tj
T*
(And Specialised Health Services Commission for Wales have commented. For\
example, )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 461.47327 Tm
(1. The cost components need to be updated more regularly than in the pas\
t but it is unclear what the )Tj
T*
(update cycle will be or whether there is the capability to manage it and\
that there needs to be a clear )Tj
T*
(description of how annual population changes will be included in the for\
mula calculation )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 393.19833 Tm
(2. Clarity is required in the formula calculations )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 357.97871 Tm
(3. Population aspects of the formula require updating to take into accou\
nt the 2001 census data. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 322.75908 Tm
(4. Changes in the formula variables will need a smoothing mechanism to e\
nsure that yearly chance )Tj
T*
(fluctuations are moderated )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 271.01181 Tm
(Other issues )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 235.79218 Tm
(1. Specialised Health Services Commission for Wales commented that formu\
la does not include any socio )Tj
T*
(- economic factors. There is a presumption that they do not influence ac\
cess to health care or health )Tj
T*
(conditions )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 167.51726 Tm
(2. Bro Taf Health Authority comment on the HCFHS tables and the difficul\
ty they have in responding )Tj
T*
(since the tables are incomplete and could be subject to change , the con\
trol total is incorrect and the tables )Tj
T*
(should have included a comparison with the current formula at Local Heal\
th Group level. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 99.24232 Tm
(3. Cardiff and Vale NHS Trust comments that the formula focuses on the h\
ealth needs of the population. )Tj
T*
(There is however, a supply cost factor which is referred to in the Engli\
sh formula. This is evident in the )Tj
T*
(Trust where the land values are significantly higher which in turn feeds\
into the costs that will be unfairly )Tj
T*
(borne by the Cardiff and Vale Local Health Boards. In addition there is \
evidence that the costs of )Tj
ET
EMC
Q
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(recruiting and retaining staff are higher in the city environment with t\
he significant greater job )Tj
0 -1.2 TD
(opportunities offered to people living in and around the capital. For ex\
ample cost of temporary nursing )Tj
T*
(staff \( in Cardiff \) is approximately \24313m for 2001/02 which is sig\
nificantly higher than elsewhere in )Tj
T*
(Wales. )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 669.78941 Tm
(Annex B \( 5.3 \) )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 634.56979 Tm
(Chapter 5: A new model of allocating resources by area to health care se\
rvices )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 599.35016 Tm
(Consultation Responses Relating to the Rural Needs Adjustment )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 564.13054 Tm
(Dyfed Powys Health Authority, North West Wales NHS Trust, Montgomery Com\
munity Health Council, )Tj
T*
(Pembroke and Derwen NHS Trust, Carmarthen Community Health Council, Nort\
h Wales Health )Tj
T*
(Authority, Lynne Neagle commented on rurality. For example: )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 495.85561 Tm
(1. An explanation is required on why rurality costs have only been appli\
ed to 7.5% of expenditure which )Tj
T*
(corresponds to the travel element of community health services. There ar\
e rural costs evident in other )Tj
T*
(services and impacts on costs on a far wider scale in secondary care )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 427.58069 Tm
(2. Is there supporting evidence, such as the differences in the number o\
f visits per whole time equivalent )Tj
T*
(between rural and urban areas, to support Task Group Cs proposals )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 375.8334 Tm
(3. An explanation and rationale is required to explain why rural cost ad\
justments have been applied only )Tj
T*
(to travel intensive elements of community health services. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 324.08614 Tm
(4. The level and composition of the rurality factor be urgently consider\
ed, so as to avoid worsening the )Tj
T*
(access to services for Dyfed Powys residents. Any adjustment for additio\
nal costs must be evidence based. )Tj
T*
(Adjustments could be made for excess costs in rural areas that are not v\
alid or based on clear research and )Tj
T*
(evidence. If they are not evidence based and additional costs clearly pr\
oven then the new formula will not )Tj
T*
(be able to have the confidence of the service or the patients )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 222.75592 Tm
(5. The Scottish model should not be dismissed when Wales is more rural w\
ith smaller urban conurbations )Tj
T*
(than Scotland )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 171.00864 Tm
(6. An explanation for and rationale why the dismissal of the Scottish ev\
idence in relations to rural cost )Tj
T*
(premiums for both hospital services and GMS services. It is accepted tha\
t the level of premium may be )Tj
T*
(different but there will surely be a level to be established. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 102.73372 Tm
(7. An explanation for and rationale behind the removal of the ambulance \
service weighting is required )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 67.5141 Tm
(8. In rural areas there are a higher percentage of self employed people \
which would be considered low )Tj
T*
(paid but because they are self employed they are not reflected in social\
deprivation figures. A rural )Tj
ET
EMC
Q
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(deprivation should be explored )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 719.37236 Tm
(9. No explanation is given on why the figures in Table 1 page 72 of the \
Townsend Report are different to )Tj
0 -1.2 TD
(those appearing in table 1 of the consultation letter )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 667.62509 Tm
(10. It should be a clear principle that any adjustments that are made fo\
r additional costs be evidenced and )Tj
T*
(research based. )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 615.87781 Tm
(Annex B \( 5.4 \) )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 580.65817 Tm
(Chapter 5: A new model of allocating resources by area to health care se\
rvices )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 545.43855 Tm
(Consultation Responses Relating to Urban Issues )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 510.21892 Tm
(Bro Taf Health Authority, Cardiff and Vale NHS Trust and BroTaf Health A\
uthority Directorate of Public )Tj
T*
(Health and Policy commented on urban issues. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 458.47165 Tm
(1. There is a need to complete and publish work on urban issues )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 423.25201 Tm
(2. Urban issues work to cover the areas such as asylum seekers, ethnic m\
inority groups , prisoners, )Tj
T*
(children with complex and high cost medical conditions, student populati\
ons , HIV, mental health )Tj
T*
(problems and those with generic disorders, market forces for GMS , respo\
nsibilities for emergency )Tj
T*
(planning and outbreak control. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 338.44945 Tm
(3. There is a need to monitor ethnic minority utilisation )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 303.22981 Tm
(4. There is substantial evidence which has yet to be evaluated and inclu\
ded within the formula. This work )Tj
T*
(needs to be carried out as soon as possible and certainly before the for\
mula is implemented. There are )Tj
T*
(clear examples of urban life and in particular the high demands placed o\
n health in the capital city by the )Tj
T*
(significant number of homeless, ethnic minorities and travellers. )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 218.42725 Tm
(Annex B \( 5.5 \) )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 183.20763 Tm
(Chapter 5: A new model of allocating resources by area to health care se\
rvices )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 147.98799 Tm
(Consultation Responses Relating to the GMS formula )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 112.76837 Tm
(North Glamorgan NHS Trust, Dyfed Powys Health Authority, Iechyd Morgannw\
g Health Authority )Tj
/T1_1 1 Tf
(, )Tj
/T1_0 1 Tf
T*
(Gwent Health Authority and Bro Taf Health Authority commented on GMS. Fo\
r example: )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 61.02109 Tm
(1. Clarification is sought on whether the intention is that non -cash li\
mited services over time would )Tj
T*
(become cash limited. Implementing such an approach would not be possible\
without reforming the )Tj
ET
EMC
Q
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(remuneration structure for GP\222s . What are the implications and risks\
associated with applying the GMS )Tj
0 -1.2 TD
(allocation formula to both cash limited and non cash limited resources. \
)Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 702.84471 Tm
(2. There needs to be clarity about what is proposed for implementation i\
n 2003 given that the work being )Tj
T*
(undertaken in England needs to be considered before deciding on a way fo\
rward. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 651.09744 Tm
(3. The removal of the current cash limit on primary care infrastructure \
costs would remove financial )Tj
T*
(control at local and national level. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 599.35016 Tm
(4. No account has been taken of nurse activity e.g smears , vaccinations\
, and health promotion activities )Tj
T*
(and rurality which impacts on branch surgeries and on-call arrangements \
)Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 547.60289 Tm
(5. Clarification is required on the impact of cash limiting demand led s\
ervices particularly how this is )Tj
T*
(linked with the GMS Red Book Statements of Fees and Allowances )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 495.85561 Tm
(Annex B \( 5.6 \) )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 460.63599 Tm
(Chapter 5: A new model of allocating resources by area to health care se\
rvices )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 425.41635 Tm
(Consultation Responses relating to the Prescribing Formula )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 390.19673 Tm
(1. Task Group E forwarded the following detailed response : )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 354.9771 Tm
(Principle )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 319.75746 Tm
(There is a strong agreement from the Group that the principle of using a\
needs based formula to allocate )Tj
T*
(resources is sound and is therefore the legitimate aim of the current ex\
ercise. The discussion therefore is )Tj
T*
(whether the method proposed by the research team is appropriate. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 251.48254 Tm
(There is a more interesting discussion about how medicines reduce the he\
alth divide. The prescription of )Tj
T*
(many symptomatic remedies \(a substantial part of the expenditure on med\
icines\) increases in line with )Tj
T*
(deprivation and it is possible that some medicines maintain or reinforce\
the divide. Access to medicines is )Tj
T*
(rarely if ever cited as a major determinant of better health and it is q\
uestionable whether redistributing )Tj
T*
(prescribing resources will have the desired effect. )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 150.15233 Tm
(Project Brief )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 114.93269 Tm
(It is the Group\222s view that many of the current distortions in the us\
e of resources are between therapeutic )Tj
T*
(areas. For example, ulcer healing drugs have become the largest area of \
expenditure over recent years. )Tj
T*
(Their usage outstrips identifiable pathology. On the other hand, expendi\
ture on some areas of )Tj
T*
(cardiovascular medicine is lower than would be needed to prevent or trea\
t disease. However, the )Tj
T*
(researchers have interpreted the project brief as having to maintain the\
current level of relative expenditure )Tj
ET
EMC
Q
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(in each programme area and therefore each British National Formulary the\
rapeutic group. That restriction )Tj
0 -1.2 TD
(appears to have reduced the validity of the exercise. )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 702.84471 Tm
(Determination of Need )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 667.62509 Tm
(The issue of whether the Welsh Health Survey is a robust measure of heal\
th need underpins the whole of )Tj
T*
(the resource allocation exercise and was referred to in the groups earli\
er correspondence \(letter from )Tj
T*
(Eifion Williams, 26 June 2001\). It is not the role of our group nor thi\
s letter to develop the issues involved )Tj
T*
(other than those which are particular to prescribing. They are:- )Tj
ET
EMC
/Lbl <>BDC
BT
/T1_2 1 Tf
6.88652 0 0 6.88652 35.13403 582.82251 Tm
(l)Tj
/T1_0 1 Tf
( )Tj
ET
EMC
/LBody <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 49.18942 582.82251 Tm
(exclusion of the young and old. WHS excluded children. However, young ch\
ildren and especially )Tj
T*
(infants receive disproportionately large numbers of prescriptions. It ca\
nnot be assumed that their )Tj
T*
(patterns of need can be extrapolated from adult data. Therefore, if WHS \
is to be used to measure )Tj
T*
(prescribing needs, a separate exercise to capture children\222s data mus\
t be commissioned. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 49.18942 498.01994 Tm
(Similarly, the elderly receive disproportionately high rates of prescrib\
ed medicines. This is )Tj
T*
(especially true of patients in nursing homes who are likely to be too in\
firm to complete surveys. )Tj
T*
(Has this part of the population been adequately reflected in WHS or is a\
dditional work needed? )Tj
ET
EMC
/Lbl <>BDC
BT
/T1_2 1 Tf
6.88652 0 0 6.88652 35.13403 429.74503 Tm
(l)Tj
/T1_0 1 Tf
( )Tj
ET
EMC
/LBody <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 49.18942 429.74503 Tm
(recognition of rare/resource intensive needs. A small number of patients\
have a requirement for )Tj
T*
(expensive therapy. A part of the available resource will need to be ring\
fenced to reflect this group. )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
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(Costing the Prescribing appropriate to need )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 342.77812 Tm
(The proposed model uses the GP Morbidity Database to determine the appro\
priate prescribing cost for a )Tj
T*
(given need. However there is no evidence to suggest that this is a robus\
t method. In fact, attempts at )Tj
T*
(correlating actual prescribing data of GPMD practices with prescribing e\
ntered into GPMD suggest that it )Tj
T*
(is extremely unreliable. For many practices, the two sets of data appear\
to be unrelated. Therefore, it is not )Tj
T*
(possible to use GPMD for this purpose. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(Discussions on the 20 November focussed on what alternative could be use\
d. To the Group\222s knowledge, )Tj
T*
(there is no currently available alternative. Instead, there would be log\
ic in evolving a benchmarking model )Tj
T*
(as suggested by the Task and Finish Group on Prescribing whose report ha\
s already been approved by the )Tj
T*
(Health and Social Services Committee. )Tj
ET
EMC
/P <>BDC
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/T1_1 1 Tf
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(Implementation )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(The report\222s authors suggest that prescribing should not be cash limi\
ted. The Group did not support this )Tj
T*
(view. In fact, there may be good reason to suggest that such an approach\
will cause money to move )Tj
T*
(towards prescribing as opposed to areas where there are cash limits. Tha\
t would be a distortion of resource )Tj
T*
(usage. )Tj
ET
EMC
Q
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(The Group\222s discussion highlighted the need to carefully work through\
how any changes in funding )Tj
0 -1.2 TD
(between areas would be implemented at LHG and practice level. If they me\
an moving money between )Tj
T*
(areas, that would require detailed work in "loser" areas to ensure that \
there was no negative effect on )Tj
T*
(health. If they imply putting substantially more money into prescribing \
overall, that may be a difficult )Tj
T*
(policy issue given that Wales already spends some 20% more per capita th\
an England on prescribing. )Tj
ET
EMC
/P <>BDC
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(Finally, there was recognition in the Group that an approach on prescrib\
ing must be developed. Members )Tj
T*
(expressed a willingness to be involved in and support this work. )Tj
ET
EMC
/P <>BDC
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/T1_0 1 Tf
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(2. Celtic Dimensions forwarded the following detailed response : )Tj
ET
EMC
/P <>BDC
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(Background )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(Prescribing is a very important element of NHS resources and has value f\
ar greater than its cost. The )Tj
T*
(primary care drugs bill is 13% of all NHS and 49% of Primary Care. It is\
also growing at nearly twice the )Tj
T*
(rate of other NHS expenditure. Prescribers have many conflicting pressur\
es )Tj
ET
EMC
/Lbl <>BDC
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/T1_2 1 Tf
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(l)Tj
/T1_0 1 Tf
( )Tj
ET
EMC
/LBody <>BDC
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/T1_0 1 Tf
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(Different views of clinical practice )Tj
ET
EMC
/Lbl <>BDC
BT
/T1_2 1 Tf
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(l)Tj
/T1_0 1 Tf
( )Tj
ET
EMC
/LBody <>BDC
BT
/T1_0 1 Tf
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(Local guidelines and protocols )Tj
ET
EMC
/Lbl <>BDC
BT
/T1_2 1 Tf
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(l)Tj
/T1_0 1 Tf
( )Tj
ET
EMC
/LBody <>BDC
BT
/T1_0 1 Tf
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(Need to satisfy NSF and NICE guidelines )Tj
ET
EMC
/Lbl <>BDC
BT
/T1_2 1 Tf
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(l)Tj
/T1_0 1 Tf
( )Tj
ET
EMC
/LBody <>BDC
BT
/T1_0 1 Tf
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(Each prescriber has a their own range of drugs they favour and this coul\
d be any 500 for 5000 so )Tj
T*
(there is not common practice )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(There are also few outcome data available and many of these are surrogat\
e anyway )Tj
ET
EMC
/Lbl <>BDC
BT
/T1_2 1 Tf
6.88652 0 0 6.88652 35.13403 326.25047 Tm
(l)Tj
/T1_0 1 Tf
( )Tj
ET
EMC
/LBody <>BDC
BT
/T1_0 1 Tf
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(Lowering cholesterol is biochemical and does not necessarily mean it has\
extended life )Tj
ET
EMC
/Lbl <>BDC
BT
/T1_2 1 Tf
6.88652 0 0 6.88652 35.13403 309.72282 Tm
(l)Tj
/T1_0 1 Tf
( )Tj
ET
EMC
/LBody <>BDC
BT
/T1_0 1 Tf
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(Antibiotics eradicate infection which might have self-resolved anyway )Tj
ET
EMC
/Lbl <>BDC
BT
/T1_2 1 Tf
6.88652 0 0 6.88652 35.13403 293.19518 Tm
(l)Tj
/T1_0 1 Tf
( )Tj
ET
EMC
/LBody <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 49.18942 293.19518 Tm
(Chronic pain relief continues used in periods of remission as the patien\
t has no way of knowing if )Tj
T*
(they are in pain unless they stop taking the medicine )Tj
ET
EMC
/Lbl <>BDC
BT
/T1_2 1 Tf
6.88652 0 0 6.88652 35.13403 260.13988 Tm
(l)Tj
/T1_0 1 Tf
( )Tj
ET
EMC
/LBody <>BDC
BT
/T1_0 1 Tf
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(There are many examples, these are just a selection )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
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(Allocation Methods )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(There seem to be three basic ways of looking at the allocation )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(1. Historical where previous patterns are used as the basis for projecti\
ng future use )Tj
T*
(2. Population based on a crude or age/sex related weighting )Tj
T*
(3. New Formula which looks at the likely needs of a given population tak\
ing into account disease patterns, )Tj
T*
(socio-economic and health status of the area factors )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(There is such large variations in prescribing practice that unless accou\
nt is taken of some sort of outcome )Tj
T*
(measure it will mean that there may be inappropriate changes in prescrib\
ing practice in order to )Tj
ET
EMC
Q
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(accommodate the allocated budget. )Tj
ET
EMC
/P <>BDC
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(Examples )Tj
ET
EMC
/P <>BDC
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(Some examples are shown to illustrate these differences: - )Tj
ET
EMC
/P <>BDC
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(Mental Health )Tj
ET
EMC
/P <>BDC
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(There are two main models of treatment. )Tj
ET
EMC
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(Social Model based on therapy, counselling, in-patient stays and communi\
ty care )Tj
ET
EMC
/P <>BDC
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/T1_0 1 Tf
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(Medical Model relying on prescription medicines to treat and counter hab\
its of addiction )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(Both are valid and are generally used in combination. The Social model w\
ill be drug light but community/)Tj
0 -1.2 TD
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nity/secondary. They may )Tj
T*
(give roughly similar results but, depending on the route taken, this wil\
l make a large difference to the )Tj
T*
(prescribing spend. The Social Model eats resources whilst the Medical Mo\
del is much less costly to the )Tj
T*
(NHS )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(Which model is used is the decision of the prescriber backed up by pract\
ice, LHG and NHS Trust )Tj
T*
(Protocols. Depending on how the locality operates, differences will occu\
r in their prescribing costs. )Tj
ET
EMC
/P <>BDC
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(Cholesterol Reduction )Tj
ET
EMC
/P <>BDC
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(The lowering of cholesterol is generally accepted as being beneficial an\
d helps to prevent secondary )Tj
T*
(cardio-vascular problems. This lowering can also be partly achieved by l\
ifestyle modification \(diet, )Tj
T*
(smoking, exercise, tea/coffee and generally reviewing life\) )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(The practices with the time resources and belief to devote to lifestyle \
issues will certainly have lower )Tj
T*
(prescribing costs but may have far more latestage CV problems. )Tj
ET
EMC
/P <>BDC
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(Infections )Tj
ET
EMC
/P <>BDC
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(Older, cheaper antibiotics are less effective through resistance brought\
about by use and are more likely to )Tj
T*
(have patients with allergic reactions. It will involve more visits, more\
emergencies and more prescriptions )Tj
T*
(but will be cheap on the prescribing bill. The secondary costs will be f\
ar greater )Tj
ET
EMC
/P <>BDC
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(Newer antibiotics are more expensive but generally much more effective a\
nd reduced allergies. They are )Tj
T*
(more likely to work first time and may cost more but the whole episode w\
ould be cheaper and the )Tj
T*
(outcome better )Tj
ET
EMC
Q
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(Recommendations )Tj
ET
EMC
/P <>BDC
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/T1_0 1 Tf
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(Given these variations brought about by different views on prescribing w\
e would recommend the )Tj
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(following )Tj
ET
EMC
/P <>BDC
BT
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(1. Continue to use historical trends )Tj
T*
(2. Develop models of uniformity and conformity around prescribing practi\
ces )Tj
T*
(3. Share best practices to obtain this convergence of practice )Tj
T*
(4. Develop outcomes and surrogate outcomes to apply to the prescribing d\
ata )Tj
T*
(5. Use a combination of historical and outcome to develop a fairer alloc\
ation system )Tj
T*
(6. Link prescribing to other relevant parts of the service so that an in\
crease in one generates a decrease in )Tj
T*
(others )Tj
T*
(7. Horizon scans for patent expiry and the consequent price drop, as thi\
s will radically change prescribing )Tj
T*
(costs. Effective, expensive brands suddenly become effective, cheap gene\
rics )Tj
T*
(8. Retain a National Assembly for Wales contingency reserve to modulate \
across LHGs while the systems )Tj
T*
(are being set up )Tj
T*
(9. Get very up to date data to monitor this system constantly and allow \
LHGs to modify their prescribing )Tj
T*
(following self-audit \(Data provision is currently a black hole\) )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(Other responses on prescribing were received from Iechyd Morgannwg Healt\
h Authority, Ynys Mon )Tj
T*
(Local Health Group, Gwent Health Authority, Bro Taf Health Authority, No\
rth Wales Health Authority . )Tj
T*
(For example: )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(1. The use of BNF chapters to group and cost drugs has not been demonstr\
ated as an appropriate approach )Tj
T*
(in allocating costs. The cost variations between e.g. distalgesics, anti\
-depressants and Parkinson drugs are )Tj
T*
(likely to be significant )Tj
T*
(2. The use of prescribing data from eight practices linked to the GPMD t\
o calculate the link between )Tj
T*
(expressed need and cost is not robust as the evidence is that the prescr\
ibing data within the database is )Tj
T*
(incomplete. )Tj
T*
(3. The assumption that these practices are exemplar is questionable. )Tj
T*
(4. The GPMD does not include prescribing data for children which is a si\
gnificant omission in the model. )Tj
T*
(5. The report states that for both prescribing and GMS that there is lit\
tle direct cost data available . Direct )Tj
T*
(cost data is available at GP practice level. )Tj
T*
(6. Removal of a cash limit would reduce financial control locally and na\
tionally and would create )Tj
T*
(difficulties around providing incentives for clinically effective and co\
st effective prescribing )Tj
T*
(7. The GPMD was from self selecting GPs and potentially those with the m\
ost enthusiastic approach to )Tj
T*
(information and patient management. They are potentially not representat\
ive. )Tj
T*
(8. The drugs budget was allocated on the basis of only 8 databases. Ther\
e is concerns that the allocation of )Tj
T*
(weights for arthritis in the calculation for coronary heart disease drug\
s. )Tj
T*
(9. In considering the proposals for the prescribing allocation due regar\
d must be given to the separation of )Tj
T*
(the drugs dispensing allocation and the prescribing budgets. )Tj
T*
(10. Strategically the best way of achieving cost effective prescribing i\
s to set realistic budgets , provide )Tj
T*
(practitioners with good evidence, advice and incentivise change. Using t\
he proposed formula would )Tj
ET
EMC
Q
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(produce dramatic redistributions that realistic budgets could not be set\
. Accordingly the ownership of the )Tj
0 -1.2 TD
(budgets and the incentive scheme by GPs could collapse. )Tj
ET
EMC
/P <>BDC
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/T1_1 1 Tf
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(Annex B \( 5.7 \) )Tj
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/P <>BDC
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(Chapter 5: A new model of allocating resources by area to health care se\
rvices )Tj
ET
EMC
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(Consultation Responses relating to Implementation Issues )Tj
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(North West Wales NHS Trust, North Glamorgan NHS Trust, Dyfed Powys Healt\
h Authority, Carmarthen )Tj
T*
(Community Health Council, Meirionydd Community Health Council, Pembrokes\
hire and Derwen NHS )Tj
T*
(Trust , Iechyd Morganwwg Health Authority. Ian Lucas MP, The Welsh NHS C\
onfederation, North East )Tj
T*
(Wales NHS Trust , Gwent Health Authority, Conwy and Denbighshire NHS Tru\
st , Bro Taf Health )Tj
T*
(Authority, Cardiff and Vale NHS Trust , Ceredigion and Mid Wales NHS Tru\
st, North Wales Health )Tj
T*
(Authority, Royal College of Nursing Wales, Unison, and the Finance and A\
ssets Task Group commented )Tj
T*
(on implementation issues. For example : )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(1. It is crucially important to determine how growth is defined. Growth \
can be presented as the cash uplift )Tj
T*
(above GDP. The true inflationary pressures in the NHS are generally reco\
gnised as being well above )Tj
T*
(general inflation. This with unavoidable cost pressures gives an estimat\
ed real growth figure of )Tj
T*
(approximately 1% or less, compared to a 7% cash uplift . Unless the redi\
stribution is adjusted via the real )Tj
T*
(growth Local Health Groups that "lose" under the formula will nee to cut\
services. If real growth is used )Tj
T*
(the three year timescale is unrealistic. )Tj
ET
EMC
/P <>BDC
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(2. The timescales for implementing any new formula needs to be realistic\
if services are not to be )Tj
T*
(destabilised )Tj
ET
EMC
/P <>BDC
BT
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(3. Achievement towards a new formula present a major challenge . The all\
ied changes in the structure of )Tj
T*
(NHS Wales up to 2003 make this task even more demanding with considerabl\
e organisational )Tj
T*
(development. )Tj
ET
EMC
/P <>BDC
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(4. It is a fairly high risk strategy to begin the implementation of the \
new formula from 2003/04. A )Tj
T*
("bedding in" period should be allowed for the new structure of the NHS i\
n Wales prior to the start of the )Tj
T*
(implementation of the new formula. )Tj
ET
EMC
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(5. The new formula should be implemented over a reasonable time span so \
as not to lead to a deterioration )Tj
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ET
EMC
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(6. It is essential that the statement that no area will receive less res\
ource than at present refers to resources )Tj
T*
(in real terms and confirmation on this point is sought )Tj
ET
EMC
/P <>BDC
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(7. If at all possible the implementation of the new formula should be fa\
cilitated by the provision of new )Tj
ET
EMC
Q
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(and additional resources from the National Assembly \( i.e over and abov\
e the current 7% planning )Tj
0 -1.2 TD
(provision \) )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(8. It will be essential for each area of Wales to still have an element \
of real growth each year and to ensure )Tj
T*
(that not all real growth is differentially allocated. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 651.09744 Tm
(9. Before implementing the formula it will be necessary to establish wha\
t the existing resource spend at )Tj
T*
(LHG level is. This is problematic for Hospital and Community services du\
e to the absence of accurate )Tj
T*
(costing methods and the absence of information to relate hospital and co\
mmunity activity to individual GP )Tj
T*
(practices. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 566.29486 Tm
(10. The proposed introduction date of 2003 coincides with the introducti\
on of new organisational )Tj
T*
(structures and a new financial framework with the introduction of resour\
ce limits to the NHS , under )Tj
T*
(Resource Accounting and Budgeting. This adds further complexity to the f\
inancial picture and a greater )Tj
T*
(degree of uncertainty and financial risk. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 481.49229 Tm
(11. The equalisation period will be heavily dependent upon the degree to\
which there is to be any re-)Tj
T*
(distribution of baseline funding or core inflation. At present this is n\
ot proposed but rather a concept of )Tj
T*
(differential growth is being explored. It should be recognised that the \
cost of sustaining core NHS services )Tj
T*
(accounts for the vast majority of the NHS cash uplift each year. Growth \
must be calculated after allowing )Tj
T*
(for NHS pay awards and core inflationary costs plus the cost of sustaini\
ng core services. The latter )Tj
T*
(element could account for 2% of revenue increase annually above NHS infl\
ation. Comparisons of headline )Tj
T*
(cash uplifts with GDP uplifts are not appropriate for determining growth\
in NHS funds. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(12. The pace of change needs to be fully orchestrated . Utilisation of t\
he GDP deflator does not measure )Tj
T*
(the inflation experience in the NHS. Potentially greater use should be m\
ade of the inequalities funding to )Tj
T*
(assist the pace of change. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 278.83186 Tm
(13. There is concern about the applicability of the approach to LHB\222s\
both in the degree of sensitivity )Tj
T*
(within the formula and the ability to produce an accurate position state\
ment of present utilisation. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 227.08459 Tm
(14. No account has been taken of cross -border issues. Some LHG\222s imp\
ort a substantial number of )Tj
T*
(English residents onto their registered GP populations. England is opera\
ting on a registered rather than )Tj
T*
(resident population and difficulties would be encountered if we were not\
able to follow suit. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 158.80966 Tm
(15. Strategic decisions need to be made about whether we take the progra\
mme basis of the formula )Tj
T*
(through to budgeting and commissioning. If the allocation formula struct\
ure, as the start point for )Tj
T*
(determining resource distribution across programmes and then for distrib\
uting the increases, is utilised the )Tj
T*
(way in which planning and commissioning systems are designed and the way\
in which report activities are )Tj
T*
(read will need to be changed. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 57.47945 Tm
(16. A strategy for information to support the directional change needs t\
o be developed. )Tj
ET
EMC
Q
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(17. The next Welsh Health Survey needs to be commissioned shortly to imp\
rove information and to )Tj
0 -1.2 TD
(ensure that changes are measured. Any deviations from the original surve\
y will need to be carefully )Tj
T*
(managed. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 684.99001 Tm
(18. There is a need to take into account the financial risks associated \
with organisational change and an )Tj
T*
(unstable formula before developing a final implementation plan. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 633.24274 Tm
(19. There is a need to develop a clear pace of change policy for impleme\
ntation which recognises true cost )Tj
T*
(increases and pressures of sustainability in the NHS when determining gr\
owth funding available for re - )Tj
T*
(distribution. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 564.96782 Tm
(20. The implementation plan will need to reflect the impact of the dissa\
ggregation of exisiting Health )Tj
T*
(Authority LTAs and other expenditures to LHGs which has the potential to\
enhance any imbalance with )Tj
T*
(the proposed funding flows. In addition, following implementation of the\
Costing Review in Wales, the )Tj
T*
(impact of the revised fair shares for Local Health Groups LTAs will also\
need to be reflected. This will )Tj
T*
(consider the price and volume variances for actual service usage in each\
LHG compared to the notional )Tj
T*
(price and volume targets included within the formula. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(21. Implementation of such a radical change in formula distribution will\
take a significant period of time )Tj
T*
(from the date when the formula is considered robust enough to be utilise\
d. An equalisation period of 7 )Tj
T*
(years may be required. The potential volatility of the formula in its ea\
rly stages indicates the need for a )Tj
T*
(conservative policy in relation to equalisation. It may only be possible\
to allocate differential growth to )Tj
T*
(those furthest from target with all others receiving standard uplifts un\
til the stability of any formula is )Tj
T*
(proven. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(22. The recovery plans of Trusts and Health Authorities will need to be \
considered in implementation. )Tj
T*
(Within recovery plans there may be assumptions on the use of growth to c\
ontribute to the recovery plan. If )Tj
T*
(growth funding for the implementation phase is to be targeted towards eq\
ualisation, this would impact on )Tj
T*
(existing recovery plans and could lead to an increased number of recover\
y plans. In addition by )Tj
T*
(committing growth towards equalisation \( given the scale of equalisatio\
n \) no growth would be available )Tj
T*
(for the services to meet NSFs / NICE guidelines, development and service\
charges. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 211.39423 Tm
(23. Cardiff and Vale NHS Trust in partnership with Bro Taf Health Author\
ity have identified a strategic )Tj
T*
(change agenda which dwarfs the future resource capacity of both the Trus\
t and Bro Taf Health Authority. )Tj
T*
(These strategic challenges will have significant capital and revenue imp\
lications. It will not be possible to )Tj
T*
(secure these from Local Health Boards and will require direct interventi\
on and funding by the Assembly. )Tj
T*
(It is recommended that a programmes approach be adopted based on strateg\
ies or NSF\222s that reinfiorce the )Tj
T*
(strategic lead to be adopted by the Assembly. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 93.53636 Tm
(24. Finance & Assets Task & Finish Group comments on implementation issu\
es. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 58.31673 Tm
(It is recognised that until the HSSC has agreed final recommendations re\
garding resource allocation in the )Tj
T*
(NHS, the implementation issues cannot be fully scoped. However, prelimin\
ary discussion at the Finance )Tj
ET
EMC
Q
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(and Assets Task & Finish Group has identified relevant issues that will \
need consideration once the )Tj
0 -1.2 TD
(recommendations are finalised. Comments are offered in the following thr\
ee broad categories: )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(1. Developmental Issues )Tj
T*
(2. Structural Change Issues )Tj
T*
(3. Pace of Change Issues )Tj
ET
EMC
/P <>BDC
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(Developmental Issues )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 599.35016 Tm
(Developing an Approach to Assess the Effect of Action to Reduce Health I\
nequalities )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 564.13054 Tm
(The subject of Professor Townsend\222s report is the need for action to \
reduce health inequalities in Wales. )Tj
T*
(The link between poverty and ill health is argued strongly and is suppor\
ted with clear evidence of how )Tj
T*
(poor health outcomes and access to services are influenced by socio-econ\
omic and environmental factors. )Tj
T*
(The report recommends a \221dual strategy\222 for action and a number of\
the recommendations refer to actions )Tj
T*
(required outside the health service. Consideration needs to be given to \
the basis for measuring and )Tj
T*
(assessing progress in the \221dual strategy\222 and for ensuring that ac\
tion to target health inequalities is focused )Tj
T*
(at communities below LHB level. )Tj
ET
EMC
/P <>BDC
BT
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ET
EMC
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BT
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(The recommendation on developing a comprehensive financial information s\
trategy is significant. The key )Tj
T*
(elements, which are around the need to identify health care activity to \
individual GP practice level and to )Tj
T*
(develop and standardise costing of services, require time and financial \
support. The resource implications )Tj
T*
(of this recommendation need to be understood if adopted. The requirement\
s must be integrated into the )Tj
T*
(All-Wales IM&T strategy and the timescales for delivery need to be consi\
dered in light of the fact that )Tj
T*
(without progress in this area, the detailed refinement required prior to\
implementation of a number of the )Tj
T*
(recommendations in \221Targeting Poor Health\222 will prove challenging.\
)Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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ET
EMC
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/T1_0 1 Tf
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(There are a number of very detailed and specific concerns that were disc\
ussed during the review period )Tj
T*
(and reflected in the consultation responses to the proposed methodology.\
The need for further detailed )Tj
T*
(work to develop and refine the formula prior to implementation is acknow\
ledged in the report. It is )Tj
T*
(important that the issues around all three elements of the funding formu\
la are considered. There is a need )Tj
T*
(to clearly describe and scope the further developmental work required Ho\
spital and Community Services, )Tj
T*
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T*
(Morbidity Database. It is assumed that the new Standing Advisory Committ\
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T*
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ET
EMC
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(1. The concerns regarding the detail of the methodology can be addressed\
)Tj
T*
(2. The re-distributive impact of the formula at LHB level can be clarifi\
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T*
(3. An informed judgement on timescale for implementation can be made )Tj
ET
EMC
Q
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ET
EMC
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EMC
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(The structural changes in the NHS have now been finalised. However, some\
details require further )Tj
0 -1.2 TD
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applied in practice e.g. the )Tj
T*
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recommends that the formula )Tj
T*
(should be applied consistently at the different levels of administrative\
authority. The methodology for )Tj
T*
(being able to apply the above to, for example, Trust catchments and spec\
ialist services needs further )Tj
T*
(clarification. The Gordon Formula allocates only \2431.4 bn of a total N\
HS budget of \2433.2 bn. Further work )Tj
T*
(is required to establish how the formula could be applied to meet the re\
quirements above. )Tj
ET
EMC
/P <>BDC
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BT
/T1_0 1 Tf
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ET
EMC
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BT
/T1_0 1 Tf
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(Further discussion is required in order to establish whether there is an\
intention to allocate a single unified )Tj
T*
(funding stream to the LHBs or whether it is intended to continue to sepa\
rately identify three or more )Tj
T*
(separate funding streams. Confirmation is required on whether dispensing\
or prescribing allocations will )Tj
T*
(be made at LHB level. These issues will impact on \221pace of change\222\
considerations in the sense that )Tj
T*
(equalisation and pace of change issues will either be through a single f\
unding stream against a single )Tj
T*
(target or three or more funding streams and targets with potentially dif\
ferent timescales for moving to )Tj
T*
(equity. Clearly a unified funding stream is more easily handled in this \
respect though consideration would )Tj
T*
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such a change )Tj
/T1_2 1 Tf
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ET
EMC
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BT
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ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(The proposed introduction date of April 2003 coincides with the introduc\
tion of new organisational )Tj
T*
(structures and a new financial framework with the introduction of resour\
ce limits to the NHS, under )Tj
T*
(Resource Accounting and Budgeting. This adds further complexity to the f\
inancial picture and a greater )Tj
T*
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ET
EMC
/P <>BDC
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BT
/T1_0 1 Tf
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(Notional Targets or Cash Limited Budgets )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(Within the report there is a statement that Wales should await the appro\
ach being adopted in England )Tj
T*
(before deciding on the way forward for non-cash limited GMS. There needs\
to be clarity about what is )Tj
T*
(proposed for implementation from 2003. )Tj
ET
EMC
/P <>BDC
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(The formula combines cash limited and non-cash limited GMS expenditure t\
o distribute a notional )Tj
T*
(allocation at LHG level. Implementing such an approach would not be poss\
ible without reforming the )Tj
T*
(remuneration structure for GPs. For both GMS and prescribing, the propos\
als suggest that the formula )Tj
T*
(should be used to calculate notional allocation at LHG level only. Both \
of these budgets have traditionally )Tj
T*
(been managed at practice and LHG level. The impact of removing a cash li\
mit needs to be considered. )Tj
ET
EMC
Q
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(This discussion also needs to be linked to the issues around whether or \
not there is a unified funding )Tj
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EMC
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ET
EMC
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BT
/T1_0 1 Tf
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(The basis on which LHBs will be funded is not yet clear i.e. registered \
or resident population. )Tj
T*
(Compatibility with English Primary Care Organisations should be consider\
ed. The report\222s proposals are )Tj
T*
(not clear as to whether the recommendation is for the use of census base\
d population data or GP registered )Tj
T*
(populations. This needs to be clarified along with the approach to updat\
ing the formula for population )Tj
T*
(changes. )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
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(Pace of Change Issues )Tj
ET
EMC
/P <>BDC
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BT
/T1_0 1 Tf
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(Need to Establish Robust Current Resource Baselines at LHB Level )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(The fundamental issue in assessing the timescale for implementation of t\
he proposals is the scale of the )Tj
T*
(changes from current resource distribution. This work has not been compl\
eted due to the absence of )Tj
T*
(reliable information at GP practice level for Hospital and Community Ser\
vices. The need to develop more )Tj
T*
(consistent costing methodologies also impacts on the reliability of the \
baselines into the future. This is a )Tj
T*
(considerable task but is essential to identify the true distance from ta\
rget of each LHB. Practice level )Tj
T*
(information is available for both Prescribing and GMS therefore robust b\
aselines are already in existence. )Tj
T*
(This could allow the consideration of introduction of the changes for GM\
S and prescribing in the first )Tj
T*
(instance with HCHS at a later timescale. )Tj
ET
EMC
/P <>BDC
9.83789 341.53291 m
527.71793 341.53291 l
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BT
/T1_0 1 Tf
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(Need to Calculate a Tolerance Around the Target Share / Distance from Ta\
rget at LHB Level )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 308.39577 Tm
(The application of the Welsh Health Survey at an LHB level presents risk\
s in relation to the stability of the )Tj
T*
(formula over time. Statistical analysis has shown that the survey is rel\
atively stable at HA level, but more )Tj
T*
(volatile at an LHG level. This volatility cannot be reflected in resourc\
e distribution at small population )Tj
T*
(levels as the consequences for service planning and delivery could be hi\
ghly damaging. The error rate in )Tj
T*
(the formula at LHB level has been assessed as 4%. That suggests that a t\
olerance of + or \226 4% should be )Tj
T*
(set around the target share for each LHB. This is a significant range an\
d further work is required to )Tj
T*
(validate the approach and confirm an appropriate tolerance. This also im\
pacts on the re-distributive )Tj
T*
(elements of the formula as in practice it would mean that any distance f\
rom target of 4% or less would be )Tj
T*
(assumed to be \221on target\222 and not treated differentially for resou\
rce allocation purposes. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(Need to Consider Risk Management Arrangements in Year 1 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 105.73534 Tm
(Consideration should be given to introducing a mechanism for handling th\
e financial and service risks )Tj
T*
(especially in Year 1 of the implementation. Requiring a \221steady state\
\222 in financial flows could be )Tj
T*
(beneficial in addressing the instability and reducing the risks to servi\
ces. This could be combined with a )Tj
T*
(formal review of budgets fro the start of Year 2. )Tj
ET
EMC
Q
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550.33327 749.85539 l
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0 0 0 rg
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/T1_0 1 Tf
0 Tc 0 Tw 0 Ts 100 Tz 0 Tr 13.77304 0 0 13.77304 9.83789 751.93788 Tm
(Balance between Targeting Funds at Reducing Health Inequalities and Othe\
r Priorities for Health )Tj
ET
9.83789 733.32774 m
69.88834 733.32774 l
S
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 735.41023 Tm
(Resources )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 700.1906 Tm
(There is a need to consider the balance between the allocation of resour\
ces specifically to reduce )Tj
0 -1.2 TD
(inequalities and to ensure access to NHS services where there is a healt\
h need irrespective of the socio-)Tj
T*
(economic background. Reductions in waiting times for access must still b\
e seen as, and resourced as, a )Tj
T*
(priority regardless of geographic / socio-economic differences. The impl\
ications of distributing resources )Tj
T*
(according to expressed need have elsewhere led to a targeting of resourc\
es away from the most deprived )Tj
T*
(areas. Further work is required to validate the results of one year\222s\
WHS. There are also some significant )Tj
T*
(political issues regarding a policy of not meeting demand for services a\
mongst the relatively "better-off" )Tj
T*
(populations, e.g. orthopaedics waiting times. )Tj
ET
EMC
/P <>BDC
9.83789 547.19496 m
456.24963 547.19496 l
S
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 549.27745 Tm
(Resource Requirements of all Recommendations will Impact on Pace of Chan\
ge )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 514.05782 Tm
(The proposals to introduce an equity grant, an advocacy grant and a sepa\
rate inequalities fund will reduce )Tj
T*
(the level of resource available to move towards target shares and theref\
ore lengthen the transition period. )Tj
T*
(The funding of a comprehensive financial information strategy will also \
impact as above, though the need )Tj
T*
(for some development is a pre-requisite for the development of the formu\
la to allow the implementation. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 429.25525 Tm
(Pace of Change Must be Subject to Further Consideration )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 394.03561 Tm
(The report proposes that resources should be allocated on the basis of t\
he new formula from April 2003 )Tj
T*
(and that the transition to the new target shares should be completed ove\
r a maximum of five and )Tj
T*
(preferably three years. The equalisation period will be heavily dependen\
t upon the degree to which there is )Tj
T*
(to be any re-distribution of baseline funding or core inflation. At pres\
ent this is not proposed, but rather )Tj
T*
(the concept of differential growth is being explored. It should be recog\
nised that the cost of sustaining )Tj
T*
(core NHS services accounts for the vast majority of the NHS cash uplift \
each year. Growth must be )Tj
T*
(calculated after allowing for NHS pay awards and core inflationary costs\
plus the cost of sustaining core )Tj
T*
(services. This latter element could account for 2% of revenue increase a\
nnually above NHS inflation. )Tj
T*
(Comparisons of headline cash uplifts with GDP uplifts are not appropriat\
e for determining growth in NHS )Tj
T*
(funds. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 210.06717 Tm
(The Standing Advisory Group recommended needs to be constituted as a mat\
ter of urgency to confirm and )Tj
T*
(oversee the outstanding developmental work. In addition, modelling work \
should commence to assess the )Tj
T*
(feasibility of the proposed pace of change timescale of three and a maxi\
mum of five years. This should be )Tj
T*
(based on )Tj
/T1_1 1 Tf
(: )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 125.2646 Tm
(1. A range of maximum distances from target. )Tj
T*
(2. An estimate of all issues that require resourcing universally across \
all areas of the NHS, e.g. inflation, )Tj
T*
(pay, clinical governance, NICE guidance. )Tj
T*
(3. The resource requirements of Townsend\222s other recommendations, e.g\
. equity grant, advocacy grant, )Tj
T*
(inequalities fund and Financial Information Strategy. )Tj
T*
(4. Assumptions on the cost and pace of implementation of the NHS Plan fo\
r Wales. )Tj
ET
EMC
Q
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0 i
BT
/T1_0 1 Tf
0 Tc 0 Tw 0 Ts 100 Tz 0 Tr 13.77304 0 0 13.77304 9.83789 754.592 Tm
(5. Future resource availability assumptions. )Tj
0 -1.2 TD
(6. Clarity on the detail of the NHS structure )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 702.84471 Tm
(In practice it is likely that the pace of change policy will need to be \
a decision reserved for the Health and )Tj
T*
(Social Services Committee on an annual basis pending a review of resourc\
es available and priorities for )Tj
T*
(funding for the next year. This could be within the context of a broad t\
imescale of a stated number of )Tj
T*
(years provided that the annual assessment of resources and priorities wa\
s accepted as reasonable )Tj
/T1_1 1 Tf
(. )Tj
ET
EMC
/P <>BDC
BT
/T1_2 1 Tf
13.77304 0 0 13.77304 9.83789 618.04214 Tm
(Conclusions )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 582.82251 Tm
(It is clear that there is a significant level of detailed developmental \
work that needs to be completed prior )Tj
T*
(to implementation. The key issue is how and when that work will be taken\
forward and whether an )Tj
T*
(implementation date of April 2003 is realistic or advisable under the ci\
rcumstances. A further key issue is )Tj
T*
(that the concerns that do exist are addressed and that the formula has c\
redibility, as without it )Tj
T*
(implementation will not be possible. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 481.49229 Tm
(It is clear, that the existing methodology for allocating resources in W\
ales is not equitable. It is also true )Tj
T*
(that most of the pace of change issues raised will apply to any new form\
ula that is introduced. It is also )Tj
T*
(important to note that no formula for allocating resources will be perfe\
ct. There is a need to undertake the )Tj
T*
(necessary detailed work to develop a robust methodology and for the Advi\
sory Committee on Resource )Tj
T*
(Allocation to review at a later date whether sufficient progress has bee\
n made to allow implementation in )Tj
T*
(whole or in part from April 2003. )Tj
ET
EMC
/P <>BDC
BT
/T1_2 1 Tf
13.77304 0 0 13.77304 9.83789 363.63443 Tm
(Annex B \( 5.8 \) )Tj
ET
EMC
/P <>BDC
BT
/T1_2 1 Tf
13.77304 0 0 13.77304 9.83789 328.41481 Tm
(Chapter 5: A new model of allocating resources by area to health care se\
rvices )Tj
ET
EMC
/P <>BDC
BT
/T1_2 1 Tf
13.77304 0 0 13.77304 9.83789 293.19518 Tm
(Consultation Responses on the Health Inequalities / Health Inequalities \
Fund )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 257.97556 Tm
(Bro Taf Health Authority , Unison , and Gwent Health Authority have comm\
ented. For example : )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 222.75592 Tm
(1. An inequalities fund outside of the formula can be used to address co\
ncentrations of deprived or )Tj
T*
(specific priorities. Communities First is focusing on the 100 most depri\
ved communities in Wales based )Tj
T*
(on the Oxford Index of Deprivation and local knowledge. It would seem ap\
propriate that the same )Tj
T*
(measures continue to be used for the inequalities fund. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 137.95335 Tm
(2. A recurrent Inequalities Fund needs to target interventions which all\
ow the Acheson Report )Tj
T*
(recommendations that " a pace of change" policy, which allows deprived a\
reas to make the fastest )Tj
T*
(progress to be addressed. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 69.67842 Tm
(3. The Inequalities fund should continue to be linked to other resources\
that tackle the determinants of )Tj
T*
(health i.e. Communities First )Tj
ET
EMC
Q
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(4. The question needs to be asked about the size of any Inequalities Fun\
d. Research will be required to )Tj
0 -1.2 TD
(determine the appropriate level of resources that should be allocated to\
the health inequalities fund to )Tj
T*
(begin to " make a difference " )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 680.66135 Tm
(5. What is the role and scale of the Inequalities Fund? Will it be on th\
e basis of some kind of challenge )Tj
T*
(between competing areas and organisations? )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 628.91406 Tm
(6. The inequalities Fund should continue until the objective of the equa\
l health is achieved. It is important )Tj
T*
(that the fund can be used flexibly, according to the needs of the local \
population and that it can be targeted )Tj
T*
(towards prevention and care. )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 560.63914 Tm
(Annex B \( 6 )Tj
/T1_0 1 Tf
(\) )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 525.41951 Tm
(Chapter 6: A review of existing methods of allocating resources using in\
direct models )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 490.19989 Tm
(Consultation responses on using the indirect models )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 454.98026 Tm
(Bro Taf Health Authority and Gwent Health Authority have commented )Tj
/T1_1 1 Tf
(. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 419.76064 Tm
(1. There is a need to develop an indirect needs approach to facilitate a\
full evaluation of both approaches )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 384.541 Tm
(2. An interim indirect needs approach be implemented to minimise risk pe\
nding completion of the )Tj
T*
(resource allocation review and implementation of the proposed structural\
changes )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 332.79372 Tm
(3. There is concern that only one formula approach is being pursued and \
the collection of data for a )Tj
T*
(sophisticated indirect resource allocation methodology is not being comp\
leted. There is no "fall back )Tj
T*
(position" if for any reason the direct approach cannot be implemented. )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 550.51321 264.5188 Tm
(Annex C )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 229.29918 Tm
(Appendix: Independent Research Team\222s Response to the Consultation Co\
ncerns )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 194.07954 Tm
(Introduction )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 158.85991 Tm
(This Appendix provides a synthesis of the main technical issues raised b\
y the 46 detailed responses )Tj
T*
(returned to the research team. These responses have been summarised belo\
w as a series of questions and )Tj
T*
(answers. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 90.58499 Tm
(The research team was delighted that all but one of the responses suppor\
ted the use of the direct method )Tj
T*
(for measuring health need for NHS resource allocation in Wales. The team\
believes that the use of direct )Tj
T*
(indicators of health need \(rather than indirect measures, such as morta\
lity or hospital usage\) is an )Tj
T*
(innovative and significant scientific advance in the field of health res\
ource allocation which, if )Tj
ET
EMC
Q
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(implemented, will provide Wales with the fairest and most scientifically\
accurate method of health )Tj
0 -1.2 TD
(resource allocation in the UK. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 702.84471 Tm
(The research team used a wide range of the most valid and reliable healt\
h statistics currently available )Tj
T*
(\(including data from the 1998 Welsh Health Survey\) to measure health n\
eed in Wales. The resource )Tj
T*
(allocation formula proposed by the research team is open and transparent\
and allows for alternative )Tj
T*
(measures of health need to be easily incorporated or substituted into th\
e formula as and when they become )Tj
T*
(available. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 601.5145 Tm
(Despite the encouraging support for the direct method of measuring healt\
h need, about half of the )Tj
T*
(consultation responses raised concerns about issues of data quality part\
icularly with regard to the use of )Tj
T*
(1998 Welsh Health Survey \(WHS\), NHS financial information \( )Tj
/T1_1 1 Tf
(eg )Tj
/T1_0 1 Tf
(TRF2 returns, )Tj
/T1_1 1 Tf
(etc )Tj
/T1_0 1 Tf
(\), General Practice )Tj
T*
(Morbidity Database \(GMPD\), small area population estimates, Hospital E\
pisode Statistics \(HES\), Cancer )Tj
T*
(Registry statistics, Notifiable Disease Statistics and so on. Most of th\
e questions and answers below are )Tj
T*
(about these statistical and \221technical\222 issues. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 483.65663 Tm
(Q )Tj
/T1_1 1 Tf
(Is the sample size of the 1998 Welsh Health Survey large enough for reso\
urce allocation )Tj
/T1_0 1 Tf
(? )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 448.437 Tm
(A The 1998 WHS sent questionnaires to over 50,000 adults and received re\
sponses from almost 30,000 )Tj
T*
(people \(National Assembly for Wales, 1999\). A response rate of approxi\
mately 60% was achieved across )Tj
T*
(Wales with around 1,000 or more responses per Local Health Group/ Unitar\
y Authority District area. The )Tj
T*
(1998 WHS was one of the largest surveys ever undertaken in the UK both i\
n terms of the number of )Tj
T*
(respondents and the proportion of the population covered. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 347.10678 Tm
(The 1998 WHS received valid responses from approximately 1% of the Welsh\
adult population. No other )Tj
T*
(social survey in Britain has had responses from such a high proportion o\
f the population. The only other )Tj
T*
(recent studies with a comparable sampling fraction are the Longitudinal \
Study \(LS\) and the Sample of )Tj
T*
(Anonymised Records \(SAR\), which are both drawn from the national Censu\
s rather than being surveys )Tj
T*
(like the WHS. By comparison, decisions on monetary policy are made and i\
nterest rates set based on )Tj
T*
(changes in the inflation rate \(measured by the RPI\). The weights for t\
he RPI are based on the results of the )Tj
T*
(annual Family Expenditure Survey which receives responses from about 7,0\
00 households in the UK \(the )Tj
T*
(FES has an approximate 60% response rate like the WHS\). There are 24 mi\
llion households in the UK so )Tj
T*
(the FES samples only about 0.0003% of all UK households and major econom\
ic decisions which affect )Tj
T*
(the whole population are based upon the results of this survey. The WHS \
sample of almost 30,000 adults )Tj
T*
(\(1% of the Welsh adult population\) is very large and reliable by compa\
rison. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(Q )Tj
/T1_1 1 Tf
(The WHS measures self-reported health. Is self-reported health a good me\
asure of the \221true\222 level of )Tj
T*
(health need )Tj
/T1_0 1 Tf
(? )Tj
ET
EMC
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BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 94.86342 Tm
(A The \221true\222 level of health need is a philosophical concept that \
cannot be measured directly. What can be )Tj
T*
(measured directly are the opinions of doctors or patients about health. \
The question, therefore, is: whose )Tj
T*
(opinion is the most valid for health resource allocation - doctors\222 o\
r the populations\222? )Tj
ET
EMC
Q
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(Firstly, there is a huge scientific literature which shows that self-rep\
orted health measures are very good )Tj
0 -1.2 TD
(predictors of health need and health outcomes. Over 1,500 articles on se\
lf-rated health have been )Tj
T*
(published in the )Tj
/T1_1 1 Tf
(British Medical Journal )Tj
/T1_0 1 Tf
(alone in the past five years. It is impossible to summarise all this )Tj
T*
(literature here, however, two recent examples on the utility of self-rat\
ed health measures should suffice. )Tj
T*
(Heistaro )Tj
/T1_1 1 Tf
(et al )Tj
/T1_0 1 Tf
(\(2001\) concluded, from a study of over 21,000 people in Finland, that \
" )Tj
/T1_1 1 Tf
(poor self rated )Tj
T*
(health is a strong predictor of mortality, and the association is only p\
artially explained by medical )Tj
T*
(history, cardiovascular disease risk factors, and education )Tj
/T1_0 1 Tf
(". Similarly, Burstr\366m and Fredlund \(2001\) )Tj
T*
(recently concluded, from a large study of over 170,000 adults in Sweden,\
that " )Tj
/T1_1 1 Tf
(poor self rated health is a )Tj
T*
(strong predictor of subsequent mortality in all subgroups studied, and t\
hat self rated health therefore may )Tj
T*
(be a useful outcome measure )Tj
/T1_0 1 Tf
(". )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 570.62354 Tm
(Secondly, there is no way to prevent individuals from going to see their\
doctor when they think they are ill )Tj
T*
(and it is people\222s perception of their own health status rather than \
the \221true\222 level of disease that results in )Tj
T*
(their seeking and receiving health care. Therefore, a population\222s pe\
rceived level of health need, which )Tj
T*
(results in health care expenditure, is, in general, a better measure for\
resource allocation purposes than )Tj
T*
(epidemiological measures of the level of disease prevalent in a populati\
on. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 469.29332 Tm
(Thirdly, the philosophical basis for the research team\222s approach to \
NHS resource allocation is the social )Tj
T*
(model of health. This is the belief that health should be defined more b\
roadly than the narrow medical )Tj
T*
(\221disease\222 model, which defines health need solely in terms of path\
ological abnormalities which are )Tj
T*
(indicated by signs and symptoms and with success being measured solely i\
n terms of symptom response )Tj
T*
(and survival rates. A broader \221social\222 model of health is required\
for resource allocation which )Tj
T*
(acknowledges that people\222s feelings of pain and discomfort and their \
perceptions of change in usual )Tj
T*
(functioning are important and that they may legitimately require health \
services even when there is no )Tj
T*
(disease currently detectable by medical science \(Bowling, 1997\). The n\
eed for a broader concept of health )Tj
T*
(was acknowledged in the constitution of the World Health Organisation \(\
WHO\) which has adopted a )Tj
T*
(broad social definition of health as )Tj
/T1_1 1 Tf
("a complete state of physical, mental and social well-being and not just\
)Tj
T*
(the absence of disease and infirmity )Tj
/T1_0 1 Tf
(" \(WHO, 1974\). )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 268.79723 Tm
(By definition, a social health model-based resource allocation must take\
account of the views of the )Tj
T*
(population about their health needs. It must move beyond the idea that d\
octors are the sole legitimate )Tj
T*
(arbiters of health need. Disease model-based resource allocations - whic\
h only make use of \221hard\222 )Tj
T*
(epidemiological data on disease prevalence - are both politically and sc\
ientifically naive. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(They are politically naive because, in the 21 )Tj
11.01843 0 0 11.01843 256.55434 186.0851 Tm
(st )Tj
13.77304 0 0 13.77304 266.65823 182.55919 Tm
(Century, it is impossible to convince politicians that )Tj
-18.64661 -1.2 Td
(\221doctors know best\222 and that patients\222 views should be ignored.\
The medical disease model can be viewed )Tj
T*
(as paternalistic at best and patronising at worst. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(Finally, it must be stressed that, although doctors\222 and patients\222\
opinions on health may sometimes differ )Tj
T*
(at the individual level, at a population level there is often much close\
r agreement )Tj
/T1_1 1 Tf
(eg )Tj
/T1_0 1 Tf
(population-based )Tj
T*
(estimates of health need are often higher than medical/epidemiological e\
stimates but they show very )Tj
T*
(similar distributions between areas. Since health resource allocation is\
based upon the relative distribution )Tj
T*
(of health need between areas and not on the absolute level of health nee\
d within an area, a self-reported )Tj
ET
EMC
Q
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(measure of health need can result in the correct resource allocation at \
area level even where it )Tj
0 -1.2 TD
(overestimates the \221true\222 level of health need \(see )Tj
/T1_1 1 Tf
(Targeting Poor Health )Tj
/T1_0 1 Tf
(Volume 2 and Office for National )Tj
T*
(Statistics \(ONS\) report in Appendix D for more discussion on this poin\
t\). )Tj
ET
EMC
/P <>BDC
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/T1_0 1 Tf
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(Q )Tj
/T1_1 1 Tf
(Are self reported measures of health adequate for secondary and tertiary\
care resource allocation? )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(A Self-reported morbidity is a proxy measure of \221true\222 health need\
, especially at a secondary level, but it )Tj
T*
(is still an appropriate measure at area level. For example, if 10% of al\
l cases reporting arthritis can benefit )Tj
T*
(from a surgical intervention then, as long as this ratio 1:10 is constan\
t across a geographical area, the )Tj
T*
(measure of perceived need will be an accurate proxy for resource allocat\
ion within that budget. This is not )Tj
T*
(true if allocating money across DRGs where the ratio is likely to differ\
. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(Q )Tj
/T1_1 1 Tf
(Does under-reporting of health needs by some sections of society distort\
the resource allocation )Tj
T*
(results )Tj
/T1_0 1 Tf
(? )Tj
ET
EMC
/P <>BDC
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/T1_0 1 Tf
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(A Postal surveys like the WHS are also known to suffer from a number of \
systematic biases. In particular, )Tj
T*
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ET
EMC
/Lbl <>BDC
BT
/T1_2 1 Tf
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(l)Tj
/T1_0 1 Tf
( )Tj
ET
EMC
/LBody <>BDC
BT
/T1_0 1 Tf
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(the very elderly )Tj
ET
EMC
/Lbl <>BDC
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/T1_2 1 Tf
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(l)Tj
/T1_0 1 Tf
( )Tj
ET
EMC
/LBody <>BDC
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/T1_0 1 Tf
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(the very sick )Tj
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EMC
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/T1_2 1 Tf
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(l)Tj
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( )Tj
ET
EMC
/LBody <>BDC
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/T1_0 1 Tf
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(the poorest and most deprived )Tj
ET
EMC
/Lbl <>BDC
BT
/T1_2 1 Tf
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(l)Tj
/T1_0 1 Tf
( )Tj
ET
EMC
/LBody <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 49.18942 396.68973 Tm
(ethnic minority respondents \(particularly where English is a second lan\
guage\) )Tj
ET
EMC
/Lbl <>BDC
BT
/T1_2 1 Tf
6.88652 0 0 6.88652 35.13403 380.16208 Tm
(l)Tj
/T1_0 1 Tf
( )Tj
ET
EMC
/LBody <>BDC
BT
/T1_0 1 Tf
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(the functionally illiterate )Tj
ET
EMC
/Lbl <>BDC
BT
/T1_2 1 Tf
6.88652 0 0 6.88652 35.13403 363.63443 Tm
(l)Tj
/T1_0 1 Tf
( )Tj
ET
EMC
/LBody <>BDC
BT
/T1_0 1 Tf
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(people with certain disabilities \( )Tj
/T1_1 1 Tf
(eg )Tj
/T1_0 1 Tf
(learning, seeing, hearing\) )Tj
ET
EMC
/Lbl <>BDC
BT
/T1_2 1 Tf
6.88652 0 0 6.88652 35.13403 347.10678 Tm
(l)Tj
/T1_0 1 Tf
( )Tj
ET
EMC
/LBody <>BDC
BT
/T1_0 1 Tf
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(young single people \(particularly young men\) )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(These biases mean that the results from postal surveys need to be treate\
d with caution if they are to be )Tj
T*
(used to compare illness rates between socio-economic and demographic )Tj
/T1_1 1 Tf
(groups )Tj
/T1_0 1 Tf
(. However, these )Tj
T*
(systematic biases are not so problematic when comparing )Tj
/T1_1 1 Tf
(areas )Tj
/T1_0 1 Tf
(, since the postal survey bias is between )Tj
T*
(groups and not between areas, )Tj
/T1_1 1 Tf
(eg )Tj
/T1_0 1 Tf
(poorer people are equally unlikely to respond to the questionnaire in )Tj
T*
(both Anglesey and Cardiff \(see Appendix 1 of )Tj
/T1_1 1 Tf
(Targeting Poor Health )Tj
/T1_0 1 Tf
(Volume 2, Gordon )Tj
/T1_1 1 Tf
(et al )Tj
/T1_0 1 Tf
(, 2001\). )Tj
T*
(This means that, although the )Tj
/T1_1 1 Tf
(absolute )Tj
/T1_0 1 Tf
(rates of ill health recorded in the WHS at UA level may well be )Tj
T*
(incorrect, the )Tj
/T1_1 1 Tf
(relative )Tj
/T1_0 1 Tf
(rates of ill health between areas are much more reliably measured. The r\
esource )Tj
T*
(allocation formula is designed to allocate money to each area on the bas\
is of its relative health need, not )Tj
T*
(its absolute health need, therefore the limitations of the WHS for measu\
ring absolute health need are not )Tj
T*
(problematic for resource allocation. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(The proposed research allocation formula makes use of administrative sta\
tistics of health need \(such as the )Tj
T*
(Cancer Registry data\). There are similar concerns that these administra\
tive statistics may also contain )Tj
T*
(systematic biases \(despite the fact that the Cancer Registry has been o\
perating for 30 years\). For example, )Tj
T*
(Dickinson )Tj
/T1_1 1 Tf
(et al )Tj
/T1_0 1 Tf
(\(2001\) performed a pathological review of 720 Cancer Registry cases in\
Cumbria and )Tj
T*
(found an approximate error rate of 10%. While this may be problematic fo\
r epidemiological studies, it is )Tj
T*
(not so problematic for research allocation purposes since patients whose\
cancer is incorrectly diagnosed )Tj
ET
EMC
Q
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(will still receive treatment and have health resources spent upon them. \
However good doctors are and )Tj
0 -1.2 TD
(however carefully they make diagnoses, some mistakes will always be made\
and patients will occasionally )Tj
T*
(receive the wrong treatment. A good resource allocation formula must inc\
lude funds to cover these )Tj
T*
(expenditures. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 669.78941 Tm
(The research discussed in Appendix 1 of )Tj
/T1_1 1 Tf
(Targeting Poor Health )Tj
/T1_0 1 Tf
(Volume 2 demonstrates that there are no )Tj
T*
(detectable systematic biases in the WHS data between UA areas which woul\
d prevent the use of these data )Tj
T*
(for resource allocation purposes. These results have been independently \
confirmed by the ONS \(see )Tj
T*
(Appendix D of this report\). )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 584.98685 Tm
(Q )Tj
/T1_1 1 Tf
(Have the additional health needs of the elderly been adequately accounte\
d for in the new formula? )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 549.76723 Tm
(A Older people often take longer to recover from illness than younger pe\
ople so there are additional health )Tj
T*
(costs associated with treating the elderly. These additional costs have \
been included in the new health )Tj
T*
(resource allocation formula and additional work in this area has been pr\
oposed. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 481.49229 Tm
(Response rates in the WHS from people over 75 were slightly lower than t\
hose from middle-aged people. )Tj
T*
(However, the response rates for the over 75s were higher than those for \
the youngest adults \(18 to 30\). )Tj
T*
(The research team found that these response biases were adequately corre\
cted in the WHS by the post-)Tj
T*
(stratification population weighting used in that survey \(see Appendix 1\
of )Tj
/T1_1 1 Tf
(Targeting Poor Health )Tj
/T1_0 1 Tf
(Volume )Tj
T*
(2\). These results have been independently confirmed by the ONS \(see Ap\
pendix D of this report\). )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 380.16208 Tm
(Q )Tj
/T1_1 1 Tf
(Are the number of health indicators used in the formula broad enough to \
adequately measure the health )Tj
T*
(needs of the Welsh population? )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 328.41481 Tm
(A The current NHS resource allocation formula in Wales uses the death ra\
tes of people under 75 from all )Tj
T*
(causes as its sole indicator of health need. It is self evident that it \
is more valid to allocate health resources )Tj
T*
(for pregnancy services or cancer services on the basis of the number of \
pregnant women and the number )Tj
T*
(of people with cancer than it is to allocate them on the basis of the di\
stribution of the number of dead )Tj
T*
(people. There are a number of reasons for this, including: )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 227.08459 Tm
(1. The NHS mainly provides services for people who are alive, not dead. \
In particular, it provides the bulk )Tj
T*
(of its services for the \221sick\222 rather than the \221healthy\222. )Tj
T*
(2. The NHS provides a considerable number of services for people with he\
alth conditions that only very )Tj
T*
(rarely result in death, )Tj
/T1_1 1 Tf
(eg )Tj
/T1_0 1 Tf
(tooth decay, back pain, food poisoning, arthritis, )Tj
/T1_1 1 Tf
(etc )Tj
/T1_0 1 Tf
(. )Tj
T*
(3. The geographical distribution of health need and death are not the sa\
me. )Tj
T*
(4. A large number of people in Wales require NHS services in any given y\
ear but only a relatively small )Tj
T*
(number will die under the age of 75 \(approximately 15,000 people per ye\
ar\). )Tj
ET
EMC
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/T1_0 1 Tf
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(The research team has proposed using a wide range of indicators of healt\
h need in the new resource )Tj
T*
(allocation formula drawn from the Vital Statistics, Hospital Episode Sta\
tistics, Cancer Registry, Welsh )Tj
T*
(Health Survey, GP Morbidity Database, Notifiable Disease Statistics, )Tj
/T1_1 1 Tf
(etc )Tj
/T1_0 1 Tf
(. However, a small number of )Tj
T*
(consultation responses were concerned that even this range of health con\
dition indicators would be )Tj
ET
EMC
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0 0 612 792 re
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BT
/T1_0 1 Tf
0 Tc 0 Tw 0 Ts 100 Tz 0 Tr 13.77304 0 0 13.77304 9.83789 754.592 Tm
(adequate to measure the health needs of the Welsh population at LHG leve\
l. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 719.37236 Tm
(There are thousands of health conditions listed in the International Cla\
ssification of Diseases \(ICD-10\) )Tj
0 -1.2 TD
(and even more listed by the International Classification of Impairments,\
Disabilities and Handicaps )Tj
T*
(\(ICIDH-2\). Since people can suffer from several different diseases of \
differing levels of severity, then the )Tj
T*
(possible combinations of type, number and severity of health conditions \
that the Welsh population could )Tj
T*
(suffer from is far greater than the number of atoms in the Universe. For\
tunately, only a minority of people )Tj
T*
(in Wales suffer from any disease and most people who are ill in Wales on\
ly suffer from a small range of )Tj
T*
(the potential health conditions \( )Tj
/T1_1 1 Tf
(eg )Tj
/T1_0 1 Tf
(many people in Wales have lower back pain but very few have )Tj
T*
(leprosy\). )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 568.4592 Tm
(It is possible to use a statistical technique of \221classical test theo\
ry\222 to measure the correlation between the )Tj
T*
(main health need indicators used in the resource allocation formula and \
the almost infinite set of health )Tj
T*
(conditions the Welsh population could potentially have. This correlation\
is above 0.96 \(see Appendix 1 in )Tj
/T1_1 1 Tf
T*
(Targeting Poor Health )Tj
/T1_0 1 Tf
(Volume 2\) which demonstrates that the health conditions used in the for\
mula are )Tj
T*
(broad enough to measure the health needs of the population. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 467.12898 Tm
(Q )Tj
/T1_1 1 Tf
(Would it be better to use just a reliable single indicator of health nee\
d, such as Limiting Long Term )Tj
T*
(Illness from the 1991 Census, rather than the broad range of indicators \
proposed by the research team? )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 415.38171 Tm
(A There is a very high correlation between the distribution of Limiting \
Long Term Illness \(LLTI\) at LHG )Tj
T*
(level in the 1991 Census and the 1998 WHS. This correlation is 0.94 or 0\
.96 depending on how LLTI is )Tj
T*
(measured \(raw data or age-adjusted \226 see Appendix D of this report a\
nd Appendix 1 of )Tj
/T1_1 1 Tf
(Targeting Poor )Tj
T*
(Health )Tj
/T1_0 1 Tf
(Volume 2\). This means that, if LLTI data was used from either the 1998 \
WHS or the 1991 Census, )Tj
T*
(then an almost identical health resource allocation at small area level \
would result. However, this )Tj
T*
(allocation would not be as valid as the formula proposed by the research\
team since not all LLTIs are )Tj
T*
(equally serious or involve equal amounts of money to treat. For example,\
it costs, on average, more to )Tj
T*
(treat a person with cancer than a person with arthritis. By using a rang\
e of health condition indicators, it is )Tj
T*
(possible to include these treatment cost differences within the health r\
esource allocation formula. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 247.9409 Tm
(In addition, the NHS does not just provide services for people with LLTI\
s. It also provides services for )Tj
T*
(\221healthy\222 people such as pregnant women, immunizations for childre\
n, )Tj
/T1_1 1 Tf
(etc )Tj
/T1_0 1 Tf
(. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 196.19363 Tm
(Q )Tj
/T1_1 1 Tf
(A formula based on people\222s perception of health and other available \
health statistics is unlikely to )Tj
T*
(identify the need for rare, expensive or specialist interventions and dr\
ugs. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 144.44635 Tm
(A No formula-based allocation can adequately identify the need for rare \
and expensive interventions and )Tj
T*
(drugs at LHG level. Predicting which area will have the next case of Gre\
en Monkey Disease is impossible. )Tj
T*
(These kind of very expensive drugs treatments will always need to be fun\
ded from central contingency )Tj
T*
(funds not relatively small local budgets. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 59.64378 Tm
(Q )Tj
/T1_1 1 Tf
(The GPMD was not intended for use in resource allocation and the data ma\
y not be adequate for )Tj
T*
(prescribing allocations. )Tj
ET
EMC
Q
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0 0 612 792 re
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0 i
BT
/T1_0 1 Tf
0 Tc 0 Tw 0 Ts 100 Tz 0 Tr 13.77304 0 0 13.77304 9.83789 738.90163 Tm
(A All GP morbidity databases collect and have been used to provide evide\
nce on prescribing behaviour. If )Tj
0 -1.2 TD
(the concerns about the data quality of the GPMD can be substantiated, th\
en these results can be checked )Tj
T*
(using alternative data sources in Wales such as the General Practice Res\
earch Database \(GPRD\). The )Tj
T*
(ONS have already used this source to provide valid and reliable data on \
health in Wales \(see Appendix D\). )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 654.09904 Tm
(Conclusion )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 618.87943 Tm
(There is strong support in the consultation responses for proceeding wit\
h the direct method for NHS )Tj
T*
(resource allocation in Wales. However, a number of concerns have been ra\
ised about issues of health need )Tj
T*
(and financial information quality. The most valid and reliable health an\
d financial information currently )Tj
T*
(available has been used by the research team in the proposed new formula\
e for GMS, prescribing and )Tj
T*
(TRF2 resource allocations. The proposed new formulae are designed to be \
open and transparent and can )Tj
T*
(easily be updated if and when better health need and financial data beco\
me available. However, the data )Tj
T*
(used in the proposed new health resource allocation formulae are of suff\
icient quality to allow their rapid )Tj
T*
(implementation. It is unlikely that improvements in the health needs dat\
a quality would result in )Tj
T*
(significant changes to the resource allocations. Statistical modelling b\
y the ONS \(see Appendix D\) has )Tj
T*
(indicated that the maximum expected absolute difference between the prop\
osed allocations and the \221true\222 )Tj
T*
(allocations at LHG area level range from just 0.06% to 0.31%, )Tj
/T1_2 1 Tf
(ie )Tj
/T1_0 1 Tf
(less than half of one percent of the total )Tj
T*
(Wales NHS allocation \(see Table 4 in Appendix D\). )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 401.85568 Tm
(The proposed formulae for GMS, prescribing and TRF2 health resource allo\
cations are much more )Tj
T*
(scientifically valid and reliable than the current allocations in Wales.\
If the new formulae are )Tj
T*
(implemented, they will result in a much fairer allocation of health reso\
urces and the \221poorest\222 areas in )Tj
T*
(Wales will receive significant additional resources which should help th\
em to meet their much higher )Tj
T*
(relative levels of health need. If the new formulae are not implemented \
and the old health resource )Tj
T*
(allocations are retained, then the \221poorest\222 areas will not receiv\
e the additional monies they need to meet )Tj
T*
(the health needs of their populations. This would almost certainly resul\
t in a continued widening of the )Tj
T*
(health gap between the \221richest\222 and \221poorest\222 areas in Wale\
s. )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 250.94252 Tm
(References )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 215.72289 Tm
(Bowling, A. \(1997\) )Tj
/T1_2 1 Tf
(Measuring Health )Tj
/T1_0 1 Tf
(, Buckingham: Open University Press. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 180.50327 Tm
(Burstr\366m, B. and Fredlund, P. \(2001\) Self rated health: Is it as go\
od a predictor of subsequent mortality )Tj
T*
(among adults as well as in higher social classes? )Tj
/T1_2 1 Tf
(J Epidemiol Community Health )Tj
/T1_0 1 Tf
(55: 836-840. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 128.75598 Tm
(Dickinson, H.O., Salotti, J.A., Birch, P.J., Reid, M.M., Malcolm, A. and\
Parker, L. \(2001\) How complete )Tj
T*
(and accurate are cancer registrations by the National Health Service Cen\
tral Register for England and )Tj
T*
(Wales? )Tj
/T1_2 1 Tf
(J Epidemiol Community Health )Tj
/T1_0 1 Tf
(55: 414-422. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 60.48106 Tm
(Heistaro, S., Jousilahti, P., Lahelmas, E., Vartiainen, E. and Puska, P.\
\(2001\) )Tj
/T1_2 1 Tf
(J Epidemiol Community )Tj
T*
(Health )Tj
/T1_0 1 Tf
(55: 227-232. )Tj
ET
EMC
Q
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(National Assembly for Wales \(1999\) )Tj
/T1_1 1 Tf
(Welsh Health Survey 1998 )Tj
/T1_0 1 Tf
(, Cardiff: National Assembly for Wales. )Tj
ET
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/T1_0 1 Tf
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(WHO \(1974\) )Tj
/T1_1 1 Tf
(Alma Ata Declaration )Tj
/T1_0 1 Tf
(, Geneva: World Health Organisation. )Tj
ET
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/P <>BDC
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/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 669.29964 Tm
(Gordon, D., Lloyd, E., Senior, M., Rigby, J., Shaw, M. and Ben Shlomo, Y\
. \(2001\) )Tj
/T1_1 1 Tf
(Targeting Poor )Tj
0 -1.2 TD
(Health: Report of the Welsh Assembly\222s National Steering Group on the\
Allocation of NHS Resources, )Tj
T*
(Volume 2: Independent Report of the Research Team )Tj
/T1_0 1 Tf
(, Cardiff: National Assembly for Wales. )Tj
ET
EMC
/P <>BDC
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/T1_2 1 Tf
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(Annex D )Tj
ET
EMC
/P <>BDC
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/T1_2 1 Tf
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( )Tj
ET
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/P <>BDC
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/T1_2 1 Tf
13.77304 0 0 13.77304 9.83789 530.58546 Tm
(Evaluation of the Welsh Health Survey for use in resource allocation )Tj
T*
(Office of National Statistics: Combined report for Stages 1,2 and 3 )Tj
ET
EMC
/P <>BDC
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/T1_2 1 Tf
13.77304 0 0 13.77304 9.83789 478.83818 Tm
(Summary )Tj
ET
EMC
/P <>BDC
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/T1_2 1 Tf
13.77304 0 0 13.77304 9.83789 443.61856 Tm
(Introduction )Tj
ET
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/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 408.39893 Tm
(This report describes work carried out by the Office for National Statis\
tics to evaluate the reliability of )Tj
T*
(estimates from the Welsh Health Survey \(WHS\) with a view to advising o\
n their suitability for use in )Tj
T*
(resource allocation. )Tj
ET
EMC
/P <>BDC
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/T1_2 1 Tf
13.77304 0 0 13.77304 9.83789 340.12401 Tm
(Survey methodology )Tj
ET
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/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 304.90437 Tm
(In general the survey methodology was found to be sound and there were n\
o substantial flaws. )Tj
ET
EMC
/P <>BDC
BT
/T1_2 1 Tf
13.77304 0 0 13.77304 9.83789 269.68475 Tm
(Validation against Welsh Public Health Common Dataset \(PHCD\) )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 234.46512 Tm
(Comparisons of estimates for individual unitary authorities for seven ty\
pes of illness were made. )Tj
T*
(Significant positive correlations were found with at least one comparati\
ve administrative data source for )Tj
T*
(five of these. This provides evidence of reliability in the survey estim\
ates for relative prevalence. There )Tj
T*
(was no correlation with administrative sources for mental illness estima\
tes, leading to concern that the )Tj
T*
(survey estimates for mental illness may not be directly related to the n\
eed for treatment. )Tj
ET
EMC
/P <>BDC
BT
/T1_2 1 Tf
13.77304 0 0 13.77304 9.83789 133.1349 Tm
(Validation against NOP non-response survey, General Practice Research Da\
tabase \(GPRD\) and )Tj
T*
(Census Long Term Limiting Illness )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 81.38763 Tm
(The non-response survey results and comparisons with Welsh GPRD estimate\
s provide evidence that the )Tj
T*
(survey estimates may be biased upwards. Comparisons with 1991 Census lon\
g term limiting illness also )Tj
T*
(support this. However the correlation between age standardised 1991 Cens\
us rates for individual )Tj
ET
EMC
Q
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(authorities and age standardised estimates from the WHS is high \(0.96\)\
. These results indicate that the )Tj
0 -1.2 TD
(survey over-estimates absolute prevalence for each unitary authority and\
for Wales as a whole, but is )Tj
T*
(reliable in terms of estimating relative prevalence across unitary autho\
rities. As it is the latter that )Tj
T*
(determines resource allocation in the proposed formula the upwards bias \
does not invalidate the survey for )Tj
T*
(use in the proposed formula. )Tj
ET
EMC
/P <>BDC
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/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 653.26176 Tm
(Sampling error )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 618.04214 Tm
(Sampling error is the error that arises because the estimates are calcul\
ated from a sample of individuals )Tj
T*
(rather than the whole population. The potential impact of sampling error\
s on WHS estimates were )Tj
T*
(estimated and the results indicated that it is not possible to be confid\
ent of correctly ranking all authorities )Tj
T*
(in terms of prevalence for any individual illness using the WHS. However\
there is little evidence that )Tj
T*
(alternative sources of information would provide more accurate rankings \
for individual illnesses. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 516.71193 Tm
(In order to assess the impact of sampling error on resource allocation, \
five possible alternative sets of )Tj
T*
(WHS estimates were simulated. These were estimates that could have been \
obtained by selecting samples )Tj
T*
(from a population with "true" prevalence and variance equal to that esti\
mated from the WHS. The )Tj
T*
(maximum difference between the "true" allocation for any authority and o\
ne of the five simulated )Tj
T*
(allocations was less than half a percent of total resources allocated. H\
owever three authorities gained or )Tj
T*
(lost more than 5% of their "true" allocation in the simulation exercise.\
)Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 398.85406 Tm
(Introduction )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 363.63443 Tm
(The National Assembly for Wales commissioned the Office for National Sta\
tistics to evaluate the )Tj
T*
(reliability of estimates from the Welsh Health Survey \(WHS\) with a vie\
w to advising on their suitability )Tj
T*
(for use in resource allocation. The project was carried out in four stag\
es. These stages were: )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 295.35951 Tm
(1. Assess the general survey methodology. )Tj
T*
(2. Calculate appropriate estimates of variance and confidence intervals.\
)Tj
T*
(3. Compare the WHS estimates with alternative sources of information rel\
ating to health. )Tj
T*
(4. Compare the WHS 1998 estimates with those from the 1995 Welsh Health \
Survey )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 210.55695 Tm
(Reports from the first three stages have been completed and this report \
combines and summarises these. )Tj
T*
(The fourth stage report is not yet finalised. )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
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(Potential sources and structure of the report )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 123.59004 Tm
(All sample survey results are subject to error. The aim of the evaluatio\
n was to assess potential sources of )Tj
T*
(error in the survey estimates and to determine whether these are of suff\
icient magnitude to preclude the )Tj
T*
(use of WHS estimates for resource allocation purposes. Errors can be div\
ided into two main categories: )Tj
T*
(sampling and non-sampling error. Sampling error is the error that arises\
because the estimates are )Tj
T*
(calculated from a sample of individuals rather than the whole population\
. Non-sampling error consists of )Tj
T*
(all other sources of error in the survey results. )Tj
ET
EMC
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(Non-sampling error arises from many different sources e.g. differences i\
n response rates between different )Tj
0 -1.2 TD
(groups of individuals \(non-response error\), data processing errors and\
mistakes made by respondents )Tj
T*
(\(respondent error\). Non-sampling error can lead to a tendency to over \
or under estimate the population )Tj
T*
(total or proportion. This tendency for an estimate to be too large or to\
o small is called bias. Stage 1 of the )Tj
T*
(evaluation assessed the overall survey methodology to examine whether su\
bstantial non-sampling errors )Tj
T*
(were likely to arise as a result of flaws in the survey methodology used\
. Stage 3 of the evaluation )Tj
T*
(compared WHS results with external information sources to assess whether\
there is evidence of )Tj
T*
(substantial bias and the potential impact of any identified bias on reso\
urce allocation. The results from )Tj
T*
(Stages 1 and 3 are reported in Section 4 of this report and in Appendice\
s I and II. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 569.29648 Tm
(The potential effect of sampling error on survey results is usually meas\
ured by the standard error of survey )Tj
T*
(estimates. This measures how close the total or proportion estimated fro\
m the survey is likely to be to the )Tj
T*
(true value on average. The smaller is the estimated standard error the m\
ore confident we can be that the )Tj
T*
(survey estimate is close to the true value. Standard errors can be estim\
ated from the survey results and )Tj
T*
(used to calculate confidence intervals for survey totals or proportions.\
These are ranges around the )Tj
T*
(estimated value within which the true value would be likely to lie \(ass\
uming there were no non-sampling )Tj
T*
(errors\). Stage 2 of the evaluation aimed to assess sampling error by ca\
lculating appropriate standard errors )Tj
T*
(and confidence intervals. The results are reported in Section 4 of this \
report and in Appendices IV and V. )Tj
T*
(Appendix III describes the methodology used to estimate the confidence i\
ntervals. )Tj
ET
EMC
/P <>BDC
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/T1_0 1 Tf
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(Section 5 of the report briefly considers alternative sources of informa\
tion on health and whether, in the )Tj
T*
(light of the results from Stages 1, 2 and 3 it appears that any of these\
might provide suitable alternatives or )Tj
T*
(supplements to the WHS results for use in a resource allocation formula.\
)Tj
ET
EMC
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/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 333.58075 Tm
(Assessment of non-sampling error )Tj
ET
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/T1_2 1 Tf
13.77304 0 0 13.77304 9.83789 298.36113 Tm
(Survey methodology )Tj
ET
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/P <>BDC
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/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 263.14149 Tm
(Stage 1 of the project assessed the overall survey methodology to examin\
e whether substantial non-)Tj
T*
(sampling errors were likely to arise as a result of flaws in the survey \
methods used. In general the )Tj
T*
(methodology was found to be sound. The weighting method used was appropr\
iate for correcting for bias )Tj
T*
(caused by varying unit response rates across age groups, gender and unit\
ary authority. No additional )Tj
T*
(adjustment was made for item non-response i.e. individuals who answered \
the questionnaire but didn\222t )Tj
T*
(answer a particular question. However this was taken into account in the\
estimates provided in Stage 2 of )Tj
T*
(this project and reported in Section 4 and Appendix IV. )Tj
ET
EMC
/P <>BDC
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/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 128.75598 Tm
(In general the survey report provided adequate information about the met\
hodology used to reduce )Tj
T*
(respondent and processing error. The survey returns were edited to ident\
ify and remove inconsistent or )Tj
T*
(implausible responses. The percentage of cases that failed edit rules wa\
s reported to be less than 0.1% for )Tj
T*
(almost all edit checks. This indicates a low rate of respondent error. T\
en percent of cases were verified )Tj
T*
(after data entry and prior to editing. However no information is given a\
bout the outcome of this 10% )Tj
T*
(verification i.e. what percentage of verified cases were found to have k\
eying errors. Therefore it is not )Tj
ET
EMC
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/T1_0 1 Tf
0 Tc 0 Tw 0 Ts 100 Tz 0 Tr 13.77304 0 0 13.77304 9.83789 754.592 Tm
(possible to assess the potential magnitude of processing errors. It is r\
ecommended that this information be )Tj
0 -1.2 TD
(provided in future Welsh Health Surveys. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 9.83789 703.75467 Tm
(Welsh Health Survey 1998, Results of the Second Welsh Health Survey, Gov\
ernment Statistical Service 1999 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 668.89644 Tm
(The Welsh Health Survey used electoral roles as the sampling frame. This\
has the advantage of including )Tj
T*
(named individuals. However it is likely to be less complete and up to da\
te than the most commonly used )Tj
T*
(alternative: the Post Office, Postcode Address File \(PAF\). This is a p\
otential source of bias but will only )Tj
T*
(be a major problem if individuals who move frequently have different hea\
lth needs to those who remain in )Tj
T*
(the area for longer. The use of the electoral role also means that relia\
ble estimates from the survey will not )Tj
T*
(be available for individuals aged under 18. However the proposed resourc\
e allocation formula uses )Tj
T*
(alternative sources of information for services to those under 18. )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 534.51093 Tm
(Validation against alternative sources of information )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 499.29131 Tm
(Although the WHS methodology was generally found to be sound there is st\
ill potential for non-sampling )Tj
T*
(errors. Variations in response rates by age, gender and unitary authorit\
y should be largely corrected for by )Tj
T*
(the weighting or stratification methods used in the estimates. However t\
here are other potential variations )Tj
T*
(in response rates e.g. by social class that may have lead to bias in the\
WHS estimates. In addition despite a )Tj
T*
(sound methodology some respondent and processing errors are almost certa\
in to remain in the survey data. )Tj
T*
(Therefore comparisons with external information sources were carried out\
in order to assess whether there )Tj
T*
(is evidence of substantial bias and the potential impact of any identifi\
ed bias on resource allocation. )Tj
ET
EMC
/P <>BDC
BT
/T1_2 1 Tf
13.77304 0 0 13.77304 9.83789 364.90579 Tm
(Comparisons with the Welsh public health common dataset \(PHCD\) )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 329.68616 Tm
(The public health common dataset \(PHCD\) contains statistics on health \
by unitary authority from a range )Tj
T*
(of administrative sources e.g. hospital episode statistics, death and ca\
ncer registrations. For most types of )Tj
T*
(illness there is no statistic within the PHCD that is directly comparabl\
e with the survey estimates in terms )Tj
T*
(of the question asked, age profile of the respondents and reporting time\
scale. However there are several )Tj
T*
(instances where some correlation might be expected between the unitary a\
uthority rates from the PHCD )Tj
T*
(and those from the WHS. Administrative data sources are also subject to \
error and this coupled with the )Tj
T*
(differences in definitions for the two sources mean that strong correlat\
ions would not be expected. )Tj
T*
(However negative correlation or complete absence of correlation for all \
illnesses would be evidence for )Tj
T*
(unreliability in the survey. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 162.24536 Tm
(Estimated rates of illness from seven Welsh Health Survey questions were\
used in the comparisons: )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 127.02573 Tm
(Q28 Have you ever been treated for any of these heart diseases? )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 91.80611 Tm
(Q29 Have you ever been treated for cancer? )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 56.58647 Tm
(Q30 Do you have any of these chest troubles or breathing difficulties no\
w? )Tj
ET
EMC
Q
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(2 )Tj
12.71358 0 0 12.71358 17.46603 751.95688 Tm
(Wales NHS Resource Allocation Review, Independent Report of the Research\
Team by David Gordon, Elizabeth )Tj
-0.60001 -1.2 Td
(Lloyd, Martyn Senior, Jan Rigby, Mary Shaw and Yoav Ben Shlomo )Tj
ET
EMC
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/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 701.84236 Tm
(Q31 Do you have any mental or nervous illness now that you have had for \
3 months or more )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 666.62273 Tm
(Q32 Do you have any of these conditions now? )Tj
0 -1.2 TD
(Arthritis )Tj
T*
(Back Pain )Tj
T*
(Stroke )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 581.82016 Tm
(Q33 Do you have diabetes? )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 546.60052 Tm
(The estimated rates from the survey were compared with crude rates from \
the PHCD for hospital episodes )Tj
T*
(and discharges and cancer and death registrations for related illnesses.\
The calculated Pearson correlation )Tj
T*
(co-efficients are given in Appendix I. A signficant positive correlation\
coefficient is evidence of a positive )Tj
T*
(association between the two measures being compared. There was significa\
nt positive correlation between )Tj
T*
(the estimates for the survey and at least one PHCD statistic for all que\
stions except Q31 \(mental illness\) )Tj
T*
(and Q33 \(diabetes\). This does not necessarily indicate that the health\
survey estimates for mental illness )Tj
T*
(and diabetes are unreliable as these conditions will not usually be the \
direct cause of a hospital episode or )Tj
T*
(of death. However the use of the estimate for mental illness in resource\
allocation will be inappropriate if )Tj
T*
(a high proportion of treatment costs for mental illness are attributable\
to hospital stays and there is no )Tj
T*
(relationship between general mental health and mental illness requiring \
hospital treatment. )Tj
ET
EMC
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/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 362.63208 Tm
(Comparisons with the Welsh Health Survey non-response survey )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 327.41245 Tm
(The National Assembly for Wales commissioned NOP to carry out a sample s\
urvey of non-respondents to )Tj
T*
(the Welsh Health Survey. Face to face interviews were carried out with 6\
01 individuals who had not )Tj
T*
(responded to the postal survey. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 259.13753 Tm
(The results from the non-response survey indicated that there might be a\
higher response rate for people )Tj
T*
(who were ill than for people with no illness particularly for heart dise\
ase. The results from the Welsh )Tj
T*
(Health Survey and those from the non-response survey for a selection of \
illnesses are shown in Table 1. )Tj
T*
(Unfortunately it is not possible to carry out statistical tests to asses\
s whether the differences are significant )Tj
T*
(because the individual responses from the non-response survey are no lon\
ger available and the reported )Tj
T*
(results were weighted by unitary authority. )Tj
ET
EMC
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/T1_2 1 Tf
13.77304 0 0 13.77304 9.83789 141.27966 Tm
(Table 1: Percentage rates of illness from the WHS compared to the non-re\
sponse survey )Tj
ET
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13.77304 0 0 13.77304 19.67577 96.22215 Tm
(Illness )Tj
ET
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/T1_0 1 Tf
13.77304 0 0 13.77304 103.87189 96.22215 Tm
(Age 18-24 )Tj
ET
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/T1_0 1 Tf
13.77304 0 0 13.77304 272.26414 96.22215 Tm
(Age 35-54 )Tj
ET
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/T1_0 1 Tf
13.77304 0 0 13.77304 440.65639 96.22215 Tm
(Age 55+ )Tj
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Q
0.45726 0.44862 0.43137 rg
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600.19453 582.37859 l
599.21074 581.39479 l
517.966 581.39479 l
h
f
516.98221 582.37859 m
516.98221 550.11032 l
517.966 551.09412 l
517.966 581.39479 l
h
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0.94942 0.9447 0.93529 rg
600.19453 582.37859 m
600.19453 550.11032 l
599.21074 551.09412 l
599.21074 581.39479 l
h
f
516.98221 550.11032 m
600.19453 550.11032 l
599.21074 551.09412 l
517.966 551.09412 l
h
f
EMC
q
0 0 612 792 re
W* n
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Q
0.45726 0.44862 0.43137 rg
11.80547 549.12653 m
95.01779 549.12653 l
94.034 548.14273 l
12.78926 548.14273 l
h
f
11.80547 549.12653 m
11.80547 516.85826 l
12.78926 517.84206 l
12.78926 548.14273 l
h
f
0.94942 0.9447 0.93529 rg
95.01779 549.12653 m
95.01779 516.85826 l
94.034 517.84206 l
94.034 548.14273 l
h
f
11.80547 516.85826 m
95.01779 516.85826 l
94.034 517.84206 l
12.78926 517.84206 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
96.00159 549.12653 m
179.21391 549.12653 l
178.23012 548.14273 l
96.98538 548.14273 l
h
f
96.00159 549.12653 m
96.00159 516.85826 l
96.98538 517.84206 l
96.98538 548.14273 l
h
f
0.94942 0.9447 0.93529 rg
179.21391 549.12653 m
179.21391 516.85826 l
178.23012 517.84206 l
178.23012 548.14273 l
h
f
96.00159 516.85826 m
179.21391 516.85826 l
178.23012 517.84206 l
96.98538 517.84206 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
180.19771 549.12653 m
263.41005 549.12653 l
262.42625 548.14273 l
181.1815 548.14273 l
h
f
180.19771 549.12653 m
180.19771 516.85826 l
181.1815 517.84206 l
181.1815 548.14273 l
h
f
0.94942 0.9447 0.93529 rg
263.41005 549.12653 m
263.41005 516.85826 l
262.42625 517.84206 l
262.42625 548.14273 l
h
f
180.19771 516.85826 m
263.41005 516.85826 l
262.42625 517.84206 l
181.1815 517.84206 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
264.39383 549.12653 m
347.60617 549.12653 l
346.62238 548.14273 l
265.37762 548.14273 l
h
f
264.39383 549.12653 m
264.39383 516.85826 l
265.37762 517.84206 l
265.37762 548.14273 l
h
f
0.94942 0.9447 0.93529 rg
347.60617 549.12653 m
347.60617 516.85826 l
346.62238 517.84206 l
346.62238 548.14273 l
h
f
264.39383 516.85826 m
347.60617 516.85826 l
346.62238 517.84206 l
265.37762 517.84206 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
348.58995 549.12653 m
431.80229 549.12653 l
430.8185 548.14273 l
349.57375 548.14273 l
h
f
348.58995 549.12653 m
348.58995 516.85826 l
349.57375 517.84206 l
349.57375 548.14273 l
h
f
0.94942 0.9447 0.93529 rg
431.80229 549.12653 m
431.80229 516.85826 l
430.8185 517.84206 l
430.8185 548.14273 l
h
f
348.58995 516.85826 m
431.80229 516.85826 l
430.8185 517.84206 l
349.57375 517.84206 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
432.78609 549.12653 m
515.99841 549.12653 l
515.01462 548.14273 l
433.76988 548.14273 l
h
f
432.78609 549.12653 m
432.78609 516.85826 l
433.76988 517.84206 l
433.76988 548.14273 l
h
f
0.94942 0.9447 0.93529 rg
515.99841 549.12653 m
515.99841 516.85826 l
515.01462 517.84206 l
515.01462 548.14273 l
h
f
432.78609 516.85826 m
515.99841 516.85826 l
515.01462 517.84206 l
433.76988 517.84206 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
516.98221 549.12653 m
600.19453 549.12653 l
599.21074 548.14273 l
517.966 548.14273 l
h
f
516.98221 549.12653 m
516.98221 516.85826 l
517.966 517.84206 l
517.966 548.14273 l
h
f
0.94942 0.9447 0.93529 rg
600.19453 549.12653 m
600.19453 516.85826 l
599.21074 517.84206 l
599.21074 548.14273 l
h
f
516.98221 516.85826 m
600.19453 516.85826 l
599.21074 517.84206 l
517.966 517.84206 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
11.80547 515.87448 m
95.01779 515.87448 l
94.034 514.89069 l
12.78926 514.89069 l
h
f
11.80547 515.87448 m
11.80547 483.60622 l
12.78926 484.59001 l
12.78926 514.89069 l
h
f
0.94942 0.9447 0.93529 rg
95.01779 515.87448 m
95.01779 483.60622 l
94.034 484.59001 l
94.034 514.89069 l
h
f
11.80547 483.60622 m
95.01779 483.60622 l
94.034 484.59001 l
12.78926 484.59001 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
96.00159 515.87448 m
179.21391 515.87448 l
178.23012 514.89069 l
96.98538 514.89069 l
h
f
96.00159 515.87448 m
96.00159 483.60622 l
96.98538 484.59001 l
96.98538 514.89069 l
h
f
0.94942 0.9447 0.93529 rg
179.21391 515.87448 m
179.21391 483.60622 l
178.23012 484.59001 l
178.23012 514.89069 l
h
f
96.00159 483.60622 m
179.21391 483.60622 l
178.23012 484.59001 l
96.98538 484.59001 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
180.19771 515.87448 m
263.41005 515.87448 l
262.42625 514.89069 l
181.1815 514.89069 l
h
f
180.19771 515.87448 m
180.19771 483.60622 l
181.1815 484.59001 l
181.1815 514.89069 l
h
f
0.94942 0.9447 0.93529 rg
263.41005 515.87448 m
263.41005 483.60622 l
262.42625 484.59001 l
262.42625 514.89069 l
h
f
180.19771 483.60622 m
263.41005 483.60622 l
262.42625 484.59001 l
181.1815 484.59001 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
264.39383 515.87448 m
347.60617 515.87448 l
346.62238 514.89069 l
265.37762 514.89069 l
h
f
264.39383 515.87448 m
264.39383 483.60622 l
265.37762 484.59001 l
265.37762 514.89069 l
h
f
0.94942 0.9447 0.93529 rg
347.60617 515.87448 m
347.60617 483.60622 l
346.62238 484.59001 l
346.62238 514.89069 l
h
f
264.39383 483.60622 m
347.60617 483.60622 l
346.62238 484.59001 l
265.37762 484.59001 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
348.58995 515.87448 m
431.80229 515.87448 l
430.8185 514.89069 l
349.57375 514.89069 l
h
f
348.58995 515.87448 m
348.58995 483.60622 l
349.57375 484.59001 l
349.57375 514.89069 l
h
f
0.94942 0.9447 0.93529 rg
431.80229 515.87448 m
431.80229 483.60622 l
430.8185 484.59001 l
430.8185 514.89069 l
h
f
348.58995 483.60622 m
431.80229 483.60622 l
430.8185 484.59001 l
349.57375 484.59001 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
432.78609 515.87448 m
515.99841 515.87448 l
515.01462 514.89069 l
433.76988 514.89069 l
h
f
432.78609 515.87448 m
432.78609 483.60622 l
433.76988 484.59001 l
433.76988 514.89069 l
h
f
0.94942 0.9447 0.93529 rg
515.99841 515.87448 m
515.99841 483.60622 l
515.01462 484.59001 l
515.01462 514.89069 l
h
f
432.78609 483.60622 m
515.99841 483.60622 l
515.01462 484.59001 l
433.76988 484.59001 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
516.98221 515.87448 m
600.19453 515.87448 l
599.21074 514.89069 l
517.966 514.89069 l
h
f
516.98221 515.87448 m
516.98221 483.60622 l
517.966 484.59001 l
517.966 514.89069 l
h
f
0.94942 0.9447 0.93529 rg
600.19453 515.87448 m
600.19453 483.60622 l
599.21074 484.59001 l
599.21074 514.89069 l
h
f
516.98221 483.60622 m
600.19453 483.60622 l
599.21074 484.59001 l
517.966 484.59001 l
h
f
EMC
EMC
EMC
/P <>BDC
q
0 0 612 792 re
W* n
0 0 0 rg
BT
/T1_0 1 Tf
0 Tc 0 Tw 0 Ts 100 Tz 0 Tr 13.77304 0 0 13.77304 103.87189 745.26991 Tm
(WHS )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 188.06802 745.26991 Tm
(Non-)Tj
0 -1.2 TD
(response )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 272.26414 745.26991 Tm
(WHS )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 356.46027 745.26991 Tm
(Non-)Tj
T*
(response )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 440.65639 745.26991 Tm
(WHS )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 524.85251 745.26991 Tm
(Non-)Tj
T*
(response )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 19.67577 695.49022 Tm
(Heart )Tj
T*
(Disease )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 103.87189 695.49022 Tm
(2.8 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 188.06802 695.49022 Tm
(0 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 272.26414 695.49022 Tm
(12.4 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 356.46027 695.49022 Tm
(3 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 440.65639 695.49022 Tm
(40.4 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 524.85251 695.49022 Tm
(16 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 19.67577 645.71051 Tm
(Cancer )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 103.87189 645.71051 Tm
(1.0 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 188.06802 645.71051 Tm
(1 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 272.26414 645.71051 Tm
(3.9 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 356.46027 645.71051 Tm
(3 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 440.65639 645.71051 Tm
(9.3 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 524.85251 645.71051 Tm
(6 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 19.67577 612.45847 Tm
(Mental )Tj
T*
(Illness )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 103.87189 612.45847 Tm
(9.6 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 188.06802 612.45847 Tm
(5 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 272.26414 612.45847 Tm
(15.0 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 356.46027 612.45847 Tm
(10 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 440.65639 612.45847 Tm
(14.4 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 524.85251 612.45847 Tm
(14 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 19.67577 562.67876 Tm
(Diabetes )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 103.87189 562.67876 Tm
(0.6 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 188.06802 562.67876 Tm
(0 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 272.26414 562.67876 Tm
(2.0 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 356.46027 562.67876 Tm
(2 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 440.65639 562.67876 Tm
(7.4 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 524.85251 562.67876 Tm
(3 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 19.67577 529.42671 Tm
(Arthritis )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 103.87189 529.42671 Tm
(3.6 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 188.06802 529.42671 Tm
(6 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 272.26414 529.42671 Tm
(18.7 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 356.46027 529.42671 Tm
(11 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 440.65639 529.42671 Tm
(46 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 524.85251 529.42671 Tm
(43 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 19.67577 496.17467 Tm
(Back Pain )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 103.87189 496.17467 Tm
(18.5 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 188.06802 496.17467 Tm
(21 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 272.26414 496.17467 Tm
(32.0 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 356.46027 496.17467 Tm
(34 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 440.65639 496.17467 Tm
(36.4 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 524.85251 496.17467 Tm
(42 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
10.59465 0 0 10.59465 9.83789 453.84703 Tm
(Notes: WHS : % of respondents to WHS who stated that they had the illnes\
s weighted by unitary authority \(Total respondents: 2987)Tj
(4\). )Tj
T*
(Non-response: % of respondents to Non-response Survey who stated that th\
ey had the illness weighted by unitary authority \(Total )Tj
T*
(respondents: 552\). )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
10.17085 0 0 10.17085 9.83789 397.12404 Tm
(3 )Tj
12.71358 0 0 12.71358 17.46603 393.86937 Tm
(Welsh Health '98 Non Response Survey, Tabulations prepared for the Welsh\
Office by NOP Social & Political, )Tj
-0.60001 -1.2 Td
(November 1998. )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 343.75484 Tm
(Comparisons with General Practice Research Database \(GPRD\) )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 308.53522 Tm
(In order to examine the potential upward bias in estimates more fully, c\
omparisons were made with )Tj
T*
(information from the GPRD. The following questions from the WHS were use\
d in the comparisons: )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 256.78793 Tm
(Q28 Have you ever been treated for any of these heart diseases? )Tj
T*
(Yes: high blood pressure \(or hypertension\) )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 205.04066 Tm
(Q30 Do you have any of these chest troubles or breathing difficulties no\
w? )Tj
T*
(Yes: Asthma )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 153.29338 Tm
(Q31 Do you have any mental or nervous illness now that you have had for \
3 months or more )Tj
T*
(Yes: Depression )Tj
T*
(Yes: Anxiety )Tj
T*
(Yes: Schizophrenia )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 68.49081 Tm
(Q32 Do you have any of these conditions now? )Tj
T*
(Yes: Stroke )Tj
ET
EMC
Q
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9.83789 149.37885 m
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602.16211 149.37885 m
602.16211 35.41638 l
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0 Tc 0 Tw 0 Ts 100 Tz 0 Tr 13.77304 0 0 13.77304 9.83789 747.74866 Tm
(Q33 Do you have diabetes? )Tj
0 -1.2 TD
(Yes and it's treated by injection )Tj
ET
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BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 696.00137 Tm
(The results are shown in Appendix II. For hypertension and stroke the WH\
S estimates are higher than )Tj
T*
(those from the GRPD but this is to be expected due to the different time\
scales being considered. The )Tj
T*
(GRPD relates to treatment or incidence in the last four years whereas Q2\
8 asks if treatment has ever been )Tj
T*
(received and Q32 could be interpreted as meaning "have you ever had a st\
roke?". The GPRD prevalence )Tj
T*
(rates for insulin treated diabetes and for schizophrenia are within the \
confidence intervals for the WHS )Tj
T*
(estimates. For asthma, depression and anxiety there is some evidence tha\
t the WHS estimates are too high )Tj
T*
(for those under 65. )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 561.61588 Tm
(Comparisons with Long Term Limiting Illness from 1991 Census )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 526.39624 Tm
(The 1991 Census contains information on the prevalence of long term limi\
ting illness for the population. )Tj
T*
(As this is the only reliable source of information relating to illness f\
or the whole population it may be )Tj
T*
(useful to compare the rates recorded in the Census with those recorded i\
n the WHS. Some changes in )Tj
T*
(prevalence between 1991 and 1998 would be expected due to population mov\
ements, ageing, births and )Tj
T*
(deaths and also to changes in health. However strong correlation between\
age standardised rates would be )Tj
T*
(expected. Table 2 shows rates of long term limiting illness from the WHS\
and the 1991 Census age )Tj
T*
(standardised to the 1998 population estimates for Wales. As can be seen \
the estimates from the WHS are )Tj
T*
(substantially higher. However the correlation between the unitary author\
ity estimates from the WHS and )Tj
T*
(those from the Census is high at 0.96. )Tj
ET
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(4 )Tj
12.71358 0 0 12.71358 17.46603 358.54036 Tm
(Key Health Statistics from General Practice 1998, Series MB6 no 2 publis\
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ET
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(Some comparisons were made in the report of the Bristol University resea\
rch team. As noted in that report )Tj
T*
(the WHS question is worded to specifically include disability as well as\
illness whereas the Census )Tj
T*
(question did not mention disability. In addition there is some evidence \
that Census estimates slightly )Tj
T*
(underestimate true prevalence by around 2 percentage points. However the\
se factors could not account for )Tj
T*
(such large differences between the WHS and the Census. These results pro\
vide further evidence that )Tj
T*
(individuals who are ill are more likely to respond to the WHS leading to\
an upwards bias in estimated )Tj
T*
(prevalence rates. )Tj
ET
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13.77304 0 0 13.77304 9.83789 189.29662 Tm
(Table 2: Rates of long term limiting illness for persons aged 30 or over\
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T*
(mid-year population estimates for Wales )Tj
ET
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/T1_0 1 Tf
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( )Tj
ET
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(Welsh Health )Tj
1.194 -1.2 Td
(Survey* )Tj
ET
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/T1_0 1 Tf
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(1991 Census )Tj
ET
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(Difference \(WHS-)Tj
2.0955 -1.2 Td
(Census\) )Tj
ET
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/T1_0 1 Tf
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(Isle of Anglesey )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 307.51808 77.93176 Tm
(37% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 437.29816 77.93176 Tm
(22% )Tj
ET
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/T1_0 1 Tf
13.77304 0 0 13.77304 578.55119 77.93176 Tm
(16 )Tj
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469.43066 165.5495 l
h
f
341.61816 134.26503 m
470.41446 134.26503 l
469.43066 135.24883 l
342.60196 135.24883 l
h
f
EMC
q
0 0 612 792 re
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471.39824 166.53329 m
600.19453 166.53329 l
599.21074 165.5495 l
472.38203 165.5495 l
h
f
471.39824 166.53329 m
471.39824 134.26503 l
472.38203 135.24883 l
472.38203 165.5495 l
h
f
0.94942 0.9447 0.93529 rg
600.19453 166.53329 m
600.19453 134.26503 l
599.21074 135.24883 l
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h
f
471.39824 134.26503 m
600.19453 134.26503 l
599.21074 135.24883 l
472.38203 135.24883 l
h
f
EMC
q
0 0 612 792 re
W* n
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Q
0.45726 0.44862 0.43137 rg
11.80547 133.28125 m
210.85428 133.28125 l
209.87048 132.29745 l
12.78926 132.29745 l
h
f
11.80547 133.28125 m
11.80547 101.01299 l
12.78926 101.99678 l
12.78926 132.29745 l
h
f
0.94942 0.9447 0.93529 rg
210.85428 133.28125 m
210.85428 101.01299 l
209.87048 101.99678 l
209.87048 132.29745 l
h
f
11.80547 101.01299 m
210.85428 101.01299 l
209.87048 101.99678 l
12.78926 101.99678 l
h
f
EMC
q
0 0 612 792 re
W* n
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0.45726 0.44862 0.43137 rg
211.83807 133.28125 m
340.63437 133.28125 l
339.65057 132.29745 l
212.82187 132.29745 l
h
f
211.83807 133.28125 m
211.83807 101.01299 l
212.82187 101.99678 l
212.82187 132.29745 l
h
f
0.94942 0.9447 0.93529 rg
340.63437 133.28125 m
340.63437 101.01299 l
339.65057 101.99678 l
339.65057 132.29745 l
h
f
211.83807 101.01299 m
340.63437 101.01299 l
339.65057 101.99678 l
212.82187 101.99678 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
341.61816 133.28125 m
470.41446 133.28125 l
469.43066 132.29745 l
342.60196 132.29745 l
h
f
341.61816 133.28125 m
341.61816 101.01299 l
342.60196 101.99678 l
342.60196 132.29745 l
h
f
0.94942 0.9447 0.93529 rg
470.41446 133.28125 m
470.41446 101.01299 l
469.43066 101.99678 l
469.43066 132.29745 l
h
f
341.61816 101.01299 m
470.41446 101.01299 l
469.43066 101.99678 l
342.60196 101.99678 l
h
f
EMC
q
0 0 612 792 re
W* n
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0.45726 0.44862 0.43137 rg
471.39824 133.28125 m
600.19453 133.28125 l
599.21074 132.29745 l
472.38203 132.29745 l
h
f
471.39824 133.28125 m
471.39824 101.01299 l
472.38203 101.99678 l
472.38203 132.29745 l
h
f
0.94942 0.9447 0.93529 rg
600.19453 133.28125 m
600.19453 101.01299 l
599.21074 101.99678 l
599.21074 132.29745 l
h
f
471.39824 101.01299 m
600.19453 101.01299 l
599.21074 101.99678 l
472.38203 101.99678 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
11.80547 100.02919 m
210.85428 100.02919 l
209.87048 99.04539 l
12.78926 99.04539 l
h
f
11.80547 100.02919 m
11.80547 67.76093 l
12.78926 68.74472 l
12.78926 99.04539 l
h
f
0.94942 0.9447 0.93529 rg
210.85428 100.02919 m
210.85428 67.76093 l
209.87048 68.74472 l
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h
f
11.80547 67.76093 m
210.85428 67.76093 l
209.87048 68.74472 l
12.78926 68.74472 l
h
f
EMC
q
0 0 612 792 re
W* n
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Q
0.45726 0.44862 0.43137 rg
211.83807 100.02919 m
340.63437 100.02919 l
339.65057 99.04539 l
212.82187 99.04539 l
h
f
211.83807 100.02919 m
211.83807 67.76093 l
212.82187 68.74472 l
212.82187 99.04539 l
h
f
0.94942 0.9447 0.93529 rg
340.63437 100.02919 m
340.63437 67.76093 l
339.65057 68.74472 l
339.65057 99.04539 l
h
f
211.83807 67.76093 m
340.63437 67.76093 l
339.65057 68.74472 l
212.82187 68.74472 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
341.61816 100.02919 m
470.41446 100.02919 l
469.43066 99.04539 l
342.60196 99.04539 l
h
f
341.61816 100.02919 m
341.61816 67.76093 l
342.60196 68.74472 l
342.60196 99.04539 l
h
f
0.94942 0.9447 0.93529 rg
470.41446 100.02919 m
470.41446 67.76093 l
469.43066 68.74472 l
469.43066 99.04539 l
h
f
341.61816 67.76093 m
470.41446 67.76093 l
469.43066 68.74472 l
342.60196 68.74472 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
471.39824 100.02919 m
600.19453 100.02919 l
599.21074 99.04539 l
472.38203 99.04539 l
h
f
471.39824 100.02919 m
471.39824 67.76093 l
472.38203 68.74472 l
472.38203 99.04539 l
h
f
0.94942 0.9447 0.93529 rg
600.19453 100.02919 m
600.19453 67.76093 l
599.21074 68.74472 l
599.21074 99.04539 l
h
f
471.39824 67.76093 m
600.19453 67.76093 l
599.21074 68.74472 l
472.38203 68.74472 l
h
f
EMC
EMC
EMC
/P <>BDC
q
0 0 612 792 re
W* n
0 0 0 rg
BT
/T1_0 1 Tf
0 Tc 0 Tw 0 Ts 100 Tz 0 Tr 13.77304 0 0 13.77304 19.67577 745.37041 Tm
(Gwynedd )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 307.51808 745.37041 Tm
(35% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 437.29816 745.37041 Tm
(21% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 578.55119 745.37041 Tm
(14 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 19.67577 712.11836 Tm
(Conwy )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 307.51808 712.11836 Tm
(38% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 437.29816 712.11836 Tm
(22% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 578.55119 712.11836 Tm
(16 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 19.67577 678.8663 Tm
(Denbighshire )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 307.51808 678.8663 Tm
(38% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 437.29816 678.8663 Tm
(24% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 578.55119 678.8663 Tm
(14 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 19.67577 645.61426 Tm
(Flintshire )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 307.51808 645.61426 Tm
(37% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 437.29816 645.61426 Tm
(22% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 578.55119 645.61426 Tm
(14 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 19.67577 612.3622 Tm
(Wrexham )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 307.51808 612.3622 Tm
(36% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 437.29816 612.3622 Tm
(25% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 578.55119 612.3622 Tm
(12 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 19.67577 579.11015 Tm
(Powys )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 307.51808 579.11015 Tm
(34% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 437.29816 579.11015 Tm
(20% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 578.55119 579.11015 Tm
(14 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 19.67577 545.85809 Tm
(Ceredigion )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 307.51808 545.85809 Tm
(35% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 437.29816 545.85809 Tm
(20% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 578.55119 545.85809 Tm
(15 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 19.67577 512.60605 Tm
(Pembrokeshire )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 307.51808 512.60605 Tm
(37% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 437.29816 512.60605 Tm
(21% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 578.55119 512.60605 Tm
(15 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 19.67577 479.35399 Tm
(Carmarthenshire )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 307.51808 479.35399 Tm
(41% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 437.29816 479.35399 Tm
(27% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 578.55119 479.35399 Tm
(15 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 19.67577 446.10194 Tm
(Swansea )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 307.51808 446.10194 Tm
(41% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 437.29816 446.10194 Tm
(27% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 578.55119 446.10194 Tm
(15 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 19.67577 412.8499 Tm
(Neath Port Talbot )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 307.51808 412.8499 Tm
(45% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 437.29816 412.8499 Tm
(32% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 578.55119 412.8499 Tm
(13 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 19.67577 379.59784 Tm
(Bridgend )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 307.51808 379.59784 Tm
(42% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 437.29816 379.59784 Tm
(29% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 578.55119 379.59784 Tm
(13 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 19.67577 346.34579 Tm
(Vale of Glamorgan )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 307.51808 346.34579 Tm
(35% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 437.29816 346.34579 Tm
(22% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 578.55119 346.34579 Tm
(13 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 19.67577 313.09373 Tm
(Cardiff )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 307.51808 313.09373 Tm
(38% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 437.29816 313.09373 Tm
(23% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 578.55119 313.09373 Tm
(14 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 19.67577 279.84169 Tm
(Rhondda, Cynon, Taff )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 307.51808 279.84169 Tm
(45% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 437.29816 279.84169 Tm
(34% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 578.55119 279.84169 Tm
(11 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 19.67577 246.58963 Tm
(Merthyr Tydfil )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 307.51808 246.58963 Tm
(51% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 437.29816 246.58963 Tm
(35% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 578.55119 246.58963 Tm
(16 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 19.67577 213.33759 Tm
(Caerphilly )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 307.51808 213.33759 Tm
(48% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 437.29816 213.33759 Tm
(33% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 578.55119 213.33759 Tm
(15 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 19.67577 180.08553 Tm
(Blaenau Gwent )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 307.51808 180.08553 Tm
(48% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 437.29816 180.08553 Tm
(33% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 578.55119 180.08553 Tm
(15 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 19.67577 146.83348 Tm
(Torfaen )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 307.51808 146.83348 Tm
(44% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 437.29816 146.83348 Tm
(29% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 578.55119 146.83348 Tm
(15 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 19.67577 113.58142 Tm
(Monmouthshire )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 307.51808 113.58142 Tm
(35% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 437.29816 113.58142 Tm
(20% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 578.55119 113.58142 Tm
(15 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 19.67577 80.32938 Tm
(Newport )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 307.51808 80.32938 Tm
(41% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 437.29816 80.32938 Tm
(25% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 578.55119 80.32938 Tm
(16 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
10.59465 0 0 10.59465 9.83789 38.00175 Tm
(* Respondents who answered "Yes" to Q27: Do you have any long-term illne\
ss, health problem, or handicap which limits your daily )Tj
ET
EMC
Q
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158.43987 224.99031 l
h
f
157.45607 225.97411 m
157.45607 194.9772 l
158.43987 195.961 l
158.43987 224.99031 l
h
f
0.94942 0.9447 0.93529 rg
267.40285 225.97411 m
267.40285 194.9772 l
266.41905 195.961 l
266.41905 224.99031 l
h
f
157.45607 194.9772 m
267.40285 194.9772 l
266.41905 195.961 l
158.43987 195.961 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
268.38663 225.97411 m
378.3334 225.97411 l
377.34961 224.99031 l
269.37042 224.99031 l
h
f
268.38663 225.97411 m
268.38663 194.9772 l
269.37042 195.961 l
269.37042 224.99031 l
h
f
0.94942 0.9447 0.93529 rg
378.3334 225.97411 m
378.3334 194.9772 l
377.34961 195.961 l
377.34961 224.99031 l
h
f
268.38663 194.9772 m
378.3334 194.9772 l
377.34961 195.961 l
269.37042 195.961 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
379.3172 225.97411 m
489.26398 225.97411 l
488.28018 224.99031 l
380.30099 224.99031 l
h
f
379.3172 225.97411 m
379.3172 194.9772 l
380.30099 195.961 l
380.30099 224.99031 l
h
f
0.94942 0.9447 0.93529 rg
489.26398 225.97411 m
489.26398 194.9772 l
488.28018 195.961 l
488.28018 224.99031 l
h
f
379.3172 194.9772 m
489.26398 194.9772 l
488.28018 195.961 l
380.30099 195.961 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
490.24776 225.97411 m
600.19453 225.97411 l
599.21074 224.99031 l
491.23155 224.99031 l
h
f
490.24776 225.97411 m
490.24776 194.9772 l
491.23155 195.961 l
491.23155 224.99031 l
h
f
0.94942 0.9447 0.93529 rg
600.19453 225.97411 m
600.19453 194.9772 l
599.21074 195.961 l
599.21074 224.99031 l
h
f
490.24776 194.9772 m
600.19453 194.9772 l
599.21074 195.961 l
491.23155 195.961 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
11.80547 193.99341 m
156.47227 193.99341 l
155.48848 193.00961 l
12.78926 193.00961 l
h
f
11.80547 193.99341 m
11.80547 162.99651 l
12.78926 163.9803 l
12.78926 193.00961 l
h
f
0.94942 0.9447 0.93529 rg
156.47227 193.99341 m
156.47227 162.99651 l
155.48848 163.9803 l
155.48848 193.00961 l
h
f
11.80547 162.99651 m
156.47227 162.99651 l
155.48848 163.9803 l
12.78926 163.9803 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
157.45607 193.99341 m
267.40285 193.99341 l
266.41905 193.00961 l
158.43987 193.00961 l
h
f
157.45607 193.99341 m
157.45607 162.99651 l
158.43987 163.9803 l
158.43987 193.00961 l
h
f
0.94942 0.9447 0.93529 rg
267.40285 193.99341 m
267.40285 162.99651 l
266.41905 163.9803 l
266.41905 193.00961 l
h
f
157.45607 162.99651 m
267.40285 162.99651 l
266.41905 163.9803 l
158.43987 163.9803 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
268.38663 193.99341 m
378.3334 193.99341 l
377.34961 193.00961 l
269.37042 193.00961 l
h
f
268.38663 193.99341 m
268.38663 162.99651 l
269.37042 163.9803 l
269.37042 193.00961 l
h
f
0.94942 0.9447 0.93529 rg
378.3334 193.99341 m
378.3334 162.99651 l
377.34961 163.9803 l
377.34961 193.00961 l
h
f
268.38663 162.99651 m
378.3334 162.99651 l
377.34961 163.9803 l
269.37042 163.9803 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
379.3172 193.99341 m
489.26398 193.99341 l
488.28018 193.00961 l
380.30099 193.00961 l
h
f
379.3172 193.99341 m
379.3172 162.99651 l
380.30099 163.9803 l
380.30099 193.00961 l
h
f
0.94942 0.9447 0.93529 rg
489.26398 193.99341 m
489.26398 162.99651 l
488.28018 163.9803 l
488.28018 193.00961 l
h
f
379.3172 162.99651 m
489.26398 162.99651 l
488.28018 163.9803 l
380.30099 163.9803 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
490.24776 193.99341 m
600.19453 193.99341 l
599.21074 193.00961 l
491.23155 193.00961 l
h
f
490.24776 193.99341 m
490.24776 162.99651 l
491.23155 163.9803 l
491.23155 193.00961 l
h
f
0.94942 0.9447 0.93529 rg
600.19453 193.99341 m
600.19453 162.99651 l
599.21074 163.9803 l
599.21074 193.00961 l
h
f
490.24776 162.99651 m
600.19453 162.99651 l
599.21074 163.9803 l
491.23155 163.9803 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
11.80547 162.01271 m
156.47227 162.01271 l
155.48848 161.02892 l
12.78926 161.02892 l
h
f
11.80547 162.01271 m
11.80547 131.01581 l
12.78926 131.9996 l
12.78926 161.02892 l
h
f
0.94942 0.9447 0.93529 rg
156.47227 162.01271 m
156.47227 131.01581 l
155.48848 131.9996 l
155.48848 161.02892 l
h
f
11.80547 131.01581 m
156.47227 131.01581 l
155.48848 131.9996 l
12.78926 131.9996 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
157.45607 162.01271 m
267.40285 162.01271 l
266.41905 161.02892 l
158.43987 161.02892 l
h
f
157.45607 162.01271 m
157.45607 131.01581 l
158.43987 131.9996 l
158.43987 161.02892 l
h
f
0.94942 0.9447 0.93529 rg
267.40285 162.01271 m
267.40285 131.01581 l
266.41905 131.9996 l
266.41905 161.02892 l
h
f
157.45607 131.01581 m
267.40285 131.01581 l
266.41905 131.9996 l
158.43987 131.9996 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
268.38663 162.01271 m
378.3334 162.01271 l
377.34961 161.02892 l
269.37042 161.02892 l
h
f
268.38663 162.01271 m
268.38663 131.01581 l
269.37042 131.9996 l
269.37042 161.02892 l
h
f
0.94942 0.9447 0.93529 rg
378.3334 162.01271 m
378.3334 131.01581 l
377.34961 131.9996 l
377.34961 161.02892 l
h
f
268.38663 131.01581 m
378.3334 131.01581 l
377.34961 131.9996 l
269.37042 131.9996 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
379.3172 162.01271 m
489.26398 162.01271 l
488.28018 161.02892 l
380.30099 161.02892 l
h
f
379.3172 162.01271 m
379.3172 131.01581 l
380.30099 131.9996 l
380.30099 161.02892 l
h
f
0.94942 0.9447 0.93529 rg
489.26398 162.01271 m
489.26398 131.01581 l
488.28018 131.9996 l
488.28018 161.02892 l
h
f
379.3172 131.01581 m
489.26398 131.01581 l
488.28018 131.9996 l
380.30099 131.9996 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
490.24776 162.01271 m
600.19453 162.01271 l
599.21074 161.02892 l
491.23155 161.02892 l
h
f
490.24776 162.01271 m
490.24776 131.01581 l
491.23155 131.9996 l
491.23155 161.02892 l
h
f
0.94942 0.9447 0.93529 rg
600.19453 162.01271 m
600.19453 131.01581 l
599.21074 131.9996 l
599.21074 161.02892 l
h
f
490.24776 131.01581 m
600.19453 131.01581 l
599.21074 131.9996 l
491.23155 131.9996 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
11.80547 130.03201 m
156.47227 130.03201 l
155.48848 129.04822 l
12.78926 129.04822 l
h
f
11.80547 130.03201 m
11.80547 99.03511 l
12.78926 100.01891 l
12.78926 129.04822 l
h
f
0.94942 0.9447 0.93529 rg
156.47227 130.03201 m
156.47227 99.03511 l
155.48848 100.01891 l
155.48848 129.04822 l
h
f
11.80547 99.03511 m
156.47227 99.03511 l
155.48848 100.01891 l
12.78926 100.01891 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
157.45607 130.03201 m
267.40285 130.03201 l
266.41905 129.04822 l
158.43987 129.04822 l
h
f
157.45607 130.03201 m
157.45607 99.03511 l
158.43987 100.01891 l
158.43987 129.04822 l
h
f
0.94942 0.9447 0.93529 rg
267.40285 130.03201 m
267.40285 99.03511 l
266.41905 100.01891 l
266.41905 129.04822 l
h
f
157.45607 99.03511 m
267.40285 99.03511 l
266.41905 100.01891 l
158.43987 100.01891 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
268.38663 130.03201 m
378.3334 130.03201 l
377.34961 129.04822 l
269.37042 129.04822 l
h
f
268.38663 130.03201 m
268.38663 99.03511 l
269.37042 100.01891 l
269.37042 129.04822 l
h
f
0.94942 0.9447 0.93529 rg
378.3334 130.03201 m
378.3334 99.03511 l
377.34961 100.01891 l
377.34961 129.04822 l
h
f
268.38663 99.03511 m
378.3334 99.03511 l
377.34961 100.01891 l
269.37042 100.01891 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
379.3172 130.03201 m
489.26398 130.03201 l
488.28018 129.04822 l
380.30099 129.04822 l
h
f
379.3172 130.03201 m
379.3172 99.03511 l
380.30099 100.01891 l
380.30099 129.04822 l
h
f
0.94942 0.9447 0.93529 rg
489.26398 130.03201 m
489.26398 99.03511 l
488.28018 100.01891 l
488.28018 129.04822 l
h
f
379.3172 99.03511 m
489.26398 99.03511 l
488.28018 100.01891 l
380.30099 100.01891 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
490.24776 130.03201 m
600.19453 130.03201 l
599.21074 129.04822 l
491.23155 129.04822 l
h
f
490.24776 130.03201 m
490.24776 99.03511 l
491.23155 100.01891 l
491.23155 129.04822 l
h
f
0.94942 0.9447 0.93529 rg
600.19453 130.03201 m
600.19453 99.03511 l
599.21074 100.01891 l
599.21074 129.04822 l
h
f
490.24776 99.03511 m
600.19453 99.03511 l
599.21074 100.01891 l
491.23155 100.01891 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
11.80547 98.05133 m
156.47227 98.05133 l
155.48848 97.06754 l
12.78926 97.06754 l
h
f
11.80547 98.05133 m
11.80547 67.05441 l
12.78926 68.03821 l
12.78926 97.06754 l
h
f
0.94942 0.9447 0.93529 rg
156.47227 98.05133 m
156.47227 67.05441 l
155.48848 68.03821 l
155.48848 97.06754 l
h
f
11.80547 67.05441 m
156.47227 67.05441 l
155.48848 68.03821 l
12.78926 68.03821 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
157.45607 98.05133 m
267.40285 98.05133 l
266.41905 97.06754 l
158.43987 97.06754 l
h
f
157.45607 98.05133 m
157.45607 67.05441 l
158.43987 68.03821 l
158.43987 97.06754 l
h
f
0.94942 0.9447 0.93529 rg
267.40285 98.05133 m
267.40285 67.05441 l
266.41905 68.03821 l
266.41905 97.06754 l
h
f
157.45607 67.05441 m
267.40285 67.05441 l
266.41905 68.03821 l
158.43987 68.03821 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
268.38663 98.05133 m
378.3334 98.05133 l
377.34961 97.06754 l
269.37042 97.06754 l
h
f
268.38663 98.05133 m
268.38663 67.05441 l
269.37042 68.03821 l
269.37042 97.06754 l
h
f
0.94942 0.9447 0.93529 rg
378.3334 98.05133 m
378.3334 67.05441 l
377.34961 68.03821 l
377.34961 97.06754 l
h
f
268.38663 67.05441 m
378.3334 67.05441 l
377.34961 68.03821 l
269.37042 68.03821 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
379.3172 98.05133 m
489.26398 98.05133 l
488.28018 97.06754 l
380.30099 97.06754 l
h
f
379.3172 98.05133 m
379.3172 67.05441 l
380.30099 68.03821 l
380.30099 97.06754 l
h
f
0.94942 0.9447 0.93529 rg
489.26398 98.05133 m
489.26398 67.05441 l
488.28018 68.03821 l
488.28018 97.06754 l
h
f
379.3172 67.05441 m
489.26398 67.05441 l
488.28018 68.03821 l
380.30099 68.03821 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
490.24776 98.05133 m
600.19453 98.05133 l
599.21074 97.06754 l
491.23155 97.06754 l
h
f
490.24776 98.05133 m
490.24776 67.05441 l
491.23155 68.03821 l
491.23155 97.06754 l
h
f
0.94942 0.9447 0.93529 rg
600.19453 98.05133 m
600.19453 67.05441 l
599.21074 68.03821 l
599.21074 97.06754 l
h
f
490.24776 67.05441 m
600.19453 67.05441 l
599.21074 68.03821 l
491.23155 68.03821 l
h
f
EMC
EMC
EMC
/P <>BDC
q
0 0 612 792 re
W* n
0 0 0 rg
BT
/T1_0 1 Tf
0 Tc 0 Tw 0 Ts 100 Tz 0 Tr 10.59465 0 0 10.59465 9.83789 756.29329 Tm
(activities or the work you can do, as a percentage of those who answered\
question 27. )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 722.15784 Tm
(Effects on resource allocation if some illnesses are over estimated )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 686.93822 Tm
(The amount of resources received by each authority under the proposed fo\
rmula is dependent on the )Tj
0 -1.2 TD
(estimated ratio of people with a particular illness in the authority to \
the total number with the illness in )Tj
T*
(Wales. Because of this an upwards bias in the estimates does not have an\
y affect on resource allocation )Tj
T*
(providing it is constant across all authorities and illnesses. An upward\
s bias for some illnesses but not for )Tj
T*
(others will have some effect on estimates. However these are likely to b\
e relatively small because the )Tj
T*
(amount of total resources allocated for any particular illness is limite\
d to actual past expenditure on that )Tj
T*
(illness in Wales. The effect on resource allocation if the WHS estimates\
for heart disease, mental illness )Tj
T*
(and stroke were over estimated by 20% are shown in Table 3. The ranking \
of authorities in terms of )Tj
T*
(resource allocation under the formula were unchanged. )Tj
ET
EMC
/P <>BDC
BT
/T1_2 1 Tf
13.77304 0 0 13.77304 9.83789 519.49741 Tm
(Table 3: Effects of over-estimation for selected illness )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 19.67577 474.4399 Tm
( )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 165.32637 475.34985 Tm
(Actual estimates )Tj
T*
(from WHS )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 276.25694 475.34985 Tm
("True" resource )Tj
T*
(allocation if heart )Tj
T*
(disease, mental )Tj
T*
(illness and stroke )Tj
T*
(overestimated by )Tj
T*
(20% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 387.1875 475.34985 Tm
(Difference )Tj
T*
(between WHS )Tj
T*
(results and )Tj
T*
(simulated "true" )Tj
T*
(result )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 498.11807 475.34985 Tm
(Difference as )Tj
T*
(percentage of )Tj
T*
("true" allocation )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 19.67577 367.08772 Tm
(Isle of Anglesey )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 195.96466 367.08772 Tm
(\24329,542,454 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 306.89522 367.08772 Tm
(\24329,522,842 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 440.07454 367.08772 Tm
(\24319,612 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 559.48506 367.08772 Tm
(0.07% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 19.67577 335.10703 Tm
(Gwynedd )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 195.96466 335.10703 Tm
(\24351,833,991 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 306.89522 335.10703 Tm
(\24351,823,754 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 440.07454 335.10703 Tm
(\24310,237 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 559.48506 335.10703 Tm
(0.02% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 19.67577 303.12633 Tm
(Conwy )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 195.96466 303.12633 Tm
(\24354,780,361 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 306.89522 303.12633 Tm
(\24354,772,453 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 446.43134 303.12633 Tm
(\2437,908 )Tj
ET
EMC
/P <>BDC
BT
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156.47227 445.36378 l
155.48848 444.37999 l
12.78926 444.37999 l
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11.80547 445.36378 m
11.80547 414.36688 l
12.78926 415.35068 l
12.78926 444.37999 l
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0.94942 0.9447 0.93529 rg
156.47227 445.36378 m
156.47227 414.36688 l
155.48848 415.35068 l
155.48848 444.37999 l
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EMC
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267.40285 445.36378 l
266.41905 444.37999 l
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f
157.45607 445.36378 m
157.45607 414.36688 l
158.43987 415.35068 l
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f
0.94942 0.9447 0.93529 rg
267.40285 445.36378 m
267.40285 414.36688 l
266.41905 415.35068 l
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157.45607 414.36688 m
267.40285 414.36688 l
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EMC
q
0 0 612 792 re
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268.38663 445.36378 m
378.3334 445.36378 l
377.34961 444.37999 l
269.37042 444.37999 l
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268.38663 445.36378 m
268.38663 414.36688 l
269.37042 415.35068 l
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f
0.94942 0.9447 0.93529 rg
378.3334 445.36378 m
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377.34961 415.35068 l
377.34961 444.37999 l
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268.38663 414.36688 m
378.3334 414.36688 l
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h
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EMC
q
0 0 612 792 re
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379.3172 445.36378 m
489.26398 445.36378 l
488.28018 444.37999 l
380.30099 444.37999 l
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379.3172 445.36378 m
379.3172 414.36688 l
380.30099 415.35068 l
380.30099 444.37999 l
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f
0.94942 0.9447 0.93529 rg
489.26398 445.36378 m
489.26398 414.36688 l
488.28018 415.35068 l
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379.3172 414.36688 m
489.26398 414.36688 l
488.28018 415.35068 l
380.30099 415.35068 l
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EMC
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0 0 612 792 re
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600.19453 445.36378 l
599.21074 444.37999 l
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490.24776 445.36378 m
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0.94942 0.9447 0.93529 rg
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600.19453 414.36688 l
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490.24776 414.36688 m
600.19453 414.36688 l
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EMC
q
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156.47227 413.38309 l
155.48848 412.39929 l
12.78926 412.39929 l
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11.80547 413.38309 m
11.80547 382.38618 l
12.78926 383.36998 l
12.78926 412.39929 l
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0.94942 0.9447 0.93529 rg
156.47227 413.38309 m
156.47227 382.38618 l
155.48848 383.36998 l
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11.80547 382.38618 m
156.47227 382.38618 l
155.48848 383.36998 l
12.78926 383.36998 l
h
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EMC
q
0 0 612 792 re
W* n
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0.45726 0.44862 0.43137 rg
157.45607 413.38309 m
267.40285 413.38309 l
266.41905 412.39929 l
158.43987 412.39929 l
h
f
157.45607 413.38309 m
157.45607 382.38618 l
158.43987 383.36998 l
158.43987 412.39929 l
h
f
0.94942 0.9447 0.93529 rg
267.40285 413.38309 m
267.40285 382.38618 l
266.41905 383.36998 l
266.41905 412.39929 l
h
f
157.45607 382.38618 m
267.40285 382.38618 l
266.41905 383.36998 l
158.43987 383.36998 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
268.38663 413.38309 m
378.3334 413.38309 l
377.34961 412.39929 l
269.37042 412.39929 l
h
f
268.38663 413.38309 m
268.38663 382.38618 l
269.37042 383.36998 l
269.37042 412.39929 l
h
f
0.94942 0.9447 0.93529 rg
378.3334 413.38309 m
378.3334 382.38618 l
377.34961 383.36998 l
377.34961 412.39929 l
h
f
268.38663 382.38618 m
378.3334 382.38618 l
377.34961 383.36998 l
269.37042 383.36998 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
379.3172 413.38309 m
489.26398 413.38309 l
488.28018 412.39929 l
380.30099 412.39929 l
h
f
379.3172 413.38309 m
379.3172 382.38618 l
380.30099 383.36998 l
380.30099 412.39929 l
h
f
0.94942 0.9447 0.93529 rg
489.26398 413.38309 m
489.26398 382.38618 l
488.28018 383.36998 l
488.28018 412.39929 l
h
f
379.3172 382.38618 m
489.26398 382.38618 l
488.28018 383.36998 l
380.30099 383.36998 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
490.24776 413.38309 m
600.19453 413.38309 l
599.21074 412.39929 l
491.23155 412.39929 l
h
f
490.24776 413.38309 m
490.24776 382.38618 l
491.23155 383.36998 l
491.23155 412.39929 l
h
f
0.94942 0.9447 0.93529 rg
600.19453 413.38309 m
600.19453 382.38618 l
599.21074 383.36998 l
599.21074 412.39929 l
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490.24776 382.38618 m
600.19453 382.38618 l
599.21074 383.36998 l
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EMC
EMC
EMC
/P <>BDC
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0 0 612 792 re
W* n
0 0 0 rg
BT
/T1_0 1 Tf
0 Tc 0 Tw 0 Ts 100 Tz 0 Tr 12.71358 0 0 12.71358 19.67577 746.38087 Tm
(Swansea )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 189.60786 746.38087 Tm
(\243107,119,168 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 300.53844 746.38087 Tm
(\243107,155,067 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 435.84093 746.38087 Tm
(-\24335,899 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 555.25145 746.38087 Tm
(-0.03% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 19.67577 714.40018 Tm
(Neath Port Talbot )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 195.96466 714.40018 Tm
(\24371,380,755 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 306.89522 714.40018 Tm
(\24371,402,192 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 435.84093 714.40018 Tm
(-\24321,437 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 555.25145 714.40018 Tm
(-0.03% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 19.67577 682.41948 Tm
(Bridgend )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 195.96466 682.41948 Tm
(\24360,637,817 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 306.89522 682.41948 Tm
(\24360,632,617 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 446.43134 682.41948 Tm
(\2435,200 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 559.48506 682.41948 Tm
(0.01% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 19.67577 650.43878 Tm
(Vale of Glamorgan )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 195.96466 650.43878 Tm
(\24348,860,650 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 306.89522 650.43878 Tm
(\24348,860,169 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 455.96652 650.43878 Tm
(\243482 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 559.48506 650.43878 Tm
(0.00% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 19.67577 618.4581 Tm
(Cardiff )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 189.60786 618.4581 Tm
(\243135,475,343 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 300.53844 618.4581 Tm
(\243135,471,195 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 446.43134 618.4581 Tm
(\2434,148 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 559.48506 618.4581 Tm
(0.00% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 19.67577 586.4774 Tm
(Rhondda, Cynon, Taff )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 189.60786 586.4774 Tm
(\243121,336,340 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 300.53844 586.4774 Tm
(\243121,346,442 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 435.84093 586.4774 Tm
(-\24310,102 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 555.25145 586.4774 Tm
(-0.01% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 19.67577 554.4967 Tm
(Merthyr Tydfil )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 195.96466 554.4967 Tm
(\24331,394,743 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 306.89522 554.4967 Tm
(\24331,401,131 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 442.19771 554.4967 Tm
(-\2436,388 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 555.25145 554.4967 Tm
(-0.02% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 19.67577 522.51601 Tm
(Caerphilly )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 195.96466 522.51601 Tm
(\24386,497,335 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 306.89522 522.51601 Tm
(\24386,513,328 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 435.84093 522.51601 Tm
(-\24315,993 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 555.25145 522.51601 Tm
(-0.02% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 19.67577 490.53531 Tm
(Blaenau Gwent )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 195.96466 490.53531 Tm
(\24339,554,102 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 306.89522 490.53531 Tm
(\24339,555,767 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 442.19771 490.53531 Tm
(-\2431,665 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 559.48506 490.53531 Tm
(0.00% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 19.67577 458.55463 Tm
(Torfaen )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 195.96466 458.55463 Tm
(\24347,509,902 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 306.89522 458.55463 Tm
(\24347,494,946 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 440.07454 458.55463 Tm
(\24314,956 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 559.48506 458.55463 Tm
(0.03% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 19.67577 426.57393 Tm
(Monmouthshire )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 195.96466 426.57393 Tm
(\24332,483,953 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 306.89522 426.57393 Tm
(\24332,487,658 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 442.19771 426.57393 Tm
(-\2433,706 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 555.25145 426.57393 Tm
(-0.01% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 19.67577 394.59323 Tm
(Newport )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 195.96466 394.59323 Tm
(\24362,557,954 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 306.89522 394.59323 Tm
(\24362,580,127 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 435.84093 394.59323 Tm
(-\24322,173 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 555.25145 394.59323 Tm
(-0.04% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(If the extent to which ill people are more likely to respond to the surv\
ey is the same across unitary )Tj
0 -1.2 TD
(authorities resource allocation is largely unaffected. There is evidence\
from the correlations with )Tj
T*
(administrative data sources and with the 1991 Census estimates that this\
is the case. There is some )Tj
T*
(evidence from comparisons with the GPRD that the difference in response \
rates for people who were ill )Tj
T*
(was greater for younger people i.e. those under 65. This could potential\
ly lead to authorities with a )Tj
T*
(younger population profile receiving too high a proportion of resources.\
However this evidence is )Tj
T*
(relatively slight being based on only three illness comparisons. )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 215.5116 Tm
(Assessment of sampling error )Tj
ET
EMC
/P <>BDC
BT
/T1_2 1 Tf
13.77304 0 0 13.77304 9.83789 180.29198 Tm
(Confidence intervals for survey estimates )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 145.07234 Tm
(At the time of writing the Stage 2 report the exact way in which the sur\
vey results might be incorporated )Tj
T*
(into resource allocation formulae were not determined. However backgroun\
d papers provided by the )Tj
T*
(National Assembly for Wales indicated that estimates of total individual\
s with each illness would be )Tj
T*
(incorporated into the formula. In order to use estimates in this way the\
y should ideally be sufficiently )Tj
T*
(accurate to enable authorities to be ranked in terms of prevalence. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 43.74213 Tm
(Confidence intervals had not been calculated in the Welsh Health Survey \
report. The aim of Stage 2 of the )Tj
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(assessment was therefore to determine appropriate formulae to estimate c\
onfiedence intervals and thus )Tj
0 -1.2 TD
(determine whether the samples were large enough to be able to confidentl\
y rank authorities in terms of )Tj
T*
(prevalence. )Tj
ET
EMC
/P <>BDC
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/T1_0 1 Tf
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(The example calculations in the final report of the research team headed\
by David Gordon at University of )Tj
T*
(Bristol used weighted sample totals rather than estimated population tot\
als. However in practice inserting )Tj
T*
(estimated population totals instead of weighted sample totals gives the \
same resource allocation result. )Tj
T*
(The calculation of confidence intervals for population totals is therefo\
re relevant and the conclusion that it )Tj
T*
(should ideally be possible to at least rank authorities still holds. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 584.98685 Tm
(The derivation of the formulae for estimated totals and variance are giv\
en in Appendix III. The resulting )Tj
T*
(confidence intervals for the main categories of illness are given in App\
endix IV. The results for each )Tj
T*
(subtype of illness were also calculated. However the incidence for most \
of these illness subtypes is too )Tj
T*
(small to obtain reliable estimates from a sample survey and this was app\
arent from the confidence )Tj
T*
(intervals. This was anticipated by the independent research team at Bris\
tol University and the proposed )Tj
T*
(formula does not rely on estimates for illness subtypes. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 467.12898 Tm
(Estimates for the main categories of illness are insufficiently precise \
to confidently rank authorities. This )Tj
T*
(means that if the direct survey estimates are used in the formula one au\
thority could obtain higher resource )Tj
T*
(allocation than another simply as a result of chance. However the estima\
tes are sufficiently precise to )Tj
T*
(indicate that some authorities have significantly greater needs than oth\
ers. Therefore, whether it would be )Tj
T*
(appropriate to use survey results for resource allocation purposes depen\
ds on how accurate the estimates )Tj
T*
(from the survey are compared to alternative sources of information. )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 349.27112 Tm
(Sensitivity of resource allocation to sampling error )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 314.0515 Tm
(As stated in paragraph 4.1 the potential extent of sampling error was to\
o large for it to be possible to )Tj
T*
(confidently correctly rank authorities in terms of prevalence using the \
survey results. However the )Tj
T*
(calculation of confidence intervals does not by itself provide sufficien\
t information to assess the impact of )Tj
T*
(this sampling error on final resource allocation. This is because the fo\
rmula incorporates information from )Tj
T*
(other sources and combines the estimates for each illness. Some addition\
al work was therefore carried to )Tj
T*
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)Tj
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13.77304 0 0 13.77304 9.83789 160.974 Tm
(In order to investigate the potential effects of sampling error on resou\
rce allocation a simulation exercise )Tj
T*
(was carried out. The actual estimates from the WHS are treated as the "t\
rue" population values for the )Tj
T*
(purposes of the study. Five alternative sets of estimates were simulated\
by selecting random numbers from )Tj
T*
(a Normal~0,1 distribution, multiplying these by the standard errors esti\
mated from the survey and then )Tj
T*
(adding to the original estimates. These simulated estimates were in effe\
ct estimates that could have been )Tj
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nd variance equal to that )Tj
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(5 )Tj
12.71358 0 0 12.71358 17.46603 754.17691 Tm
(Wales NHS Resource Allocation Review, Independent Report of the Research\
Team by David Gordon, Elizabeth )Tj
-0.60001 -1.2 Td
(Lloyd, Martyn Senior, Jan Rigby, Mary Shaw and Yoav Ben Shlomo )Tj
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/P <>BDC
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/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 704.06239 Tm
(In addition to the estimates for total numbers with a particular illness\
the formula incorporates information )Tj
0 -1.2 TD
(on average numbers of visits to health services per person with each typ\
e of illness. No attempt was made )Tj
T*
(to incorporate simulations of sampling errors in these estimates as stan\
dard errors had not previously been )Tj
T*
(calculated for these estimates and there was insufficient time to calcul\
ate them at this stage. The estimates )Tj
T*
(used in the formula are for Wales as a whole and are therefore constant \
across unitary authorities. )Tj
T*
(Sampling errors in these estimates will have some effect on relative all\
ocation between authorities because )Tj
T*
(they affect the weight given to different illnesses for some funding cat\
egories e.g. GP and nursing )Tj
T*
(services. However they are unlikely to have large effects on total resou\
rce allocation. )Tj
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/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 553.14923 Tm
(The methodology treats sampling errors for each estimate as independent \
from each other and therefore )Tj
T*
(does not take account of possible correlations between illnesses. There \
is some evidence of correlation )Tj
T*
(between illnesses from the survey and this could lead to sampling errors\
having a greater effect on )Tj
T*
(resource allocation than indicated by the simulations reported here. It \
would be possible to investigate )Tj
T*
(these effects by creating a simulated Welsh population but this was not \
feasible within the time available )Tj
T*
(for this stage of the project. )Tj
ET
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/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 435.29137 Tm
(Results )Tj
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/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 400.07175 Tm
(The full results from the simulation exercise are given in Appendix V. T\
able 4 provides a summary. No )Tj
T*
(authority gained or lost more than half a percentage point of it's share\
of total resource allocation. )Tj
T*
(However three authorities gained or lost more than 5% of their "true" al\
location for one of the simulated )Tj
T*
(sets of estimates. )Tj
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(Table 4: Simulated effects on resource allocation of sampling error )Tj
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(Maximum absolute difference from "true" values )Tj
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(Unitary authority )Tj
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(Diff. in total )Tj
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(resources )Tj
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(Diff. as a % of )Tj
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("true" )Tj
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(resources for )Tj
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(authority )Tj
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(Diff. as a % of )Tj
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(total resources )Tj
T*
(for Wales )Tj
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(Diff. In ranking )Tj
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(for total )Tj
T*
(resources )Tj
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(Isle of Anglesey )Tj
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(\243827,231 )Tj
ET
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/T1_0 1 Tf
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(2.80% )Tj
ET
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/P <>BDC
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/T1_0 1 Tf
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(0.06% )Tj
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/T1_0 1 Tf
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(1 )Tj
ET
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/T1_0 1 Tf
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(Gwynedd )Tj
ET
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/T1_0 1 Tf
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(\2431,507,313 )Tj
ET
EMC
/P <>BDC
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/T1_0 1 Tf
13.77304 0 0 13.77304 358.97829 155.30516 Tm
(2.91% )Tj
ET
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/P <>BDC
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/T1_0 1 Tf
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(0.11% )Tj
ET
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/P <>BDC
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/T1_0 1 Tf
13.77304 0 0 13.77304 543.61911 155.30516 Tm
(1 )Tj
ET
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/T1_0 1 Tf
13.77304 0 0 13.77304 14.75682 131.89099 Tm
(Conwy )Tj
ET
EMC
/P <>BDC
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/T1_0 1 Tf
13.77304 0 0 13.77304 237.13438 131.89099 Tm
(\2431,321,382 )Tj
ET
EMC
/P <>BDC
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/T1_0 1 Tf
13.77304 0 0 13.77304 358.97829 131.89099 Tm
(2.41% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 454.41928 131.89099 Tm
(0.10% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 543.61911 131.89099 Tm
(1 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 14.75682 108.47682 Tm
(Denbighshire )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 237.13438 108.47682 Tm
(\2431,410,968 )Tj
ET
EMC
/P <>BDC
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/T1_0 1 Tf
13.77304 0 0 13.77304 358.97829 108.47682 Tm
(3.47% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 454.41928 108.47682 Tm
(0.10% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 543.61911 108.47682 Tm
(0 )Tj
ET
EMC
/P <>BDC
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/T1_0 1 Tf
13.77304 0 0 13.77304 14.75682 85.06265 Tm
(Flintshire )Tj
ET
EMC
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BT
/T1_0 1 Tf
13.77304 0 0 13.77304 237.13438 85.06265 Tm
(\2431,425,082 )Tj
ET
EMC
/P <>BDC
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/T1_0 1 Tf
13.77304 0 0 13.77304 358.97829 85.06265 Tm
(2.33% )Tj
ET
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/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 454.41928 85.06265 Tm
(0.11% )Tj
ET
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/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 543.61911 85.06265 Tm
(1 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 14.75682 61.6485 Tm
(Wrexham )Tj
ET
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/T1_0 1 Tf
13.77304 0 0 13.77304 237.13438 61.6485 Tm
(\2432,954,907 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 358.97829 61.6485 Tm
(5.40% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 454.41928 61.6485 Tm
(0.22% )Tj
ET
EMC
/P <>BDC
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/T1_0 1 Tf
13.77304 0 0 13.77304 543.61911 61.6485 Tm
(3 )Tj
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EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
178.08936 460.9373 m
302.06442 460.9373 l
301.08063 459.95351 l
179.07315 459.95351 l
h
f
178.08936 460.9373 m
178.08936 438.50693 l
179.07315 439.49072 l
179.07315 459.95351 l
h
f
0.94942 0.9447 0.93529 rg
302.06442 460.9373 m
302.06442 438.50693 l
301.08063 439.49072 l
301.08063 459.95351 l
h
f
178.08936 438.50693 m
302.06442 438.50693 l
301.08063 439.49072 l
179.07315 439.49072 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
303.04822 460.9373 m
397.50542 460.9373 l
396.52162 459.95351 l
304.03201 459.95351 l
h
f
303.04822 460.9373 m
303.04822 438.50693 l
304.03201 439.49072 l
304.03201 459.95351 l
h
f
0.94942 0.9447 0.93529 rg
397.50542 460.9373 m
397.50542 438.50693 l
396.52162 439.49072 l
396.52162 459.95351 l
h
f
303.04822 438.50693 m
397.50542 438.50693 l
396.52162 439.49072 l
304.03201 439.49072 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
398.4892 460.9373 m
492.9464 460.9373 l
491.9626 459.95351 l
399.47299 459.95351 l
h
f
398.4892 460.9373 m
398.4892 438.50693 l
399.47299 439.49072 l
399.47299 459.95351 l
h
f
0.94942 0.9447 0.93529 rg
492.9464 460.9373 m
492.9464 438.50693 l
491.9626 439.49072 l
491.9626 459.95351 l
h
f
398.4892 438.50693 m
492.9464 438.50693 l
491.9626 439.49072 l
399.47299 439.49072 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
493.93019 460.9373 m
600.19453 460.9373 l
599.21074 459.95351 l
494.91399 459.95351 l
h
f
493.93019 460.9373 m
493.93019 438.50693 l
494.91399 439.49072 l
494.91399 459.95351 l
h
f
0.94942 0.9447 0.93529 rg
600.19453 460.9373 m
600.19453 438.50693 l
599.21074 439.49072 l
599.21074 459.95351 l
h
f
493.93019 438.50693 m
600.19453 438.50693 l
599.21074 439.49072 l
494.91399 439.49072 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
11.80547 437.52315 m
177.10556 437.52315 l
176.12177 436.53935 l
12.78926 436.53935 l
h
f
11.80547 437.52315 m
11.80547 415.09276 l
12.78926 416.07655 l
12.78926 436.53935 l
h
f
0.94942 0.9447 0.93529 rg
177.10556 437.52315 m
177.10556 415.09276 l
176.12177 416.07655 l
176.12177 436.53935 l
h
f
11.80547 415.09276 m
177.10556 415.09276 l
176.12177 416.07655 l
12.78926 416.07655 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
178.08936 437.52315 m
302.06442 437.52315 l
301.08063 436.53935 l
179.07315 436.53935 l
h
f
178.08936 437.52315 m
178.08936 415.09276 l
179.07315 416.07655 l
179.07315 436.53935 l
h
f
0.94942 0.9447 0.93529 rg
302.06442 437.52315 m
302.06442 415.09276 l
301.08063 416.07655 l
301.08063 436.53935 l
h
f
178.08936 415.09276 m
302.06442 415.09276 l
301.08063 416.07655 l
179.07315 416.07655 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
303.04822 437.52315 m
397.50542 437.52315 l
396.52162 436.53935 l
304.03201 436.53935 l
h
f
303.04822 437.52315 m
303.04822 415.09276 l
304.03201 416.07655 l
304.03201 436.53935 l
h
f
0.94942 0.9447 0.93529 rg
397.50542 437.52315 m
397.50542 415.09276 l
396.52162 416.07655 l
396.52162 436.53935 l
h
f
303.04822 415.09276 m
397.50542 415.09276 l
396.52162 416.07655 l
304.03201 416.07655 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
398.4892 437.52315 m
492.9464 437.52315 l
491.9626 436.53935 l
399.47299 436.53935 l
h
f
398.4892 437.52315 m
398.4892 415.09276 l
399.47299 416.07655 l
399.47299 436.53935 l
h
f
0.94942 0.9447 0.93529 rg
492.9464 437.52315 m
492.9464 415.09276 l
491.9626 416.07655 l
491.9626 436.53935 l
h
f
398.4892 415.09276 m
492.9464 415.09276 l
491.9626 416.07655 l
399.47299 416.07655 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
493.93019 437.52315 m
600.19453 437.52315 l
599.21074 436.53935 l
494.91399 436.53935 l
h
f
493.93019 437.52315 m
493.93019 415.09276 l
494.91399 416.07655 l
494.91399 436.53935 l
h
f
0.94942 0.9447 0.93529 rg
600.19453 437.52315 m
600.19453 415.09276 l
599.21074 416.07655 l
599.21074 436.53935 l
h
f
493.93019 415.09276 m
600.19453 415.09276 l
599.21074 416.07655 l
494.91399 416.07655 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
11.80547 414.10898 m
177.10556 414.10898 l
176.12177 413.12518 l
12.78926 413.12518 l
h
f
11.80547 414.10898 m
11.80547 391.67859 l
12.78926 392.66238 l
12.78926 413.12518 l
h
f
0.94942 0.9447 0.93529 rg
177.10556 414.10898 m
177.10556 391.67859 l
176.12177 392.66238 l
176.12177 413.12518 l
h
f
11.80547 391.67859 m
177.10556 391.67859 l
176.12177 392.66238 l
12.78926 392.66238 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
178.08936 414.10898 m
302.06442 414.10898 l
301.08063 413.12518 l
179.07315 413.12518 l
h
f
178.08936 414.10898 m
178.08936 391.67859 l
179.07315 392.66238 l
179.07315 413.12518 l
h
f
0.94942 0.9447 0.93529 rg
302.06442 414.10898 m
302.06442 391.67859 l
301.08063 392.66238 l
301.08063 413.12518 l
h
f
178.08936 391.67859 m
302.06442 391.67859 l
301.08063 392.66238 l
179.07315 392.66238 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
303.04822 414.10898 m
397.50542 414.10898 l
396.52162 413.12518 l
304.03201 413.12518 l
h
f
303.04822 414.10898 m
303.04822 391.67859 l
304.03201 392.66238 l
304.03201 413.12518 l
h
f
0.94942 0.9447 0.93529 rg
397.50542 414.10898 m
397.50542 391.67859 l
396.52162 392.66238 l
396.52162 413.12518 l
h
f
303.04822 391.67859 m
397.50542 391.67859 l
396.52162 392.66238 l
304.03201 392.66238 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
398.4892 414.10898 m
492.9464 414.10898 l
491.9626 413.12518 l
399.47299 413.12518 l
h
f
398.4892 414.10898 m
398.4892 391.67859 l
399.47299 392.66238 l
399.47299 413.12518 l
h
f
0.94942 0.9447 0.93529 rg
492.9464 414.10898 m
492.9464 391.67859 l
491.9626 392.66238 l
491.9626 413.12518 l
h
f
398.4892 391.67859 m
492.9464 391.67859 l
491.9626 392.66238 l
399.47299 392.66238 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
0.45726 0.44862 0.43137 rg
493.93019 414.10898 m
600.19453 414.10898 l
599.21074 413.12518 l
494.91399 413.12518 l
h
f
493.93019 414.10898 m
493.93019 391.67859 l
494.91399 392.66238 l
494.91399 413.12518 l
h
f
0.94942 0.9447 0.93529 rg
600.19453 414.10898 m
600.19453 391.67859 l
599.21074 392.66238 l
599.21074 413.12518 l
h
f
493.93019 391.67859 m
600.19453 391.67859 l
599.21074 392.66238 l
494.91399 392.66238 l
h
f
EMC
EMC
EMC
/P <>BDC
q
0 0 612 792 re
W* n
0 0 0 rg
BT
/T1_0 1 Tf
0 Tc 0 Tw 0 Ts 100 Tz 0 Tr 13.77304 0 0 13.77304 14.75682 750.54059 Tm
(Powys )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 237.13438 750.54059 Tm
(\2431,291,384 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 358.97829 750.54059 Tm
(2.46% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 454.41928 750.54059 Tm
(0.10% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 543.61911 750.54059 Tm
(1 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 14.75682 727.12643 Tm
(Ceredigion )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 237.13438 727.12643 Tm
(\2431,618,718 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 358.97829 727.12643 Tm
(5.38% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 454.41928 727.12643 Tm
(0.12% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 543.61911 727.12643 Tm
(1 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 14.75682 703.71227 Tm
(Pembrokeshire )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 237.13438 703.71227 Tm
(\2432,441,956 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 358.97829 703.71227 Tm
(4.78% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 454.41928 703.71227 Tm
(0.18% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 543.61911 703.71227 Tm
(3 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 14.75682 680.2981 Tm
(Carmarthenshire )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 237.13438 680.2981 Tm
(\2432,302,793 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 358.97829 680.2981 Tm
(2.72% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 454.41928 680.2981 Tm
(0.17% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 543.61911 680.2981 Tm
(1 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 14.75682 656.88393 Tm
(Swansea )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 237.13438 656.88393 Tm
(\2432,256,997 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 358.97829 656.88393 Tm
(2.11% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 454.41928 656.88393 Tm
(0.17% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 543.61911 656.88393 Tm
(0 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 14.75682 633.46976 Tm
(Neath Port Talbot )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 237.13438 633.46976 Tm
(\2431,504,163 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 358.97829 633.46976 Tm
(2.11% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 454.41928 633.46976 Tm
(0.11% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 543.61911 633.46976 Tm
(0 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 14.75682 610.0556 Tm
(Bridgend )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 237.13438 610.0556 Tm
(\2432,580,793 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 358.97829 610.0556 Tm
(4.26% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 454.41928 610.0556 Tm
(0.19% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 543.61911 610.0556 Tm
(1 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 14.75682 586.64143 Tm
(Vale of Glamorgan )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 237.13438 586.64143 Tm
(\2431,986,866 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 358.97829 586.64143 Tm
(4.07% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 454.41928 586.64143 Tm
(0.15% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 543.61911 586.64143 Tm
(1 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 14.75682 563.22726 Tm
(Cardiff )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 237.13438 563.22726 Tm
(\2434,263,979 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 358.97829 563.22726 Tm
(3.15% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 454.41928 563.22726 Tm
(0.31% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 543.61911 563.22726 Tm
(0 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 14.75682 539.8131 Tm
(Rhondda, Cynon, Taff )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 237.13438 539.8131 Tm
(\2432,756,608 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 358.97829 539.8131 Tm
(2.27% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 454.41928 539.8131 Tm
(0.20% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 543.61911 539.8131 Tm
(0 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 14.75682 516.39893 Tm
(Merthyr Tydfil )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 247.46416 516.39893 Tm
(\243828,921 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 358.97829 516.39893 Tm
(2.64% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 454.41928 516.39893 Tm
(0.06% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 543.61911 516.39893 Tm
(1 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 14.75682 492.98476 Tm
(Caerphilly )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 237.13438 492.98476 Tm
(\2433,678,846 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 358.97829 492.98476 Tm
(4.25% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 454.41928 492.98476 Tm
(0.27% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 543.61911 492.98476 Tm
(1 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 14.75682 469.5706 Tm
(Blaenau Gwent )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 237.13438 469.5706 Tm
(\2432,635,580 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 358.97829 469.5706 Tm
(6.66% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 454.41928 469.5706 Tm
(0.19% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 543.61911 469.5706 Tm
(0 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 14.75682 446.15643 Tm
(Torfaen )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 237.13438 446.15643 Tm
(\2432,120,385 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 358.97829 446.15643 Tm
(4.46% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 454.41928 446.15643 Tm
(0.16% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 543.61911 446.15643 Tm
(1 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 14.75682 422.74226 Tm
(Monmouthshire )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 237.13438 422.74226 Tm
(\2431,884,854 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 358.97829 422.74226 Tm
(5.80% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 454.41928 422.74226 Tm
(0.14% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 543.61911 422.74226 Tm
(0 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 14.75682 399.32809 Tm
(Newport )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 237.13438 399.32809 Tm
(\2431,219,042 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 358.97829 399.32809 Tm
(1.95% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 454.41928 399.32809 Tm
(0.09% )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 543.61911 399.32809 Tm
(2 )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 359.18953 Tm
(Alternative sources of information )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 323.96989 Tm
(Whether it would be appropriate to use survey results for resource alloc\
ation purposes depends largely on )Tj
0 -1.2 TD
(how accurate the estimates from the survey are compared to alternative s\
ources of information. There are )Tj
T*
(two main alternative sources of information: )Tj
ET
EMC
/Lbl <>BDC
BT
/T1_2 1 Tf
6.88652 0 0 6.88652 35.13403 255.69498 Tm
(l)Tj
/T1_0 1 Tf
( )Tj
ET
EMC
/LBody <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 49.18942 255.69498 Tm
(administrative data on service use and vital registrations )Tj
ET
EMC
/Lbl <>BDC
BT
/T1_2 1 Tf
6.88652 0 0 6.88652 35.13403 239.16733 Tm
(l)Tj
/T1_0 1 Tf
( )Tj
ET
EMC
/LBody <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 49.18942 239.16733 Tm
(long term limiting illness from the 1991 Census )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 203.94769 Tm
(In general direct estimates from administrative information on service u\
se are not reliable for resource )Tj
T*
(allocation because of differences in administrative methods and because \
service use is in part dependent )Tj
T*
(on the availability of services. Indirect estimates from service use bas\
ed on modeling techniques may be )Tj
T*
(suitable for use in resource allocation. These estimates would have two \
main sources of error: error in the )Tj
T*
(administrative data sources and errors in the modeling process. In addit\
ion the information might not )Tj
T*
(provide the level of breakdown in terms of types of illness that is requ\
ired by the survey. It is not within )Tj
T*
(the scope of this evaluation exercise to assess whether estimates obtain\
ed in this way would be more or )Tj
T*
(less accurate than those obtained from the WHS. In practice it would be \
unlikely that the level of error in )Tj
T*
(the administrative data could be reliably estimated. Information from vi\
tal registrations on mortality by )Tj
T*
(cause of death are more likely to be reliable at the unitary authority l\
evel and therefore suitable for use in )Tj
T*
(resource allocation but may not be directly related to the need for serv\
ices in life. )Tj
ET
EMC
Q
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(The most comprehensive information on general health in terms of populat\
ion coverage comes from the )Tj
0 -1.2 TD
(1991 Census estimates of numbers suffering from long term limiting illne\
ss. There are two main problems )Tj
T*
(with using this data source: it relates to the situation 10 years ago an\
d it does not provide estimates for )Tj
T*
(numbers suffering from different illnesses. Age standardisation can to a\
large extent compensate for the )Tj
T*
(former problem providing migration between authorities is not large. The\
latter problem is more )Tj
T*
(intractable, however, as the resource allocation formula relies on estim\
ates of prevalence for individual )Tj
T*
(illnesses in order to take account of the relative cost of treating diff\
erent types of illness. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 600.0712 Tm
(There do not appear to be any alternative sources of information on prev\
alence for individual illnesses that )Tj
T*
(have significant advantages over the WHS estimates. However the WHS esti\
mates themselves are not )Tj
T*
(ideal because of the level of sampling error. It may therefore be prefer\
able to make use of the some of )Tj
T*
(more reliable alternative sources of information e.g. mortality and Cens\
us long term limiting illness to )Tj
T*
(improve the WHS estimates. )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 498.74098 Tm
(Conclusions )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 463.52136 Tm
(There is some evidence of an upwards bias in the WHS estimates. However \
resource allocation under the )Tj
T*
(proposed formula depends on the estimates of relative prevalence across \
authorities and there is evidence )Tj
T*
(that this is reliable despite the upwards bias in estimated totals and r\
ates. It is therefore concluded that the )Tj
T*
(extent of non-sampling errors do not preclude the use of WHS estimates f\
or resource allocation purposes. )Tj
T*
(However the estimates for mental illness may not be appropriate for use \
in resource allocation because )Tj
T*
(there is little evidence of a relationship between these estimates and t\
he need for treatment. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 345.6635 Tm
(Sampling errors in the WHS estimates are too large to allow authorities \
to be confidently ranked in terms )Tj
T*
(of prevalence for any illness. However there is little evidence that the\
use of alternative sources of )Tj
T*
(information would provide a fairer allocation. The results of the simula\
tion exercise show that sampling )Tj
T*
(errors are likely to affect the relative ranking of authorities in terms\
of resource allocation and some )Tj
T*
(authorities are likely to gain or lose more than 5% of the allocation th\
ey should receive. However )Tj
T*
(sampling error is unlikely to affect the share of total resources receiv\
ed by any authority by more than 1 )Tj
T*
(percentage point. It is also possible that correlation between illnesses\
could lead to sampling error having )Tj
T*
(a slightly larger impact on resource alloction than indicated by the sim\
ulation exercise. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 194.75034 Tm
(It is for the National Assembly for Wales to decide whether the anticipa\
ted level of misallocation is )Tj
T*
(acceptable. If it is considered unacceptable it is recommended that the \
method of estimation used be )Tj
T*
(improved by incorporating auxiliary information e.g. Census long term li\
miting illness into the estimation )Tj
T*
(method. Consideration should be given to the use of model based small ar\
ea estimation techniques to )Tj
T*
(improve the estimates and reduce sampling error. However it is recognise\
d that this would be )Tj
T*
(problematical if the formula were to be applied at more than one geograp\
hic level. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 76.89247 Tm
( )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 41.67285 Tm
(Sanchia Bailey )Tj
ET
EMC
Q
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(Office for National Statistics )Tj
0 -1.2 TD
(24 September 2001 )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 551.27074 702.84471 Tm
(Annex E )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 667.62509 Tm
(RESOURCE ALLOCATION FORMULAS FOR GENERAL MEDICAL SERVICES IN BRITAIN: )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 632.40546 Tm
(IMPROVED PROPOSALS & LESSONS FOR WALES )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 299.11348 597.18582 Tm
(by )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 201.37999 561.9662 Tm
(Martyn L. Senior \(Cardiff University\) )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 243.35057 525.31111 Tm
(\(10 )Tj
11.01843 0 0 11.01843 265.15331 528.83701 Tm
(th )Tj
13.77304 0 0 13.77304 276.48024 525.31111 Tm
(December 2001\) )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 490.09148 Tm
([Note: Figures 1 to 4 and the Appendix can be found at the end of the re\
port] )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 454.87186 Tm
(Summary of Issues )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 419.65222 Tm
(This report identifies the following issues and recommendations for impr\
oving the Welsh GMS proposals )Tj
T*
(of Gordon et. al. \(2001\). It is suggested that issue 2 \(omission of c\
hildren and pregnant women\) is of )Tj
T*
(highest priority and attempts are made to address it in this report. Iss\
ues 3 \(varying consultation times\), 5 )Tj
T*
(\(rurality\), 6 \(compensating GPs for practising in deprived areas\) an\
d 7 \(temporary residents\) are next in )Tj
T*
(importance. Issues 6 and 7 are likely to be easier to deal with than iss\
ues 3 and 5. Issue 4 \(an indirect )Tj
T*
(approach to additional needs\) is deemed to be the lowest priority. )Tj
ET
EMC
/P <>BDC
BT
/T1_2 1 Tf
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(1. Choosing between Welsh, Scottish and English Formulas. )Tj
/T1_0 1 Tf
(Arguably a direct approach to resource )Tj
T*
(allocation, based on self-perceived ill health, is most justifiable for \
primary care. The main problem with )Tj
T*
(the Welsh proposals is the lack of health condition data for children in\
the Welsh Health Survey. Welsh, )Tj
T*
(Scottish and English formulas all use national GP consultation rates as \
the resource "cost" element; there )Tj
T*
(is no monetary costing of consultations. The use of consultation data fr\
om the Welsh GP Morbidity )Tj
T*
(Database \(GPMD\) compares favourably with the use of sample practice da\
ta in Scotland. All formulas, )Tj
T*
(whether indirect \(as in Scotland and England\) or direct, can incorpora\
te similar, if not identical, )Tj
T*
(adjustments for temporary residents and the unavoidable extra costs of G\
MS, neither of which are )Tj
T*
(currently in the Welsh proposals. The Scottish approach to the costs of \
rural service provision and the )Tj
T*
(English proposals on a market forces factor \(MFF\) for GP pay could be \
added to the Welsh formula, )Tj
T*
(provided they are validated by Welsh evidence. )Tj
ET
EMC
/P <>BDC
BT
/T1_2 1 Tf
13.77304 0 0 13.77304 9.83789 101.29826 Tm
(2. Omission of use of GMS by children and pregnant women )Tj
/T1_0 1 Tf
(. Suggestions for dealing with these )Tj
T*
(omissions are made and investigated. Average annual births are used as a\
measure of number of pregnant )Tj
T*
(women, and an indirect \(age-gender\) approach is applied to estimate ch\
ild consultations. The implications )Tj
T*
(of these additions for GMS resource allocations to Local Health Groups \(\
LHGs\) are presented )Tj
ET
EMC
Q
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(\(Appendix\). One outstanding issue is a measure of additional \(depriva\
tion-related\) need by children. )Tj
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(Questions on child health are a very high priority for future Welsh Heal\
th surveys. )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
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(3. Duration of consultations and home visits. )Tj
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(The English practice of incorporating duration and home )Tj
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BT
/T1_0 1 Tf
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(visit weights \(both age-related\) in the GMS formulas is not currently \
possible in Wales, as the GPMD )Tj
T*
(does not record such information. Similarly, in Scotland, data on consul\
tation duration are deemed )Tj
T*
(inadequate. The only way of addressing this issue at present appears to \
be the use of the English source )Tj
T*
(data. Recording such information is a high priority when considering imp\
rovements to the GPMD. )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
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(4. Additional/Deprivation-related GMS need. )Tj
/T1_0 1 Tf
(With the exception of children, the Welsh GMS proposals, )Tj
ET
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BT
/T1_0 1 Tf
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(as they are based on direct health condition figures, should )Tj
/T1_2 1 Tf
(not )Tj
/T1_0 1 Tf
(need any adjustments to reflect deprivation )Tj
T*
(or any other factor influencing need. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 533.23958 Tm
(There seems, therefore, little point in developing an alternative, indir\
ect approach to GMS. However, if )Tj
ET
0.62805 w
526.60231 514.82777 m
593.53929 514.82777 l
S
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 516.71193 Tm
(such an approach is deemed necessary, the English additional needs formu\
la could be readily )Tj
/T1_3 1 Tf
(exemplified )Tj
ET
439.44652 498.30013 m
492.62422 498.30013 l
S
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 500.18428 Tm
(at 1991 Census ward level. It would be significantly more time-consuming\
to )Tj
/T1_3 1 Tf
(calibrate )Tj
/T1_0 1 Tf
(either the English )Tj
T*
(or Scottish formulas using Welsh evidence on consultation rates. However\
, the use of data for the 33 )Tj
T*
(practices in the GPMD could be investigated. )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
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(5. Unavoidable costs of rurality )Tj
/T1_0 1 Tf
(. The data required to develop and estimate a Welsh equivalent of the )Tj
T*
(Scottish remoteness/rurality formula is set out in Table 2. The analytic\
al and data demands are )Tj
T*
(considerable, especially as postcoded patient records and practice payme\
nts are required. Compromises )Tj
T*
(may well be necessary. )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 347.10678 Tm
(6. A Market Forces Factor \(MFF\) for GPs )Tj
/T1_0 1 Tf
(. The English proposals for a GMS Non-Cash-Limited )Tj
T*
(formula involve a MFF designed to give GPs an incentive to work in under\
-doctored, deprived areas. The )Tj
T*
(analysis that informs this MFF should be undertaken for Wales, at least \
at LHG \(if not ward\) level. Other )Tj
T*
(possible influences \(e.g. lack of Welsh-speaking GPs\) on under-doctori\
ng should be examined. It should )Tj
T*
(be noted that the English proposal is for one year only. Research on GPs\
\222 valuations of living in non-)Tj
T*
(deprived areas is likely to be commissioned, so on-going developments of\
the English GMS formulas )Tj
T*
(should be monitored and evaluated. )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 212.72128 Tm
(7. Temporary residents. )Tj
/T1_0 1 Tf
(Scottish work suggests a national annual consultation rate of 1.5 by tem\
porary )Tj
T*
(residents \(page 7\). This can be checked for Wales using equivalent dat\
a on temporary resident )Tj
T*
(consultations from the GPMD. The Scottish formula obtains data on tempor\
ary residents by health board )Tj
T*
(from GP claims, so the same data source could be used in Wales. )Tj
ET
EMC
/P <>BDC
BT
/T1_2 1 Tf
13.77304 0 0 13.77304 9.83789 127.9187 Tm
(Components of General Medical Services \(GMS\) Formulas in Britain )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 92.69908 Tm
(The indirect approaches to GMS resource allocation in England and Scotla\
nd contain the following five )Tj
T*
(components: )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 40.9518 Tm
(1. Population by age and gender categories. )Tj
ET
EMC
Q
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454.74837 752.70784 l
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0 0 0 rg
BT
/T1_0 1 Tf
0 Tc 0 Tw 0 Ts 100 Tz 0 Tr 13.77304 0 0 13.77304 9.83789 754.592 Tm
(2. Consultation weights reflecting differential utilisation of GMS by )Tj
/T1_1 1 Tf
(age-gender )Tj
/T1_0 1 Tf
(groups. )Tj
0 -1.2 TD
(3. Additional patient needs \(e.g. deprivation-related\) over and above \
those due to age and gender. )Tj
T*
(4. Unavoidable extra costs of GMS provision, particularly those due to: \
)Tj
ET
EMC
/Lbl <>BDC
BT
/T1_2 1 Tf
6.88652 0 0 6.88652 35.13403 686.31706 Tm
(l)Tj
/T1_0 1 Tf
( )Tj
ET
EMC
/LBody <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 49.18942 686.31706 Tm
(providing services to sparse rural and/or remote populations \(as in Sco\
tland\) )Tj
ET
EMC
/Lbl <>BDC
BT
/T1_2 1 Tf
6.88652 0 0 6.88652 35.13403 669.78941 Tm
(l)Tj
/T1_0 1 Tf
( )Tj
ET
EMC
/LBody <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 49.18942 669.78941 Tm
(market forces factors \(MFF\); that is, unavoidable geographical variati\
ons in staff, land, building )Tj
T*
(and other costs \(as in England\). )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 618.04214 Tm
(1. Temporary residents. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 582.82251 Tm
(The formula proposed for Wales \(Gordon et. al., 2001\) deals with the f\
irst three components above in a )Tj
T*
(direct way as follows: )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 531.07524 Tm
(1 & 3. Adults in ill-health condition categories, which will reflect bot\
h age/gender-related need and )Tj
T*
(additional needs due to deprivation, life style and other influences. )Tj
ET
EMC
/P <>BDC
449.03256 477.44382 m
558.45935 477.44382 l
S
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 479.32796 Tm
(2. Consultation weights reflecting differential utilisation of GMS by pa\
tients in )Tj
/T1_1 1 Tf
(ill-health condition )Tj
ET
9.83789 460.91617 m
70.65962 460.91617 l
S
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 462.80032 Tm
(categories )Tj
/T1_0 1 Tf
(. The use of consultation data from 33 practices \(with about 300,000 pa\
tients\) in the GPMD )Tj
T*
(compares favourably with the 40 practices, covering about 222,000 patien\
ts, used in Scotland \(GMS )Tj
T*
(Working Group, 2000\). )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 394.52539 Tm
(4 & 5. David Gordon\222s \(DG\) proposal acknowledges that adjustments f\
or unavoidable extra costs and )Tj
T*
(temporary residents are not currently developed, but there is no reason,\
in principle, why English and )Tj
T*
(Scottish practice/proposals on these aspects cannot be added to the Wels\
h formula. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 326.25047 Tm
(More specific details of these components of the various formulas can be\
found in Figures 1 to 4. Figure 1 )Tj
T*
(refers \( )Tj
/T1_1 1 Tf
(in italics\) )Tj
/T1_0 1 Tf
(to some modifications and additions to the proposals for Wales which mig\
ht be )Tj
T*
(considered; these are discussed below. Figure 2 summarises England\222s \
existing GMS Cash-Limited )Tj
T*
(\(GMSCL\) formula \(NHS Executive, 1999\), while Figure 3 portrays the p\
roposed English formula for )Tj
T*
(GMS Non-Cash-Limited \(GMSNCL\) \(ACRA, 2001a-d\). Figure 4 summarises t\
he Arbuthnott final )Tj
T*
(proposals for Scotland \(SEHD, 2000; GMS Working Group, 2000\). )Tj
ET
EMC
/P <>BDC
BT
/T1_3 1 Tf
13.77304 0 0 13.77304 9.83789 208.39261 Tm
(Improvements to the Welsh proposals and further lessons for Wales )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 173.17297 Tm
(i Separate or combined formulas for GMSCL and GMSNCL? )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 137.95335 Tm
(England \(and Wales\) have existing formulas for GMS Cash-Limited, where\
as the Arbuthnott proposals )Tj
T*
(for Scotland and the Gordon et. al. \(2001\) proposals for Wales involve\
a single formula for all GMS )Tj
T*
(resources. It is not totally logical to have two separate formulas as pr\
emises and practice staff costs \(but )Tj
T*
(not GP income\) are split between CL and NCL allocations. The intention \
in England is initially to keep )Tj
T*
(GMSCL as part of the unified budget \(that is, combined with HCHS and Pr\
escribing\), and continue to )Tj
T*
(operate GMSNCL without a cash limit. However, the Secretary of State for\
Health will be able to consider )Tj
T*
(Health Authorities\222 GMSNCL expenditures when setting their unified al\
locations. \(ACRA, 2001a\). This )Tj
ET
EMC
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BT
/T1_0 1 Tf
0 Tc 0 Tw 0 Ts 100 Tz 0 Tr 13.77304 0 0 13.77304 9.83789 753.26494 Tm
(issue is, however, one of implementation, not content, of the GMS formul\
a\(s\). )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 718.0453 Tm
(ii Replacing total consultation rates by adult consultation rates )Tj
ET
EMC
/P <>BDC
0 0 0 RG
0.69417 w 10 M 0 j 0 J []0 d
543.83238 680.74319 m
580.17944 680.74319 l
S
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 682.82568 Tm
(There is a minor inconsistency in the Gordon et. al. \(2001\) proposals \
for Wales. The numbers of adults in )Tj
ET
293.3008 664.21555 m
321.23253 664.21555 l
S
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 666.29803 Tm
(WHS health condition categories are multiplied by total \(i.e. adult plu\
s child\) national consultation rates )Tj
0 -1.2 TD
(by the same health categories from the GPMD. As separate national adult \
consultation rates from the )Tj
T*
(GPMD have been made available, they can simply replace the total rates i\
n the calculations. This produces )Tj
T*
(only a very slight redistribution of GMS resources between LHGs \(see Ap\
pendix, second numerical )Tj
T*
(column\). )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 564.96782 Tm
(iii Omission of pregnant women from the Welsh GMS proposals )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 529.74818 Tm
(The current proposals for Wales omit consultations by pregnant women. Th\
is problem can be tackled by )Tj
T*
(using average annual births \(1994-1998\) by LHG as a measure of numbers\
of pregnant women. Estimates )Tj
T*
(of pregnancy consultations by LHG are obtained by multiplying these birt\
hs by national adult consultation )Tj
T*
(rates for pregnancy. The GPMD data reveal that about 7.22% of adult cons\
ultations are for pregnancy. )Tj
T*
(Hence, when these estimated pregnancy consultations are added to the est\
imated consultations for the 15 )Tj
T*
(WHS health conditions, either the pregnancy consultations must be scaled\
down to represent 7.22% of )Tj
T*
(total \(i.e. pregnancy plus 15 WHS condition\) consultations or the esti\
mated WHS consultations must be )Tj
T*
(scaled up. \(Note: remember that estimates using WHS figures are for a 1\
% sample of the Welsh )Tj
T*
(population, while 100% of births are recorded\). To maintain comparabili\
ty with the estimates presented in )Tj
T*
(Gordon et. al. \(2001\) the pregnancy consultations are scaled down here\
. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 345.77974 Tm
(The resulting distribution of GMS resources to LHGs \(and their resource\
shares\) when these pregnancy )Tj
T*
(consultations are included is presented in the Appendix \(third and four\
th numerical columns\). )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 294.03246 Tm
(iv Omission of children from the Welsh GMS proposals )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 258.81282 Tm
(The Scottish and English formulas incorporate all age groups, whereas th\
e proposals for Wales cover only )Tj
T*
(adults as the population data comes largely from the Welsh Health Survey\
. In the Appendix \(fourth and )Tj
T*
(fifth numerical columns )Tj
/T1_2 1 Tf
(\) )Tj
/T1_0 1 Tf
(each LHG\222s share of GMS resources based on adult calculations is comp\
ared )Tj
T*
(with its percentage share of the Welsh child population aged 0 to 15 yea\
rs in 1998. If the GMS share is )Tj
T*
(less \(greater\) than the child percentage, this suggests the LHG is und\
er \(over\) resourced because of the )Tj
T*
(omission of child consultations. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 140.95497 Tm
(A partial solution to this problem is to use an indirect approach to est\
imate child consultations for the 0-4 )Tj
T*
(and 5-15 age groups by gender \(as in the currently used Welsh formula\)\
. The population numbers in these )Tj
T*
(groups are multiplied by Welsh age-gender consultation rates \(Table 1\)\
derived from General Household )Tj
T*
(Surveys \(GHS\). The GPMD indicates that child consultations are approxi\
mately 17.1% of total )Tj
T*
(consultations in Wales. Thus the estimated child consultations are scale\
d down to represent this )Tj
T*
(percentage of total \(i.e. child plus adult\) consultations. The implica\
tions for the distribution of GMS )Tj
T*
(resources of adding in these child consultations are indicated in the Ap\
pendix \(sixth numerical column\). )Tj
ET
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10.82169 638.03923 l
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602.16211 714.18445 m
602.16211 637.05544 l
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9.83789 637.05544 m
602.16211 637.05544 l
601.17831 638.03923 l
10.82169 638.03923 l
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374.91457 710.24928 l
213.78598 710.24928 l
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212.80219 711.23308 m
212.80219 688.8027 l
213.78598 689.7865 l
213.78598 710.24928 l
h
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375.89836 711.23308 m
375.89836 688.8027 l
374.91457 689.7865 l
374.91457 710.24928 l
h
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212.80219 688.8027 m
375.89836 688.8027 l
374.91457 689.7865 l
213.78598 689.7865 l
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377.86594 711.23308 m
377.86594 688.8027 l
378.84973 689.7865 l
378.84973 710.24928 l
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599.21075 711.23308 m
599.21075 688.8027 l
598.22696 689.7865 l
598.22696 710.24928 l
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377.86594 688.8027 m
599.21075 688.8027 l
598.22696 689.7865 l
378.84973 689.7865 l
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210.83461 686.83513 m
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209.85081 665.38855 l
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12.78925 664.40475 m
210.83461 664.40475 l
209.85081 665.38855 l
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212.80219 686.83513 m
212.80219 664.40475 l
213.78598 665.38855 l
213.78598 685.85133 l
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375.89836 686.83513 m
375.89836 664.40475 l
374.91457 665.38855 l
374.91457 685.85133 l
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212.80219 664.40475 m
375.89836 664.40475 l
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377.86594 686.83513 m
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599.21075 686.83513 m
599.21075 664.40475 l
598.22696 665.38855 l
598.22696 685.85133 l
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377.86594 664.40475 m
599.21075 664.40475 l
598.22696 665.38855 l
378.84973 665.38855 l
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12.78925 662.43718 m
12.78925 640.00679 l
13.77304 640.99059 l
13.77304 661.45338 l
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210.83461 662.43718 m
210.83461 640.00679 l
209.85081 640.99059 l
209.85081 661.45338 l
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12.78925 640.00679 m
210.83461 640.00679 l
209.85081 640.99059 l
13.77304 640.99059 l
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375.89836 662.43718 l
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213.78598 661.45338 l
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212.80219 662.43718 m
212.80219 640.00679 l
213.78598 640.99059 l
213.78598 661.45338 l
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375.89836 662.43718 m
375.89836 640.00679 l
374.91457 640.99059 l
374.91457 661.45338 l
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212.80219 640.00679 m
375.89836 640.00679 l
374.91457 640.99059 l
213.78598 640.99059 l
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377.86594 662.43718 m
599.21075 662.43718 l
598.22696 661.45338 l
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377.86594 662.43718 m
377.86594 640.00679 l
378.84973 640.99059 l
378.84973 661.45338 l
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599.21075 662.43718 m
599.21075 640.00679 l
598.22696 640.99059 l
598.22696 661.45338 l
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377.86594 640.00679 m
599.21075 640.00679 l
598.22696 640.99059 l
378.84973 640.99059 l
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EMC
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/P <>BDC
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0 0 612 792 re
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BT
/T1_0 1 Tf
0 Tc 0 Tw 0 Ts 100 Tz 0 Tr 13.77304 0 0 13.77304 9.83789 737.57457 Tm
(Table 1: Child consultation rates from the GHS 1993-1998 )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 273.50478 696.45221 Tm
(age 0-4 )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 464.24959 696.45221 Tm
(age 5-15 )Tj
ET
EMC
/P <>BDC
BT
/T1_2 1 Tf
13.77304 0 0 13.77304 175.75075 672.05424 Tm
(males )Tj
ET
EMC
/P <>BDC
BT
/T1_2 1 Tf
13.77304 0 0 13.77304 282.29886 672.05424 Tm
(8.15 )Tj
ET
EMC
/P <>BDC
BT
/T1_2 1 Tf
13.77304 0 0 13.77304 476.48694 672.05424 Tm
(2.12 )Tj
ET
EMC
/P <>BDC
BT
/T1_2 1 Tf
13.77304 0 0 13.77304 165.04909 647.6563 Tm
(females )Tj
ET
EMC
/P <>BDC
BT
/T1_2 1 Tf
13.77304 0 0 13.77304 282.29886 647.6563 Tm
(5.61 )Tj
ET
EMC
/P <>BDC
BT
/T1_2 1 Tf
13.77304 0 0 13.77304 476.48694 647.6563 Tm
(3.96 )Tj
ET
EMC
/P <>BDC
BT
/T1_2 1 Tf
13.77304 0 0 13.77304 9.83789 606.53394 Tm
(This is only a partial solution for at least two reasons. First, the GHS\
consultation rates do not allow for )Tj
0 -1.2 TD
(those aged 16 and 17 years to be included in the child population. Secon\
dly, a disadvantage of the indirect, )Tj
T*
(compared with the direct, approach is that it requires an additional nee\
ds adjustment. Notice in the )Tj
T*
(Appendix that the inclusion of child consultations has taken some resour\
ces away from certain more )Tj
T*
(deprived LHGs \(Merthyr Tydfil, Blaenau Gwent, Neath Port Talbot\) and g\
iven more to some affluent )Tj
ET
0 0 0 RG
0.69417 w 10 M 0 j 0 J []0 d
451.26379 521.81322 m
482.25313 521.81322 l
S
BT
/T1_2 1 Tf
13.77304 0 0 13.77304 9.83789 523.89571 Tm
(LHGs \(Monmouthshire for example\). This suggests that the direct approa\
ch for adult consultations is )Tj
T*
(appropriately reflecting additional needs in the more deprived LHGs, but\
that the indirect adjustment for )Tj
ET
9.83789 488.75792 m
40.82722 488.75792 l
S
BT
/T1_2 1 Tf
13.77304 0 0 13.77304 9.83789 490.84041 Tm
(child consultations is not \(yet\) picking up child deprivation/addition\
al needs. One possible way to correct )Tj
T*
(for this would be to use Census data on children in disadvantaged circum\
stances \(e.g. lone parent )Tj
T*
(households\) as an additional element. This latter suggestion has not be\
en tried in this report. )Tj
ET
EMC
/P <>BDC
BT
/T1_3 1 Tf
13.77304 0 0 13.77304 9.83789 422.56549 Tm
(v Incorporating duration of consultations and home visits )Tj
ET
EMC
/P <>BDC
0.62805 w
354.83875 385.4617 m
400.35864 385.4617 l
S
BT
/T1_2 1 Tf
13.77304 0 0 13.77304 9.83789 387.34586 Tm
(Whereas the proposals for Wales use just the national average )Tj
/T1_3 1 Tf
(number )Tj
/T1_2 1 Tf
(of consultations per patient per )Tj
T*
(year, the English formula also accounts for duration of consultations an\
d home visits \(see Figure 2\), both )Tj
T*
(of which are age-related. The Scottish formula also incorporates home vi\
sits \(Figure 4\), but duration data )Tj
T*
(were not of sufficient quality to recommend a duration adjustment \(GMS \
Working Group, 2000\). The )Tj
T*
(Scottish work quotes estimates that the average time spent on a home vis\
it is three times that for a surgery )Tj
T*
(consultation \(Netten and Dennett, 1997\). )Tj
ET
EMC
/P <>BDC
289.85754 267.60384 m
310.90274 267.60384 l
S
BT
/T1_2 1 Tf
13.77304 0 0 13.77304 9.83789 269.48799 Tm
(Consultation data for Wales from the GPMD does )Tj
/T1_3 1 Tf
(not )Tj
/T1_2 1 Tf
(currently record duration of consultations, and the )Tj
T*
(identification of home visits is very haphazard as it depends on whether\
or not the GP identifies the )Tj
T*
(location. )Tj
/T1_3 1 Tf
(This means that neither direct nor indirect approaches to calculating ne\
eds for GMS in Wales )Tj
T*
(can use Welsh evidence to account for home visits or varying duration of\
consultations )Tj
/T1_2 1 Tf
(. It is )Tj
T*
(recommended that future improvements to the GPMD include recording consu\
ltation duration and home )Tj
T*
(visits, the latter split into night and daytime visits. )Tj
ET
EMC
/P <>BDC
BT
/T1_2 1 Tf
13.77304 0 0 13.77304 9.83789 151.63013 Tm
(However, consideration might be given to using the English evidence. The\
English GMSCL formula )Tj
T*
(\(NHS Executive, 1999\) "makes use of estimates of average consultation \
times by International )Tj
T*
(Classification of Diseases \(ICD\) chapter and a weighting for home visi\
ts". These are "derived from the )Tj
/T1_3 1 Tf
T*
(General Medical Practitioners Workload Survey 1992/3: Joint Evidence to \
the Doctors and Dentists )Tj
T*
(Review Body from the Health Departments of Great Britain and the General\
Medical Services )Tj
T*
(Committee". )Tj
/T1_2 1 Tf
(This raises the possibility that average consultation times by ICD chapt\
er could be matched )Tj
T*
(to the health condition categories of the WHS. This should then allow a \
duration time adjustment to the )Tj
ET
EMC
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/T1_0 1 Tf
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(Gordon et. al. \(2001\) estimates for Wales. )Tj
ET
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/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 719.37236 Tm
(It is not clear from the information available whether a weight for home\
visits could be derived from the )Tj
0 -1.2 TD
(data source used in England. The Scottish formula \(GMS Working Group, 2\
000\) uses age-related home )Tj
ET
0 0 0 RG
0.62805 w 10 M 0 j 0 J []0 d
211.04822 684.43291 m
253.52426 684.43291 l
S
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 686.31706 Tm
(consultation rates from the GHS for )Tj
/T1_1 1 Tf
(Britain )Tj
/T1_0 1 Tf
(, as the Scottish sample is deemed too small \(although only )Tj
T*
(one year\222s data is considered\). Such )Tj
/T1_1 1 Tf
(age-related )Tj
/T1_0 1 Tf
(home visit rates cannot readily be matched with the WHS )Tj
T*
(health condition categories used by Gordon et. al. \(2001\). )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 618.04214 Tm
(vi Additional needs \(over and above those attributable to age and gende\
r\) )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 582.82251 Tm
(The indirect formulas used in England and Scotland have to adjust age/ge\
nder-related needs to take )Tj
T*
(account of deprivation, morbidity and other influences on GP consultatio\
ns. )Tj
/T1_1 1 Tf
(The great advantage of the )Tj
ET
0.99992 w
411.55612 546.76746 m
429.5437 546.76746 l
S
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 549.76723 Tm
(direct approach is that WHS health condition information should reflect \
)Tj
/T1_2 1 Tf
(all )Tj
/T1_1 1 Tf
(influences \(age, gender, )Tj
T*
(deprivation, life circumstances, life style or whatever\) on need )Tj
/T1_0 1 Tf
(. A possible exception to this is the )Tj
T*
(omission of children as explained above. )Tj
ET
EMC
/P <>BDC
0.69417 w
272.2556 479.40982 m
317.7755 479.40982 l
S
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 481.49229 Tm
(If the National Assembly wished to develop an indirect approach to GMS, \
then analyses of additional )Tj
T*
(need would be necessary, so that the use of SMRs \(which are not evidenc\
e-based\) in the current GMSCL )Tj
T*
(formula could be replaced. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 413.21738 Tm
(The latest research undertaken for the development of the English GMSNCL\
formula \(ACRA, 2001b\) )Tj
T*
(suggests that there are two significant drivers of additional need, name\
ly: )Tj
/T1_1 1 Tf
(under-75 standardised long-)Tj
T*
(term illness )Tj
/T1_0 1 Tf
(and the )Tj
/T1_1 1 Tf
(Jarman deprivation \(strictly speaking workload\) index )Tj
/T1_0 1 Tf
(\(see Figure 3\). The latter is )Tj
T*
(currently used to inform deprivation payments to GPs. In Scotland the Ar\
buthnott index is used \(see )Tj
T*
(Figure 4\), and specific attention is devoted to night visits which are \
significantly associated with this )Tj
T*
(index. )Tj
ET
EMC
/P <>BDC
0.62805 w
28.58299 293.47536 m
84.80453 293.47536 l
S
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 295.35951 Tm
(To )Tj
/T1_1 1 Tf
(exemplify )Tj
/T1_0 1 Tf
(the English formula in Wales would be straightforward at 1991 census war\
d level, as )Tj
T*
(limiting long-term illness for 1991 and Welsh Jarman scores are readily \
available. \(Note: there will be )Tj
T*
(problems constructing Jarman scores from 2001 Census data; ACRA, 2001e\)\
. Predicted GP consultations )Tj
T*
(could then be aggregated to LHGs. Creating the Scottish Arbuthnott index\
for Welsh zones is inadvisable, )Tj
T*
(as a special run of Census data will have to be commissioned from ONS. T\
he main problem with such )Tj
T*
(exemplification is that English \(or Scottish\) evidence is being uncrit\
ically applied to the Welsh context. )Tj
T*
(This raises the issue of calibrating such formulas using Welsh evidence \
on GP consultations. )Tj
ET
EMC
/P <>BDC
28.58299 159.08984 m
81.7607 159.08984 l
S
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 160.974 Tm
(To )Tj
/T1_1 1 Tf
(calibrate )Tj
/T1_0 1 Tf
(such formulas for Wales would be significantly more problematic and time\
-consuming, as )Tj
T*
(data on GP consultations in Wales would be required. The only obvious op\
tion would be to investigate use )Tj
T*
(of data for the 33 practices in the GPMD, which covers about 300,000 pat\
ients, but this is a small number )Tj
T*
(of practices for multiple regression analysis. )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 76.17143 Tm
(vii Unavoidable costs of rurality )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 40.9518 Tm
(Only the Scottish GMS formula \(Figure 4\) addresses the rurality issue,\
and the implications of applying it )Tj
ET
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601.17831 173.98405 l
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h
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9.83789 35.41638 l
10.82169 35.41638 l
10.82169 173.98405 l
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602.16211 174.96785 m
602.16211 35.41638 l
601.17831 35.41638 l
601.17831 173.98405 l
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12.78925 172.01648 m
363.46161 172.01648 l
362.47781 171.03268 l
13.77304 171.03268 l
h
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12.78925 172.01648 m
12.78925 139.74821 l
13.77304 140.73201 l
13.77304 171.03268 l
h
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363.46161 172.01648 m
363.46161 139.74821 l
362.47781 140.73201 l
362.47781 171.03268 l
h
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12.78925 139.74821 m
363.46161 139.74821 l
362.47781 140.73201 l
13.77304 140.73201 l
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365.42918 172.01648 m
599.21075 172.01648 l
598.22696 171.03268 l
366.41298 171.03268 l
h
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365.42918 172.01648 m
365.42918 139.74821 l
366.41298 140.73201 l
366.41298 171.03268 l
h
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599.21075 172.01648 m
599.21075 139.74821 l
598.22696 140.73201 l
598.22696 171.03268 l
h
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365.42918 139.74821 m
599.21075 139.74821 l
598.22696 140.73201 l
366.41298 140.73201 l
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12.78925 137.78064 m
363.46161 137.78064 l
362.47781 136.79684 l
13.77304 136.79684 l
h
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12.78925 137.78064 m
12.78925 72.45708 l
13.77304 73.44087 l
13.77304 136.79684 l
h
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363.46161 137.78064 m
363.46161 72.45708 l
362.47781 73.44087 l
362.47781 136.79684 l
h
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12.78925 72.45708 m
363.46161 72.45708 l
362.47781 73.44087 l
13.77304 73.44087 l
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0 0 612 792 re
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365.42918 137.78064 m
599.21075 137.78064 l
598.22696 136.79684 l
366.41298 136.79684 l
h
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365.42918 137.78064 m
365.42918 72.45708 l
366.41298 73.44087 l
366.41298 136.79684 l
h
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599.21075 137.78064 m
599.21075 72.45708 l
598.22696 73.44087 l
598.22696 136.79684 l
h
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365.42918 72.45708 m
599.21075 72.45708 l
598.22696 73.44087 l
366.41298 73.44087 l
h
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EMC
EMC
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0 0 612 792 re
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0 0 0 RG
0.69417 w 10 M 0 j 0 J []0 d
164.72948 752.50951 m
233.96655 752.50951 l
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BT
/T1_0 1 Tf
0 Tc 0 Tw 0 Ts 100 Tz 0 Tr 13.77304 0 0 13.77304 9.83789 754.592 Tm
(to Wales have already been exemplified \(Senior and Rigby, 2001\). Again\
this is a highly contentious )Tj
0 -1.2 TD
(procedure as Scottish evidence is being transferred to Wales when it may\
be inappropriate so to do. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 702.84471 Tm
(To improve on this situation, a GMS rurality formula needs to be develop\
ed using Welsh evidence. To )Tj
T*
(calibrate the Welsh equivalent of this Scottish formula, the data specif\
ied in Table 2 will be required for )Tj
T*
(each Welsh GP practice. These data demands are considerable, especially \
as the postcodes of all patients )Tj
T*
(and GP payment information are required. The total payment per patient i\
s the response/dependent )Tj
T*
(variable in a multiple regression analysis. The statistical significance\
and influence on payments of )Tj
T*
(rurality indicators is sought over and above the influence of other fact\
ors \(demography, list inflation, HA/)Tj
T*
(LHG and deprivation\) which are controlled for in the regression. As the\
Arbuthnott index is likely to )Tj
T*
(prove time-consuming and expensive to create for Welsh areas, it is reco\
mmended that alternative )Tj
T*
(deprivation measures are tried. )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 535.40392 Tm
(viii A Market Forces Factor \(MFF\) for GPs )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 500.18428 Tm
(The current English GMSCL formula has staff, land and buildings MFFs to \
reflect geographic variations )Tj
T*
(in labour costs and property prices \(see Figure 2\). Recent work for AC\
RA \(2001a;c;d\) has considered the )Tj
T*
(extension of these MFF adjustments to the proposed GMSNCL formula \(see \
Figure 3\). The proposal is to )Tj
ET
1.14867 w
564.18893 447.15532 m
586.76295 447.15532 l
S
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 450.60133 Tm
(use, at least initially, the staff and premises MFFs from the GMSCL form\
ula, but the staff MFF will )Tj
/T1_2 1 Tf
(not )Tj
/T1_0 1 Tf
T*
(be applied to the remuneration of GPs, as the factors influencing where \
GPs prefer to work differ )Tj
T*
(significantly from other practice staff. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 382.32642 Tm
(The argument advanced \(ACRA, 2001d\) is that area deprivation figures p\
rominently in GPs\222 location )Tj
T*
(decisions, over and above the influence of deprivation on GPs\222 worklo\
ads for which Deprivation )Tj
T*
(Payments seek to compensate. Evidence suggests that GPs prefer to work \(\
and live\) in the more affluent )Tj
T*
(areas. This may be particularly so if they own, or are buying, their pra\
ctice premises, as they do not want )Tj
T*
(to risk declining or stagnant property prices. The staff MFF currently u\
sed in the GMSCL reflects higher )Tj
T*
(wages/salaries in London and South-East England. While this may give an \
appropriate incentive for GPs )Tj
T*
(to practice in deprived areas of Inner London, it will give perverse inc\
entives for them to seek to locate in )Tj
T*
(affluent areas of Outer London and the South-East. Indeed, few areas tha\
t have a high staff MFF in the )Tj
T*
(GMSCL formula are under-doctored. Moreover, this staff MFF will provide \
no incentive for GPs to )Tj
T*
(practice in deprived areas in the rest of England, some of which are und\
er-doctored. )Tj
ET
EMC
/P <>BDC
BT
/T1_2 1 Tf
13.77304 0 0 13.77304 9.83789 198.35797 Tm
(Table 2: Practice data required to calibrate a Welsh rurality formula )Tj
ET
EMC
/P <>BDC
BT
/T1_2 1 Tf
13.77304 0 0 13.77304 20.65956 152.31667 Tm
(Practice data required )Tj
ET
EMC
/P <>BDC
BT
/T1_2 1 Tf
13.77304 0 0 13.77304 373.29948 152.31667 Tm
(Possible source of data )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 20.65956 118.08083 Tm
(Total payments per patient \(excluding: improvement and )Tj
T*
(training grants; other payments for trainees and for )Tj
T*
(temporary residents\) )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 373.29948 118.08083 Tm
(Exeter database )Tj
ET
EMC
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602.16211 766.42149 m
602.16211 168.41733 l
601.17831 169.40112 l
601.17831 766.42149 l
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9.83789 168.41733 m
602.16211 168.41733 l
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13.77304 715.99402 l
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363.46161 763.80614 m
363.46161 715.01022 l
362.47781 715.99402 l
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12.78925 715.01022 m
363.46161 715.01022 l
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365.42918 763.80614 m
365.42918 715.01022 l
366.41298 715.99402 l
366.41298 762.82234 l
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599.21075 763.80614 m
599.21075 715.01022 l
598.22696 715.99402 l
598.22696 762.82234 l
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365.42918 715.01022 m
599.21075 715.01022 l
598.22696 715.99402 l
366.41298 715.99402 l
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363.46161 713.04265 l
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12.78925 713.04265 m
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13.77304 648.70288 l
13.77304 712.05885 l
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363.46161 713.04265 m
363.46161 647.71909 l
362.47781 648.70288 l
362.47781 712.05885 l
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12.78925 647.71909 m
363.46161 647.71909 l
362.47781 648.70288 l
13.77304 648.70288 l
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365.42918 713.04265 m
365.42918 647.71909 l
366.41298 648.70288 l
366.41298 712.05885 l
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599.21075 713.04265 m
599.21075 647.71909 l
598.22696 648.70288 l
598.22696 712.05885 l
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365.42918 647.71909 m
599.21075 647.71909 l
598.22696 648.70288 l
366.41298 648.70288 l
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13.77304 581.41176 l
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363.46161 645.75151 m
363.46161 580.42796 l
362.47781 581.41176 l
362.47781 644.76772 l
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363.46161 580.42796 l
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366.41298 644.76772 l
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365.42918 645.75151 m
365.42918 580.42796 l
366.41298 581.41176 l
366.41298 644.76772 l
h
f
599.21075 645.75151 m
599.21075 580.42796 l
598.22696 581.41176 l
598.22696 644.76772 l
h
f
365.42918 580.42796 m
599.21075 580.42796 l
598.22696 581.41176 l
366.41298 581.41176 l
h
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0 0 612 792 re
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12.78925 578.46037 m
363.46161 578.46037 l
362.47781 577.47658 l
13.77304 577.47658 l
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12.78925 578.46037 m
12.78925 494.44484 l
13.77304 495.42863 l
13.77304 577.47658 l
h
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363.46161 578.46037 m
363.46161 494.44484 l
362.47781 495.42863 l
362.47781 577.47658 l
h
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12.78925 494.44484 m
363.46161 494.44484 l
362.47781 495.42863 l
13.77304 495.42863 l
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q
0 0 612 792 re
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365.42918 578.46037 m
599.21075 578.46037 l
598.22696 577.47658 l
366.41298 577.47658 l
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365.42918 578.46037 m
365.42918 494.44484 l
366.41298 495.42863 l
366.41298 577.47658 l
h
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599.21075 578.46037 m
599.21075 494.44484 l
598.22696 495.42863 l
598.22696 577.47658 l
h
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365.42918 494.44484 m
599.21075 494.44484 l
598.22696 495.42863 l
366.41298 495.42863 l
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363.46161 492.47726 l
362.47781 491.49347 l
13.77304 491.49347 l
h
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12.78925 492.47726 m
12.78925 443.68135 l
13.77304 444.66515 l
13.77304 491.49347 l
h
f
363.46161 492.47726 m
363.46161 443.68135 l
362.47781 444.66515 l
362.47781 491.49347 l
h
f
12.78925 443.68135 m
363.46161 443.68135 l
362.47781 444.66515 l
13.77304 444.66515 l
h
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q
0 0 612 792 re
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365.42918 492.47726 m
599.21075 492.47726 l
598.22696 491.49347 l
366.41298 491.49347 l
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365.42918 492.47726 m
365.42918 443.68135 l
366.41298 444.66515 l
366.41298 491.49347 l
h
f
599.21075 492.47726 m
599.21075 443.68135 l
598.22696 444.66515 l
598.22696 491.49347 l
h
f
365.42918 443.68135 m
599.21075 443.68135 l
598.22696 444.66515 l
366.41298 444.66515 l
h
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12.78925 441.71378 m
363.46161 441.71378 l
362.47781 440.72998 l
13.77304 440.72998 l
h
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12.78925 441.71378 m
12.78925 341.17059 l
13.77304 342.15439 l
13.77304 440.72998 l
h
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363.46161 441.71378 m
363.46161 341.17059 l
362.47781 342.15439 l
362.47781 440.72998 l
h
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12.78925 341.17059 m
363.46161 341.17059 l
362.47781 342.15439 l
13.77304 342.15439 l
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365.42918 441.71378 m
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366.41298 440.72998 l
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365.42918 441.71378 m
365.42918 341.17059 l
366.41298 342.15439 l
366.41298 440.72998 l
h
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599.21075 441.71378 m
599.21075 341.17059 l
598.22696 342.15439 l
598.22696 440.72998 l
h
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365.42918 341.17059 m
599.21075 341.17059 l
598.22696 342.15439 l
366.41298 342.15439 l
h
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q
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12.78925 339.20302 m
363.46161 339.20302 l
362.47781 338.21922 l
13.77304 338.21922 l
h
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12.78925 339.20302 m
12.78925 222.13219 l
13.77304 223.11598 l
13.77304 338.21922 l
h
f
363.46161 339.20302 m
363.46161 222.13219 l
362.47781 223.11598 l
362.47781 338.21922 l
h
f
12.78925 222.13219 m
363.46161 222.13219 l
362.47781 223.11598 l
13.77304 223.11598 l
h
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q
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365.42918 339.20302 m
599.21075 339.20302 l
598.22696 338.21922 l
366.41298 338.21922 l
h
f
365.42918 339.20302 m
365.42918 222.13219 l
366.41298 223.11598 l
366.41298 338.21922 l
h
f
599.21075 339.20302 m
599.21075 222.13219 l
598.22696 223.11598 l
598.22696 338.21922 l
h
f
365.42918 222.13219 m
599.21075 222.13219 l
598.22696 223.11598 l
366.41298 223.11598 l
h
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EMC
q
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12.78925 220.1646 m
363.46161 220.1646 l
362.47781 219.1808 l
13.77304 219.1808 l
h
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12.78925 220.1646 m
12.78925 171.3687 l
13.77304 172.35249 l
13.77304 219.1808 l
h
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363.46161 220.1646 m
363.46161 171.3687 l
362.47781 172.35249 l
362.47781 219.1808 l
h
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12.78925 171.3687 m
363.46161 171.3687 l
362.47781 172.35249 l
13.77304 172.35249 l
h
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EMC
q
0 0 612 792 re
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365.42918 220.1646 m
599.21075 220.1646 l
598.22696 219.1808 l
366.41298 219.1808 l
h
f
365.42918 220.1646 m
365.42918 171.3687 l
366.41298 172.35249 l
366.41298 219.1808 l
h
f
599.21075 220.1646 m
599.21075 171.3687 l
598.22696 172.35249 l
598.22696 219.1808 l
h
f
365.42918 171.3687 m
599.21075 171.3687 l
598.22696 172.35249 l
366.41298 172.35249 l
h
f
EMC
EMC
EMC
/P <>BDC
q
0 0 612 792 re
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BT
/T1_0 1 Tf
0 Tc 0 Tw 0 Ts 100 Tz 0 Tr 13.77304 0 0 13.77304 20.65956 744.10632 Tm
(The LHG and Health Authority \(HA\) in which the practice )Tj
0 -1.2 TD
(is located )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 373.29948 744.10632 Tm
(National Assembly database )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 20.65956 693.34283 Tm
(A measure of list inflation )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 373.29948 693.34283 Tm
(Administrative Register \(Health )Tj
T*
(Solutions Wales\) and National )Tj
T*
(Assembly databases? )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 20.65956 626.0517 Tm
(Numbers of patients by gender and age groups \(Scottish )Tj
T*
(analysis uses 0-4, 5-14, 15-24, 25-44, 45-64, 65-74, 75-84, )Tj
T*
(85 and over\) )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 373.29948 626.0517 Tm
(Exeter and Administrative Register )Tj
T*
(\(Health Solutions Wales\) databases? )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 20.65956 558.76056 Tm
(Rurality indicator 1: hectares per patient )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 373.29948 558.76056 Tm
(National Assembly database? )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 373.29948 523.54094 Tm
(Area \(ward\) data needs attributing to )Tj
T*
(practices via patient postcodes. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 20.65956 472.77745 Tm
(Rurality indicator 2: % rural practice patients )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 373.29948 472.77745 Tm
(National Assembly database \(already )Tj
T*
(used by Senior and Rigby, 2001\) )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 20.65956 422.01396 Tm
(Rurality indicator 3: % of patients in settlements of less )Tj
T*
(than 500 population )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 373.29948 422.01396 Tm
(National Assembly\222s work on defining )Tj
T*
(settlement clusters? )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 373.29948 370.26668 Tm
(Area data needs attributing to )Tj
T*
(practices via patient postcodes. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 20.65956 319.50319 Tm
(Deprivation measure\(s\). )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 20.65956 284.28357 Tm
(Could be Welsh Index of Multiple Deprivation, Welsh )Tj
T*
(Jarman score or Townsend\222s material deprivation index. )Tj
T*
(\(Scottish Arbuthnott index likely to be time-consuming and )Tj
T*
(expensive to create\) )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 373.29948 319.50319 Tm
(Requires linkage of ward\(?\) )Tj
T*
(deprivation score with each patient via )Tj
T*
(latter\222s postcode )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 20.65956 200.46478 Tm
(Postcodes for all patients by practice in Wales )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 373.29948 200.46478 Tm
(Administrative Register \(Health )Tj
T*
(Solutions Wales\) )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 137.89584 Tm
(The proposed solution to this problem is a MFF for GPs that is deprivati\
on-related. \(Note: This solution is )Tj
T*
(an interim one only, as it will initially be applied only for one year, \
2002/3\). This has been based on the )Tj
T*
(following regression formula relating GP numbers to the English Index of\
Multiple Deprivation at health )Tj
T*
(authority level \(ACRA, 2001d\). )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 51.65781 Tm
(GPs per weighted 100,000 population = 4.36 * \(Index of Multiple Depriva\
tion\) )Tj
11.01843 0 0 11.01843 451.42906 55.1837 Tm
(-0.132 )Tj
ET
EMC
Q
endstream
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/P <>BDC
q
0 0 612 792 re
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0 0 0 rg
0 i
BT
/T1_0 1 Tf
0 Tc 0 Tw 0 Ts 100 Tz 0 Tr 13.77304 0 0 13.77304 9.83789 747.4433 Tm
(The negative weight of \2260.132 indicates that there are less GPs per p\
atient in deprived areas. This formula )Tj
0 -1.2 TD
(is used to provide predictions of the expected number of GPs per Health \
Authority. To attach monetary )Tj
T*
(weights to these values, a tentative estimate of 7.5% of salary is used \
to measure how much value GPs )Tj
T*
(place on the disamenity of locating in a deprived area. To obtain the MF\
F adjustment, health authorities )Tj
0 -1.30421 TD
(\(HAs\) are ranked from the least to most deprived. The 10 )Tj
11.01843 0 0 11.01843 329.60654 683.42314 Tm
(th )Tj
13.77304 0 0 13.77304 340.93349 679.89725 Tm
(percentile and 90 )Tj
11.01843 0 0 11.01843 439.23166 683.42314 Tm
(th )Tj
13.77304 0 0 13.77304 450.55861 679.89725 Tm
(percentile health )Tj
-31.99879 -1.2 Td
(authorities are given, respectively, interim values of 1 and 1.075, the \
latter reflecting a 7.5% of salary )Tj
0 -1.2 TD
(adjustment. Then all other health authorities are given proportionate va\
lues based on their level of )Tj
T*
(deprivation; this produces values in the approximate range 0.98 \(for th\
e least derived authority\) to 1.12 )Tj
T*
(\(for the most derived authority\). These values are then scaled up to g\
ive a minimum value of 1, indicating )Tj
T*
(no adjustment of GMS resources for the least deprived HA, to a value of \
1.14, representing a 14% )Tj
T*
(adjustment for the most deprived HA. )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 545.51173 Tm
(The implication of this English research for the Welsh GMS formula is th\
e need to establish if under-)Tj
T*
(doctored areas in Wales exist and \(if so\) are the most deprived areas,\
and whether there are any other )Tj
T*
(reasons \(e.g. too few Welsh-speaking GPs\) which could explain undoctor\
ing. )Tj
/T1_0 1 Tf
(It should not be too difficult )Tj
T*
(statistically to relate GPs per person \(preferably weighted by needs fo\
r GMS\) to the Welsh Index of )Tj
T*
(Multiple Deprivation \(IMD\) \(National Assembly for Wales, 2000\). The \
main problem will be relating GP )Tj
T*
(practices to the electoral divisions for which the Welsh IMD is measured\
. It should be even easier to )Tj
T*
(calibrate this formula at LHG level. )Tj
ET
EMC
/P <>BDC
BT
/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 411.12622 Tm
(ix Temporary residents )Tj
ET
EMC
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BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 375.9066 Tm
(The Scottish GMS formula incorporates temporary residents, who are also \
included in prescribing )Tj
T*
(formulas in England and Scotland. Limited evidence from two practices in\
Scotland suggests an average )Tj
T*
(annual consultation rate of 1.5 per temporary resident. )Tj
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EMC
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/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 307.63168 Tm
(This can be checked for Wales using equivalent data on temporary residen\
t consultations from the )Tj
T*
(GPMD. The Scottish formula obtains data on temporary residents by health\
board from GP claims, so the )Tj
T*
(same data source could be used in Wales. )Tj
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EMC
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/T1_2 1 Tf
13.77304 0 0 13.77304 9.83789 239.35675 Tm
(Acknowledgements )Tj
ET
EMC
/P <>BDC
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/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 204.13713 Tm
(The help and advice of Robin Jones \(National Assembly\), David Gordon \(\
University of Bristol\), Matt )Tj
T*
(Sutton \(University of Glasgow\) and Ian Holmes \(NHS Executive, Leeds\)\
has been invaluable. Naturally, )Tj
T*
(they are all absolved of any responsibility for the final product. )Tj
ET
EMC
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/T1_2 1 Tf
13.77304 0 0 13.77304 9.83789 135.8622 Tm
(References )Tj
ET
EMC
/P <>BDC
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/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 100.64258 Tm
(ACRA\(2001a\)01 )Tj
/T1_1 1 Tf
(GMSNCL Single Resource Allocation Formula )Tj
ET
EMC
/P <>BDC
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/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 65.42294 Tm
(TAG \(2001\)01 )Tj
/T1_1 1 Tf
(Single Resource Allocation Formula: GMSNCL Formula )Tj
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(ACRA \(2001b\)09 )Tj
/T1_1 1 Tf
(Centre for Health Economics: A GMS Needs Measure Based on the GHS )Tj
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/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 719.37236 Tm
(ACRA \(2001c\)10 )Tj
/T1_1 1 Tf
(Single National Formula for GMSNCL: Unavoidable Cost Variations )Tj
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/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 684.15273 Tm
(ACRA \(2001d\)13/TAG\(2001\)14 )Tj
/T1_1 1 Tf
(Single National Formula for GMSNCL: Unavoidable Cost Variations )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 648.93311 Tm
(ACRA \(2001e\)19/TAG\(2001\)19 )Tj
/T1_1 1 Tf
(The 2001 census; overview and implications for NHS resource )Tj
0 -1.2 TD
(allocation )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 597.18582 Tm
(GMS Working Group \(2000\) )Tj
/T1_1 1 Tf
(National Review of Resource Allocation. Report from the General Medical \
)Tj
0 -1.30421 TD
(Services Working Group )Tj
/T1_0 1 Tf
(, unpublished report submitted to Sir John Arbuthnott\222s Steering Grou\
p, 13 )Tj
11.01843 0 0 11.01843 566.84714 582.74863 Tm
(th )Tj
13.77304 0 0 13.77304 9.83789 562.69508 Tm
(July 2000. )Tj
ET
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/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 527.47545 Tm
(Gordon D, Lloyd E, Senior M L, Rigby J, Shaw M and Ben Shlomo Y \(2001\)\
)Tj
/T1_1 1 Tf
(Targeting Poor Health: )Tj
0 -1.2 TD
(Report of the Welsh Assembly\222s National Steering Group on the Allocat\
ion of NHS Resources. Volume 2: )Tj
T*
(Independent Report of the Research Team. )Tj
/T1_0 1 Tf
(Cardiff: National Assembly for Wales. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 459.20053 Tm
(National Assembly for Wales \(2000\) )Tj
/T1_1 1 Tf
(Welsh Index of Multiple Deprivation )Tj
/T1_0 1 Tf
(, London: National Statistics. )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 423.9809 Tm
(Netten A and Dennett J \(1997\) )Tj
/T1_1 1 Tf
(Unit costs of health and social care )Tj
/T1_0 1 Tf
(, Personal Social Services Research )Tj
T*
(Unit, University of Kent, Canterbury )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 372.23363 Tm
(NHS Executive \(1999\) )Tj
/T1_1 1 Tf
(Resource Allocation: Weighted Capitation Formulas )Tj
/T1_0 1 Tf
(, )Tj
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/Link <>BDC
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573.36179 370.15114 l
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13.77304 0 0 13.77304 441.36098 372.23363 Tm
(http://www.doh.gov.uk/)Tj
ET
9.83789 351.65591 m
140.29611 351.65591 l
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BT
/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 353.7384 Tm
(allocations/1999-2000/ )Tj
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0 0 0 rg
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/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 316.55119 Tm
(SEHD \(Scottish Executive Health Department\) \(2000\) )Tj
/T1_1 1 Tf
(Fair Shares For All: Final Report )Tj
/T1_0 1 Tf
(. Edinburgh: )Tj
T*
(Scottish Executive )Tj
ET
EMC
/P <>BDC
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/T1_0 1 Tf
13.77304 0 0 13.77304 9.83789 264.80391 Tm
(Senior M L and Rigby J \(2001\) )Tj
/T1_1 1 Tf
(Unavoidable Costs of Rurality and Remoteness in NHS Resource )Tj
T*
(Allocation: Applying the Scottish Evidence in Wales )Tj
/T1_0 1 Tf
(, Unpublished report produced for the National )Tj
T*
(Assembly of Wales )Tj
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EMC
/P <>BDC
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/T1_2 1 Tf
13.77304 0 0 13.77304 9.83789 196.52899 Tm
(Figure 1: Proposed Welsh GMS formula )Tj
/T1_3 1 Tf
(\(and possible modifications and additions\) )Tj
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( )Tj
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219.42661 395.03915 173.14677 28.52986 re
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219.42661 395.03915 173.14677 28.52986 re
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0 Tc 0 Tw 0 Ts 100 Tz 0 Tr 13.77304 0 0 13.77304 392.57339 395.03915 Tm
( )Tj
ET
EMC
/P <>BDC
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/T1_1 1 Tf
13.77304 0 0 13.77304 9.83789 361.19682 Tm
(Figure 2: English GMS Cash-Limited formula )Tj
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204.66978 307.30927 202.66043 30.49744 re
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129.90186 175.72646 352.19629 105.26537 re
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(Figure 3: Proposed English GMS Non-Cash-Limited formula )Tj
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220.96236 385.76749 170.0753 93.45992 re
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160.89119 279.76318 290.21761 67.88141 re
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136.29648 86.20171 339.40704 161.34131 re
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136.29648 86.20171 339.40704 161.34131 re
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(Figure 4: Scottish GMS formula proposed in Arbuthnott Final Report )Tj
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378.63628 304.29292 l
378.63628 338.74065 l
h
f
318.9854 303.30913 m
379.62007 303.30913 l
378.63628 304.29292 l
319.96919 304.29292 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
381.58765 339.72444 m
435.16629 339.72444 l
434.1825 338.74065 l
382.57144 338.74065 l
h
f
381.58765 339.72444 m
381.58765 303.30913 l
382.57144 304.29292 l
382.57144 338.74065 l
h
f
435.16629 339.72444 m
435.16629 303.30913 l
434.1825 304.29292 l
434.1825 338.74065 l
h
f
381.58765 303.30913 m
435.16629 303.30913 l
434.1825 304.29292 l
382.57144 304.29292 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
437.13387 339.72444 m
503.42607 339.72444 l
502.44228 338.74065 l
438.11766 338.74065 l
h
f
437.13387 339.72444 m
437.13387 303.30913 l
438.11766 304.29292 l
438.11766 338.74065 l
h
f
503.42607 339.72444 m
503.42607 303.30913 l
502.44228 304.29292 l
502.44228 338.74065 l
h
f
437.13387 303.30913 m
503.42607 303.30913 l
502.44228 304.29292 l
438.11766 304.29292 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
505.39365 339.72444 m
599.21075 339.72444 l
598.22696 338.74065 l
506.37744 338.74065 l
h
f
505.39365 339.72444 m
505.39365 303.30913 l
506.37744 304.29292 l
506.37744 338.74065 l
h
f
599.21075 339.72444 m
599.21075 303.30913 l
598.22696 304.29292 l
598.22696 338.74065 l
h
f
505.39365 303.30913 m
599.21075 303.30913 l
598.22696 304.29292 l
506.37744 304.29292 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
12.78925 301.34155 m
106.60635 301.34155 l
105.62256 300.35776 l
13.77304 300.35776 l
h
f
12.78925 301.34155 m
12.78925 280.18253 l
13.77304 281.16632 l
13.77304 300.35776 l
h
f
106.60635 301.34155 m
106.60635 280.18253 l
105.62256 281.16632 l
105.62256 300.35776 l
h
f
12.78925 280.18253 m
106.60635 280.18253 l
105.62256 281.16632 l
13.77304 281.16632 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
108.57393 301.34155 m
174.86613 301.34155 l
173.88234 300.35776 l
109.55772 300.35776 l
h
f
108.57393 301.34155 m
108.57393 280.18253 l
109.55772 281.16632 l
109.55772 300.35776 l
h
f
174.86613 301.34155 m
174.86613 280.18253 l
173.88234 281.16632 l
173.88234 300.35776 l
h
f
108.57393 280.18253 m
174.86613 280.18253 l
173.88234 281.16632 l
109.55772 281.16632 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
176.83371 301.34155 m
248.0715 301.34155 l
247.08771 300.35776 l
177.8175 300.35776 l
h
f
176.83371 301.34155 m
176.83371 280.18253 l
177.8175 281.16632 l
177.8175 300.35776 l
h
f
248.0715 301.34155 m
248.0715 280.18253 l
247.08771 281.16632 l
247.08771 300.35776 l
h
f
176.83371 280.18253 m
248.0715 280.18253 l
247.08771 281.16632 l
177.8175 281.16632 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
250.03908 301.34155 m
317.01782 301.34155 l
316.03403 300.35776 l
251.02287 300.35776 l
h
f
250.03908 301.34155 m
250.03908 280.18253 l
251.02287 281.16632 l
251.02287 300.35776 l
h
f
317.01782 301.34155 m
317.01782 280.18253 l
316.03403 281.16632 l
316.03403 300.35776 l
h
f
250.03908 280.18253 m
317.01782 280.18253 l
316.03403 281.16632 l
251.02287 281.16632 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
318.9854 301.34155 m
379.62007 301.34155 l
378.63628 300.35776 l
319.96919 300.35776 l
h
f
318.9854 301.34155 m
318.9854 280.18253 l
319.96919 281.16632 l
319.96919 300.35776 l
h
f
379.62007 301.34155 m
379.62007 280.18253 l
378.63628 281.16632 l
378.63628 300.35776 l
h
f
318.9854 280.18253 m
379.62007 280.18253 l
378.63628 281.16632 l
319.96919 281.16632 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
381.58765 301.34155 m
435.16629 301.34155 l
434.1825 300.35776 l
382.57144 300.35776 l
h
f
381.58765 301.34155 m
381.58765 280.18253 l
382.57144 281.16632 l
382.57144 300.35776 l
h
f
435.16629 301.34155 m
435.16629 280.18253 l
434.1825 281.16632 l
434.1825 300.35776 l
h
f
381.58765 280.18253 m
435.16629 280.18253 l
434.1825 281.16632 l
382.57144 281.16632 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
437.13387 301.34155 m
503.42607 301.34155 l
502.44228 300.35776 l
438.11766 300.35776 l
h
f
437.13387 301.34155 m
437.13387 280.18253 l
438.11766 281.16632 l
438.11766 300.35776 l
h
f
503.42607 301.34155 m
503.42607 280.18253 l
502.44228 281.16632 l
502.44228 300.35776 l
h
f
437.13387 280.18253 m
503.42607 280.18253 l
502.44228 281.16632 l
438.11766 281.16632 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
505.39365 301.34155 m
599.21075 301.34155 l
598.22696 300.35776 l
506.37744 300.35776 l
h
f
505.39365 301.34155 m
505.39365 280.18253 l
506.37744 281.16632 l
506.37744 300.35776 l
h
f
599.21075 301.34155 m
599.21075 280.18253 l
598.22696 281.16632 l
598.22696 300.35776 l
h
f
505.39365 280.18253 m
599.21075 280.18253 l
598.22696 281.16632 l
506.37744 281.16632 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
12.78925 278.21495 m
106.60635 278.21495 l
105.62256 277.23116 l
13.77304 277.23116 l
h
f
12.78925 278.21495 m
12.78925 241.79964 l
13.77304 242.78343 l
13.77304 277.23116 l
h
f
106.60635 278.21495 m
106.60635 241.79964 l
105.62256 242.78343 l
105.62256 277.23116 l
h
f
12.78925 241.79964 m
106.60635 241.79964 l
105.62256 242.78343 l
13.77304 242.78343 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
108.57393 278.21495 m
174.86613 278.21495 l
173.88234 277.23116 l
109.55772 277.23116 l
h
f
108.57393 278.21495 m
108.57393 241.79964 l
109.55772 242.78343 l
109.55772 277.23116 l
h
f
174.86613 278.21495 m
174.86613 241.79964 l
173.88234 242.78343 l
173.88234 277.23116 l
h
f
108.57393 241.79964 m
174.86613 241.79964 l
173.88234 242.78343 l
109.55772 242.78343 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
176.83371 278.21495 m
248.0715 278.21495 l
247.08771 277.23116 l
177.8175 277.23116 l
h
f
176.83371 278.21495 m
176.83371 241.79964 l
177.8175 242.78343 l
177.8175 277.23116 l
h
f
248.0715 278.21495 m
248.0715 241.79964 l
247.08771 242.78343 l
247.08771 277.23116 l
h
f
176.83371 241.79964 m
248.0715 241.79964 l
247.08771 242.78343 l
177.8175 242.78343 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
250.03908 278.21495 m
317.01782 278.21495 l
316.03403 277.23116 l
251.02287 277.23116 l
h
f
250.03908 278.21495 m
250.03908 241.79964 l
251.02287 242.78343 l
251.02287 277.23116 l
h
f
317.01782 278.21495 m
317.01782 241.79964 l
316.03403 242.78343 l
316.03403 277.23116 l
h
f
250.03908 241.79964 m
317.01782 241.79964 l
316.03403 242.78343 l
251.02287 242.78343 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
318.9854 278.21495 m
379.62007 278.21495 l
378.63628 277.23116 l
319.96919 277.23116 l
h
f
318.9854 278.21495 m
318.9854 241.79964 l
319.96919 242.78343 l
319.96919 277.23116 l
h
f
379.62007 278.21495 m
379.62007 241.79964 l
378.63628 242.78343 l
378.63628 277.23116 l
h
f
318.9854 241.79964 m
379.62007 241.79964 l
378.63628 242.78343 l
319.96919 242.78343 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
381.58765 278.21495 m
435.16629 278.21495 l
434.1825 277.23116 l
382.57144 277.23116 l
h
f
381.58765 278.21495 m
381.58765 241.79964 l
382.57144 242.78343 l
382.57144 277.23116 l
h
f
435.16629 278.21495 m
435.16629 241.79964 l
434.1825 242.78343 l
434.1825 277.23116 l
h
f
381.58765 241.79964 m
435.16629 241.79964 l
434.1825 242.78343 l
382.57144 242.78343 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
437.13387 278.21495 m
503.42607 278.21495 l
502.44228 277.23116 l
438.11766 277.23116 l
h
f
437.13387 278.21495 m
437.13387 241.79964 l
438.11766 242.78343 l
438.11766 277.23116 l
h
f
503.42607 278.21495 m
503.42607 241.79964 l
502.44228 242.78343 l
502.44228 277.23116 l
h
f
437.13387 241.79964 m
503.42607 241.79964 l
502.44228 242.78343 l
438.11766 242.78343 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
505.39365 278.21495 m
599.21075 278.21495 l
598.22696 277.23116 l
506.37744 277.23116 l
h
f
505.39365 278.21495 m
505.39365 241.79964 l
506.37744 242.78343 l
506.37744 277.23116 l
h
f
599.21075 278.21495 m
599.21075 241.79964 l
598.22696 242.78343 l
598.22696 277.23116 l
h
f
505.39365 241.79964 m
599.21075 241.79964 l
598.22696 242.78343 l
506.37744 242.78343 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
12.78925 239.83206 m
106.60635 239.83206 l
105.62256 238.84827 l
13.77304 238.84827 l
h
f
12.78925 239.83206 m
12.78925 218.67305 l
13.77304 219.65685 l
13.77304 238.84827 l
h
f
106.60635 239.83206 m
106.60635 218.67305 l
105.62256 219.65685 l
105.62256 238.84827 l
h
f
12.78925 218.67305 m
106.60635 218.67305 l
105.62256 219.65685 l
13.77304 219.65685 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
108.57393 239.83206 m
174.86613 239.83206 l
173.88234 238.84827 l
109.55772 238.84827 l
h
f
108.57393 239.83206 m
108.57393 218.67305 l
109.55772 219.65685 l
109.55772 238.84827 l
h
f
174.86613 239.83206 m
174.86613 218.67305 l
173.88234 219.65685 l
173.88234 238.84827 l
h
f
108.57393 218.67305 m
174.86613 218.67305 l
173.88234 219.65685 l
109.55772 219.65685 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
176.83371 239.83206 m
248.0715 239.83206 l
247.08771 238.84827 l
177.8175 238.84827 l
h
f
176.83371 239.83206 m
176.83371 218.67305 l
177.8175 219.65685 l
177.8175 238.84827 l
h
f
248.0715 239.83206 m
248.0715 218.67305 l
247.08771 219.65685 l
247.08771 238.84827 l
h
f
176.83371 218.67305 m
248.0715 218.67305 l
247.08771 219.65685 l
177.8175 219.65685 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
250.03908 239.83206 m
317.01782 239.83206 l
316.03403 238.84827 l
251.02287 238.84827 l
h
f
250.03908 239.83206 m
250.03908 218.67305 l
251.02287 219.65685 l
251.02287 238.84827 l
h
f
317.01782 239.83206 m
317.01782 218.67305 l
316.03403 219.65685 l
316.03403 238.84827 l
h
f
250.03908 218.67305 m
317.01782 218.67305 l
316.03403 219.65685 l
251.02287 219.65685 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
318.9854 239.83206 m
379.62007 239.83206 l
378.63628 238.84827 l
319.96919 238.84827 l
h
f
318.9854 239.83206 m
318.9854 218.67305 l
319.96919 219.65685 l
319.96919 238.84827 l
h
f
379.62007 239.83206 m
379.62007 218.67305 l
378.63628 219.65685 l
378.63628 238.84827 l
h
f
318.9854 218.67305 m
379.62007 218.67305 l
378.63628 219.65685 l
319.96919 219.65685 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
381.58765 239.83206 m
435.16629 239.83206 l
434.1825 238.84827 l
382.57144 238.84827 l
h
f
381.58765 239.83206 m
381.58765 218.67305 l
382.57144 219.65685 l
382.57144 238.84827 l
h
f
435.16629 239.83206 m
435.16629 218.67305 l
434.1825 219.65685 l
434.1825 238.84827 l
h
f
381.58765 218.67305 m
435.16629 218.67305 l
434.1825 219.65685 l
382.57144 219.65685 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
437.13387 239.83206 m
503.42607 239.83206 l
502.44228 238.84827 l
438.11766 238.84827 l
h
f
437.13387 239.83206 m
437.13387 218.67305 l
438.11766 219.65685 l
438.11766 238.84827 l
h
f
503.42607 239.83206 m
503.42607 218.67305 l
502.44228 219.65685 l
502.44228 238.84827 l
h
f
437.13387 218.67305 m
503.42607 218.67305 l
502.44228 219.65685 l
438.11766 219.65685 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
505.39365 239.83206 m
599.21075 239.83206 l
598.22696 238.84827 l
506.37744 238.84827 l
h
f
505.39365 239.83206 m
505.39365 218.67305 l
506.37744 219.65685 l
506.37744 238.84827 l
h
f
599.21075 239.83206 m
599.21075 218.67305 l
598.22696 219.65685 l
598.22696 238.84827 l
h
f
505.39365 218.67305 m
599.21075 218.67305 l
598.22696 219.65685 l
506.37744 219.65685 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
12.78925 216.70547 m
106.60635 216.70547 l
105.62256 215.72168 l
13.77304 215.72168 l
h
f
12.78925 216.70547 m
12.78925 180.29016 l
13.77304 181.27396 l
13.77304 215.72168 l
h
f
106.60635 216.70547 m
106.60635 180.29016 l
105.62256 181.27396 l
105.62256 215.72168 l
h
f
12.78925 180.29016 m
106.60635 180.29016 l
105.62256 181.27396 l
13.77304 181.27396 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
108.57393 216.70547 m
174.86613 216.70547 l
173.88234 215.72168 l
109.55772 215.72168 l
h
f
108.57393 216.70547 m
108.57393 180.29016 l
109.55772 181.27396 l
109.55772 215.72168 l
h
f
174.86613 216.70547 m
174.86613 180.29016 l
173.88234 181.27396 l
173.88234 215.72168 l
h
f
108.57393 180.29016 m
174.86613 180.29016 l
173.88234 181.27396 l
109.55772 181.27396 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
176.83371 216.70547 m
248.0715 216.70547 l
247.08771 215.72168 l
177.8175 215.72168 l
h
f
176.83371 216.70547 m
176.83371 180.29016 l
177.8175 181.27396 l
177.8175 215.72168 l
h
f
248.0715 216.70547 m
248.0715 180.29016 l
247.08771 181.27396 l
247.08771 215.72168 l
h
f
176.83371 180.29016 m
248.0715 180.29016 l
247.08771 181.27396 l
177.8175 181.27396 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
250.03908 216.70547 m
317.01782 216.70547 l
316.03403 215.72168 l
251.02287 215.72168 l
h
f
250.03908 216.70547 m
250.03908 180.29016 l
251.02287 181.27396 l
251.02287 215.72168 l
h
f
317.01782 216.70547 m
317.01782 180.29016 l
316.03403 181.27396 l
316.03403 215.72168 l
h
f
250.03908 180.29016 m
317.01782 180.29016 l
316.03403 181.27396 l
251.02287 181.27396 l
h
f
EMC
q
0 0 612 792 re
W* n
/Artifact <>BDC
Q
318.9854 216.70547 m
379.62007 216.70547 l
378.63628 215.72168 l
319.96919 215.72168 l
h
f
318.9854 216.70547 m
318.9854 180.29016 l
319.96919 181.27396 l
319.96919 215.72168 l
h
f
379.62007 216.70547 m
379.62007 180.29016 l
378.63628 181.27396 l
378.63628 215.72168 l
h
f
318.9854 180.29016 m
379.62007 180.29016 l
378.63628 181.27396 l
319.96919 181.27396 l
h
f
EMC
EMC
EMC
/P <>BDC
q
0 0 612 792 re
W* n
BT
/T1_0 1 Tf
0 Tc 0 Tw 0 Ts 100 Tz 0 Tr 12.71358 0 0 12.71358 9.83789 734.76143 Tm
( )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 18.91901 694.91043 Tm
(LHG/UA Name )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 118.94366 694.91043 Tm
(Original )Tj
0.5275 -1.2 Td
(Adult )Tj
-0.8055 -1.2 Td
(Estimates )Tj
0.04201 -1.2 Td
(\(15 WHS )Tj
0.6805 -1.2 Td
(health )Tj
-0.903 -1.2 Td
(conditions\) )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 196.38264 694.91043 Tm
(Adult )Tj
-0.8055 -1.2 Td
(Estimates )Tj
-0.26401 -1.2 Td
(using adult )Tj
0.084 -1.2 Td
(\(instead of )Tj
1.069 -1.2 Td
(total\) )Tj
-1.38901 -1.2 Td
(consultation )Tj
1.6255 -1.2 Td
(rates )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
12.71358 0 0 12.71358 267.4585 694.91043 Tm
(Adult )Tj
-0.8055 -1.2 Td
(Estimates )Tj
-0.3325 -1.2 Td
(\(Pregnancy )Tj
0.259 -1.2 Td
(+15 WHS )Tj
0.79601 -1.2 Td
(health )Tj
-0.903 -1.2 Td
(conditions\) )Tj
ET
EMC
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BT
/T1_0 1 Tf
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(% of )Tj
-0.1255 -1.2 Td
(GMS )Tj
-0.8045 -1.2 Td
(resources )Tj
0.7215 -1.2 Td
(\(adult )Tj
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(estimates\) )Tj
ET
EMC
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BT
/T1_0 1 Tf
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(Children )Tj
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(aged 0-)Tj
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(15 \(% of )Tj
0.1525 -1.2 Td
(total for )Tj
0.2225 -1.2 Td
(Wales, )Tj
0.33299 -1.2 Td
(1998\) )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(Estimates )Tj
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(\(Children )Tj
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ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(LHG/UA Name )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(Isle of Anglesey )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(3936208 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(3934363 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(2.11 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(2.24 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(3992870 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(Isle of Anglesey )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(Gwynedd )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(6789420 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(6787290 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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ET
EMC
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BT
/T1_0 1 Tf
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ET
EMC
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BT
/T1_0 1 Tf
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ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(6882838 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(Gwynedd )Tj
ET
EMC
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BT
/T1_0 1 Tf
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ET
EMC
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BT
/T1_0 1 Tf
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(7414572 )Tj
ET
EMC
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BT
/T1_0 1 Tf
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ET
EMC
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BT
/T1_0 1 Tf
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ET
EMC
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BT
/T1_0 1 Tf
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ET
EMC
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BT
/T1_0 1 Tf
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ET
EMC
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BT
/T1_0 1 Tf
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ET
EMC
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BT
/T1_0 1 Tf
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(Conwy )Tj
ET
EMC
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BT
/T1_0 1 Tf
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(Denbighshire )Tj
ET
EMC
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BT
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ET
EMC
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BT
/T1_0 1 Tf
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ET
EMC
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BT
/T1_0 1 Tf
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ET
EMC
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BT
/T1_0 1 Tf
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ET
EMC
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BT
/T1_0 1 Tf
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ET
EMC
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BT
/T1_0 1 Tf
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(5585903 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(Denbighshire )Tj
ET
EMC
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BT
/T1_0 1 Tf
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(Flintshire )Tj
ET
EMC
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BT
/T1_0 1 Tf
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ET
EMC
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BT
/T1_0 1 Tf
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ET
EMC
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BT
/T1_0 1 Tf
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ET
EMC
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BT
/T1_0 1 Tf
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ET
EMC
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BT
/T1_0 1 Tf
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ET
EMC
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BT
/T1_0 1 Tf
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ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(Flintshire )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(Wrexham )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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(7798858 )Tj
ET
EMC
/P <>BDC
BT
/T1_0 1 Tf
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ET
EMC
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/T1_0 1 Tf
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ET
EMC
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ET
EMC
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BT
/T1_0 1 Tf
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ET
EMC
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BT
/T1_0 1 Tf
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ET
EMC
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BT
/T1_0 1 Tf
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ET
EMC
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BT
/T1_0 1 Tf
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EMC
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BT
/T1_0 1 Tf
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EMC
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BT
/T1_0 1 Tf
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EMC
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EMC
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EMC
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EMC
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ET
EMC
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/T1_0 1 Tf
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ET
EMC
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EMC
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EMC
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EMC
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EMC
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EMC
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/T1_0 1 Tf
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EMC
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/T1_0 1 Tf
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ET
EMC
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/T1_0 1 Tf
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EMC
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/T1_0 1 Tf
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EMC
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EMC
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EMC
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EMC
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EMC
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