Memorandum by Manchester Joint Health
Unit, Manchester City Council (PEX 15)
This memorandum has particular reference to
the following area to be examined by the Inquiry:
Resource Allocation within the NHS—what
arrangements exist to "cushion" resource shifts implied
by the allocation formulae?
SUMMARY
(i) This memorandum analyses the pace of change
(PoC) in financial allocations over the past decade to help inform
future policy. It makes a case for a faster PoC in future and
for the PoC to benefit from independent research and scrutiny.
(ii) PoC refers to the rate at which NHS annual
allocations to PCTs move towards their targets which represent
their "fair share" of the national total.
(iii) The PoC has been very slow generally over
the past decade, with typically an approximately 20 year timescale
to achieve future financial balance, despite the large increases
in NHS funding in this period which gave the potential to have
a faster PoC.
(iv) The only exceptions to the slow PoC in the
past decade were 2006-07 and 2007-08 when the Secretary of State
received exceptional lobbying pressure from numerous organisations
to speed up the PoC.
(v) The PoC has been by far the most powerful
element in the allocation process, damping down most of the changes
implied by formula changes and data updates.
(vi) The slowness of the PoC has generally been
to the disadvantage of poor health PCTs.
(vii) The maximum accumulated loss for any one
PCT over the past seven years (where boundaries can be made consistent)
is 6.4% or £213 million. Conversely the maximum gain is 21.2%
or £445.3 million.
(viii) The main regional gainer from the slow
PoC is London which, for 2010-11 is 8.1% or £1 billion over
fair share. The main loser is East Midlands which is 5.8% or £390
million under fair share.
(ix) It is not clear whether the typical algorithm
used to distribute the PoC to individual PCTs is optimal because
of "cliff edges"' in the algorithm.
(x) The PoC has not so far received the expert
research and scrutiny which the allocation formulae have received.
(xi) It would be logical for both PoC and the
derivation of formulae to be the responsibility of the same body,
utilising independent expert research and scrutiny. The proposed
NHS Commissioning Board might fulfil this role.
(xii) The points made in this paper are particularly
important for future GP consortia when these bodies replace PCTs
under White Paper proposals.
INTRODUCTION
"The Government can have a profound influence
on the shape and performance of local public services through...
funding mechanisms.. "1
The Marmot Review Economic Framework Report 2009
p 114.
"However, many PCTs have not yet received
their full needs-based allocations. The Government must move more
quickly to ensure PCTs receive their real target allocations".2
The House of Commons Health Select Committee
Report on Health Inequalities 2009 Recommendation 9.
1. The pace of change refers to the rate
at which the NHS annual financial allocations to PCTs move towards
their targets which represent their "fair share" of
the national cake. The targets are set using a range of national
formulae covering the needs of the population due to age distribution
and underlying health, as well as allowing for unavoidable wage
and price differences.3 One half of PCTs are currently receiving
allocations above their target, while the other half receive allocations
below target. Under-target PCTs usually receive a larger than
average year-on-year increase, and over-target PCTs usually receive
a smaller than average one; by this means convergence (the attainment
of target allocations by all PCTs) is approached gradually over
a number of years. The Distance from Target (DFT) is expressed
in money or as a percentage of the target.
2. This principle is of course perfectly
sound practice to avoid financial instability to particular PCTs.
However the devil is in the detail of the overall rate and the
algorithm which is used to translate a given PoC rate into PCT
allocations. Both of these issues have so far been decided in
camera by the DH and ministers. The Advisory Committee on Resource
Allocation (ACRA) has played no part, being responsible only for
recommendations on the formulae leading to the theoretical financial
"fair share". This is despite the fact that ACRA's remit
does not specifically exclude PoC. 4, 5
3. The current process separates ACRA's
recommendations on the formulae and resultant theoretical "target"
allocations, from the DH and ministerial decision on the actual
allocations (PoC), resulting in allocations which are informed
only to a minor extent by ACRA's theory. This leads to the following
problems:
(i) There is no clear connection of method between
the two stages; the first involves a judgment by a committee of
experts based on outside research and scrutiny, while the second
stage (PoC) is another judgment this time carried out in camera
by the DH and ministers without any outside research or scrutiny.
(ii) The second stage (PoC) involves a much more
powerful formula than the first, effectively damping the great
majority of any change implied in the recommendations of ACRA,
and thus appearing to diminish the role of ACRA and not to take
its recommendations seriously. (Details of the extent of damping
are given later in this paper)
(iii) This second stage (PoC) can be divided
into two components—the overall rate of moving PCTs towards
targets, and the algorithm used to determine the rate for individual
PCTs. The overall rate is generally considered to be slow and
this rate is contentious as in point (ii). In addition it is not
clear that the algorithm is optimal since it is imposed each year
without a background of research and scrutiny.
4. Government is vulnerable to criticism
in stage 2 more than in stage 1 because stage 1 uses recommendations
from experts. The closed process of stage 2 can lead to cynicism
within the NHS on the subject of financial allocations and reduction
in confidence and satisfaction with the whole process. An example
of this occurred after the 2003-04, 2004-05 and 2005-06 allocations
when a number of organisations (The then Healthcare Commission,6
the Special Interest Group of Municipal Authorities, the North
West Public Health Association, the Association of Greater Manchester
Authorities, The Coalfield Communities Campaign, the Manchester
Joint Health Unit and a number of individual PCTs) lobbied government
over a long period when they felt that the PoC was far too slow
and injurious to health inequalities.7 This pressure appeared
to be an important factor in the speeding up of the PoC for 2006-07
and 2007-08 allocations.8 However subsequently the PoC has slowed
down, being zero for 2008-09 and very slow for 2009-10 and 2010-11
even when the lower growth in those years is taken into account.
5. The remainder of this paper gives a more
detailed description of the PoC in recent years to highlight the
source of the above concerns and provide some evidence behind
the main points of this paper—that the PoC has been inequitably
slow and that expert research and scrutiny would be beneficial
to PoC.
Analysis of recent PoC—Quantification of
the rate—is it slow?
6. This section deals with the question
of the overall rate of PoC, and gives details of the actual rate
over the past 12 years using a variety of different measures.
All information and data used for the analysis in this and later
sections is that available on the website of the Dept of Health.9
Table 1
MEASURES OF POC RELATIVE TO OVERALL GROWTH
(LAST TWO COLUMNS)
Year |
No of trusts |
Growth %
|
Minimum
increase % | Min as % of
Growth (the
lower the faster)
| % of Overall
growth used
for PoC %
|
| 1999-2000 | 100 | 6.60
| 5.46 | 82.7 | 3.45
|
| 2000-01 | 99 | 6.78
| 6.21 | 91.6 | 2.47
|
| 2001-02 | 99 | 8.91
| 8.25 | 92.6 | 1.50
|
| 2002-03 | 94 | 10.55
| 9.93 | 94.1 | 2.14
|
| 2003-04 | 304 | 8.76
| 8.30 | 94.7 | 2.75
|
| 2004-05 | 304 | 9.47
| 8.88 | 93.8 | 2.22
|
| 2005-06 | 304 | 9.14
| 8.59 | 94.0 | 2.62
|
| 2006-07 | 303 | 9.20
| 8.05 | 87.5 | 4.41
|
| 2007-08 | 303 | 9.40
| 8.01 | 85.2 | 4.85
|
| 2008-09 | 152 | 5.46
| 5.46 | 100 | 0
|
| 2009-10 | 152 | 5.50
| 5.20 | 94.5 | 1.89
|
| 2010-11 | 152 | 5.50
| 5.14 | 93.5 | 2.47
|
Note There was no PoC for 2001-02 or 2008-09, but 2001-02 had
a recurrent health inequalities adjustment which had a small effect
on DFTs.
7. The last two columns give two different measures which
are both relative to growth and show wide variation independent
of the growth. The first measure—the minimum growth for
any PCT as a percentage of the overall growth is an approximate
measure of PoC because it's translation into PoC depends on the
number of PCTs which are given the minimum. However this number
has remained similar over the past because the algorithm for over-target
PCTs has had a consistent cut-off point at +2% DFT above which
all PCTs receive the minimum. The second measure is more precise—the
percentage of the total growth which is actually used to move
PCTs closer to target. It can be seen that this is a low percentage
even in years of faster PoC.
8. 1999-2000, 2006-07 and 2007-08 stand out as having
a faster PoC than average. The last column is independent of both
the growth and the minimum growth (assuming that the potential
for re-distribution is directly proportional to growth) and therefore
should be the better measure (strictly speaking perhaps real growth
should be used rather than nominal growth but that would require
estimates of NHS inflation which would be contentious). It is
striking how small a portion of the growth actually contributes
to re-distribution—even in the best of the last eight years
it was less than 5%. In addition it varies considerably from year
to year with the highest over three times the lowest.
9. The following graphs give the percentage distances
from target for the complete range of PCTs before (opening DFT),
and after (closing DFT) PoC. For 2009-10 the percentage of growth
used for PoC was 1.89% (of the total growth of £4.4 billion)
and the graph shows how small a difference this makes to the spread
of DFTs. The only significant change is for the small number of
very under target PCTs. Most PCTs under target are hardly affected
by PoC and PCTs which are over target show a very small reduction
in DFT.
Figure 1
EFFECT OF POC 2009-10
10. The second graph is for the year of highest PoC—2007-08
where a combination of higher percentage of growth (4.85% compared
with 1.89% for 2009-10) together with higher growth (9.40% compared
with 5.50%) leads to a much more significant PoC, though even
here the great majority of under target PCTs do not get much closer
to target and also strangely the most over-target PCT do not move
much either in proportion to their very high DFTs. However the
difference between the two graphs shows what can be achieved by
using a larger but still modest percentage of growth.
Figure 2
EFFECT OF POC 2007-08
11. It is difficult to estimate precisely the time in
years to convergence because of the difficulty of estimating the
rate at which very over-target PCTs will be brought to target
as convergence approaches ie the pace of change will slow with
time as fewer PCTs become much over-target. A crude starting point
for year-on-year comparison is the reciprocal times 100 of the
"reduction in mean DFT"'. (actual times will be greater
than this for the reason above). This indicates that in most years
the timescale to convergence is greater than 10 and up to 20+
years. In the exceptional years 2006-07 and 2007-08 the timescale
reduced to around half this range. Since that time the status
quo (and zero PoC for 2008-09) has re-asserted itself.
12. It is instructive to compare NHS and Local authority
PoC. "Floor Damping" is the term used to describe the
equivalent process to PoC for local authority allocations. Comparison
with the local authority national settlement seems to confirm
the slowness of NHS pace of change. For example comparative figures
are available for the measurement in the penultimate column of
table 1. This is the minimum growth accorded to the most over-target
PCTs as a percentage of the average growth. The fastest NHS pace
was in 2007-08 when this measure was 85.2%. For the same year
the local authority settlement under formula grant for the group
of authorities which have responsibility for Education and social
services (which includes most urban authorities) had an equivalent
measure of 72.2% 10, and this was at a time when the growth in
local authority settlements (growth of 3.74% and floor of 2.7%)
was much lower than NHS growth (9.40%). This pace would lead to
convergence in just a few years compared with the usual NHS timescale
of around 20 years.
13. Another difference with local authority allocations
is that the there is a process of consultation between the Department
of Communities and Local Government and individual local authorities
on the rate of floor damping, prior to the setting of the floor
level and the degree of damping.
Analysis of recent PoC -The PoC algorithm—is it optimal?
14. The algorithm determines how the portion of growth
devoted to PoC is distributed between individual PCTs. Some criteria
are set out for each allocation, though they are not usually comprehensive;
they appear arbitrary and with policy rather than scientific justification.
For illustration one graph of recent PoC algorithms are given—2009-10
which typifies principles used over the past decade. The latest
allocations for 2009-10 and 2010-11 have the following criteria
for PoC:
(a) Average PCT growth is 5.5% for each year.
(b) Minimum growth is 5.2% in 2009-10 and 5.1% in 2010-11.
(c) No PCT will be more than 6.2% under target by the end
of 2010-11.
(d) No PCT will move further under target as a result of above
average population growth in 2010-11.
Figure 3
POC FOR 2009-10
15. For positive DFTs the algorithm is similar to previous
years with a turning point at 2% DFT (and a gradient of for the
upper straighter part of about 0.2), though the turning point
is now curved rather than a sharp point. For negative DFTs the
algorithm is different from previous years—there is zero
gradient up to -6% which might be considered unfair for PCTs between
0% and -6%, more so with increasing negative DFT. Then the steep
rise from -6% up to -8% of gradient about 1.1 which tails off
after -8% seemingly towards zero gradient via a curve. The cliff
edges (or curved cliff edges) for negative DFTs introduce the
possibility of the accusation of inequity in the treatment of
PCTs. In addition any zero gradient also carries the same possibility—existing
for both negative and positive DFT ranges.
POC AND
HEALTH INEQUALITIES
16. The slowness of the PoC has been to the disadvantage
of poor health PCTs and hence has worked against improving health
inequalities. Figure 3 shows the relationship between % DFT and
the rate of improvement in relative mortality for all PCTs in
England. The significant downward slope indicates a general trend
for mortality to improve slower as PCTs move further under target
and vice versa.
17. The 62 Spearhead PCTs (those adjudged to have the
worst health and deprivation in 1995-97) have been on average
-£6.8 million (-1.7%) under target per year for the seven
years 2003-04 to 2009-10. Excluding the 11 London Spearheads increases
this figure to -£10.6 million (-2.9%). Although these average
percentages under target seem modest, these amounts are the sort
of size that would make large differences to the quantity and
quality of public health and primary care interventions.
Figure 3
DFT AND MORTALITY IMPROVEMENT
The constraints on PoC—financial stability and adhering
to the NHS operational frameworks—do they justify the slowness?
18. The reasons given for the "high floors"
(DH term for the high minimum growth for PCTs which as explained
above plays a crucial role in determining the PoC—the higher
the minimum the slower the PoC) often relate to the ability of
PCTs to carry out satisfactorily the items in the NHS operational
framework or to the need to retain "financial stability".
Both these generalisations are of course open to various interpretations.
But both are very much the field of the professional NHS senior
manager on the ground, or possibly the academic specialist in
the management and economics of large public bodies or in health
inequalities, but such people are not directly involved in the
PoC decision. Two extreme examples set the scene for debate of
this issue.
(i) Richmond and Twickenham PCT started at 23.8% (£48.9
million) over target (the highest over target) in 2009-10. The
average growth for England was 5.50%. Richmond and Twickenham
was awarded 5.20% or £13.3 million (the high minimum growth
for any PCT). This brought the PCT marginally closer to target
at 23.5% (£50.9 million) over target. A much faster PoC would
have been possible if the minimum had been set at say 4.0% giving
this PCT an increase of £10.2 million rather than £13.3
million, a reduction of £3.1 million or 1.2% in the total
allocation of £267.4 million. Would such a reduction have
caused financial instability in the PCT or made it unable to work
within the operational framework, in the context that it was considered
to be overfunded by around £50 million according to the latest
set of fair-share formulae?
Richmond and Twickenham enjoys very good health and an 18%
excess in the number of GPs according to the latest weighted capitation
figures. It has enjoyed a cumulative excess over fair share funding
of 17.7% or £234.3 million over the past seven years.
(ii) Halton & St Helens PCT started at 4.7% (£24.8
million) under target in 2009-10. The average growth for England
was 5.50% and Halton & St Helens was awarded the same at 5.50%
thus maintaining its position of 4.7% (£26.2 million)under
target. If the minimum growth had reduced as in example (i) from
5.2% to say 4.0%, then a lot more resources would be available
for redistribution under PoC and it is likely that Halton &
St Helens would have reduced to at least -3.5% an increase of
1.2% or £6.5 million allocation. Halton & St Helens has
some of the worst health in England and provides a key component
of the failing national health inequalities target. It has a shortfall
of 20% in the number of GPs according to the latest weighted capitation
figures. It has suffered from a cumulative shortfall compared
with fair share funding of -3.7% or -£115.4 million over
the past seven years.
POC AND
THE WHITE
PAPER PROPOSALS
19. The recent White Paper12 proposes the replacement
of PCTs by GP consortia as holders of the main NHS budget. This
brings PoC into greater focus because, in order to give both GP
consortia and their constituent GP practices the fairest start
financially, it is important to use the next (and proposed to
be the last) two PCT allocation years to move PCTs as close as
possible to "fair share" target.
20. The White Paper proposes that a new body, the NHS
Commissioning Board, will be responsible for resource allocation
to GP consortia. This proposal presents an opportunity for both
the derivation of formulae and PoC to come under the responsibility
of the same body; that same body would also be in a position to
commission expert independent research on both formulae and PoC.
CONCLUSION
21. This paper makes a case for a faster Pace of Change(PoC)
in NHS financial allocations, and for the PoC to benefit from
independent research and scrutiny and to be recommended or decided
by the same body which recommends or decides on the formulae.
Reasons given for this proposal include the following: PoC
has in practice over the last twelve years been the most powerful
aspect of the resource allocation process and therefore deserves
research and scrutiny in the same way as the formulae; the setting
of PoC represents a delicate balance between equity, reducing
health inequalities and financial stability and thus requires
a wide expertise including senior NHS managers and academics;
It is not clear whether the PoC algorithms used in recent years
represent the best way to allocate PoC to individual PCTs; the
powerful damping effect of the PoC on PCT "fair shares"
set by a committee other than ACRA as at present, may be seen
as lack of faith in the formulae; the slowness of the PoC in recent
years has been criticised by local and national organisations
including the Health Select Committee and the former Healthcare
Commission.
Advantages of this policy are that allocations will have
greater fairness, justification and general acceptability (while
still remaining under the ultimate control of ministers). These
advantages are particularly important for setting allocations
for the proposed new GP consortia, and the proposed NHS Commissioning
Board could provide the single body responsible for both formulae
and PoC.
REFERENCES1 Epstein D, Smith
P C An economic framework for analysing health inequalities in
England; a report for the Economics Task Group of the Health Inequalities
Commission (Marmot Review). Centre for Health Economics. University
of York. June 2009 p 114. Available on the Marmot Review website
at: http://www.ucl.ac.uk/gheg/marmotreview/Documents/tgs
2 House of Commons Health Committee. Health Inequalities.
Third Report of session 2008-09. Vol 1. February 2009. Recommendation
9 p 123. Available on the parliament website at: http://www.publications.parliament.uk/pa/cm200809/cmselect/cmhealth/286/286.pdf
3 Dept of Health. Resource Allocation Weighted Capitation
Formula. Sixth Ed. December 2008. Available on the Department
of Health website at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_091849
4 Dept of Health. Report of the Advisory Committee on Resource
Allocation. December 2008. Available on the Department of Health
website at: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_091483.pdf
5 Bevan G Review of the Weighted Capitation Formula; a Report
submitted to the Secretary of State for Health. July 2008. Available
on the Department of Health website at: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_093167.pdf
6 Healthcare Commission. State of Healthcare Report. July
2004.
7 Hacking J, Beggars Belief Health Service J 113; 5850: 28-31.
April 2003.
8 Hacking J, The Slice is Right. Health Service J 115; 5962:
18-19. June 2005.
9 Dept of Health. Available on the Department of Health website
at: http://www.dh.gov.uk/en/Managingyourorganisation/Financeandplanning/Allocations/index.htm
10 Capaldi A Guide to Relative Needs formulae 2007/8. CIPFA/Rita
Hale & Associates Ltd. 2008.
11 Department of Communities and Local Government. Methodology
for Floor Damping in the 2008/9 Local Government Finance Settlement.
December 2007. Available from the DCLG website at: http://www.local.communities.gov.uk/finance/0809/fdamp0809/paper.pdf
12 Department of Health. Equity and excellence: liberating
the NHS. 2010. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_117353
September 2010
APPENDIX
The following table gives aggregated DFTs for seven years
from 2003-04 to 2009-10. These result from changes in formula
and data in conjunction with PoC policy over the past seven years.
It shows a large range of financial imbalance between the extremes
of Bassetlaw (6.4% under target) to Westminster (21.2 % over target)
involving tens or hundreds of £ millions losses or gains
over the period.
2003-10 Aggregate Distance from Target (DFT) over seven years
and mean % DFT for all PCTs in England in order of largest losses
to largest gains.
(Spearheads are the 62 PCTs judged to have the worst health
and deprivation in 1995-97) Minus indicates loss, otherwise figures
are gains.
| Spearhead | PCT
| 2003-10 | 2003-10
|
| = s | | DFT Total
£million
| DFT %
Overall |
| Bassetlaw PCT | -62.7
| -6.4 |
| S | Knowsley PCT | -114.5
| -6.4 |
| North East Essex PCT |
-168.4 | -6.0 |
| S | Barking and Dagenham PCT
| -103.5 | -5.9 |
| Telford and Wrekin PCT |
-80.5 | -5.8 |
| S | Barnsley PCT | -226.8
| -5.3 |
| North Somerset PCT |
-83.6 | -5.1 |
| S | Sandwell PCT | -152.0
| -4.9 |
| S | Wolverhampton City PCT |
-111.6 | -4.6 |
| S | Leicester City PCT |
-129.4 | -4.6 |
| S | Blackburn with Darwen PCT
| -68.4 | -4.5 |
| Luton Teaching PCT | -72.5
| -4.4 |
| S | Stockton-on-Tees Teaching
| -71.0 | -4.3 |
| Great Yarmouth and Waveney PCT
| -88.5 | -4.2 |
| S | Oldham PCT | -90.6
| -4.1 |
| Torbay Care Trust | -53.0
| -3.9 |
| S | Wakefield District PCT |
-123.6 | -3.8 |
| S | Liverpool PCT | -201.5
| -3.8 |
| S | County Durham PCT | -196.0
| -3.8 |
| S | Doncaster PCT | -108.3
| -3.7 |
| S | Halton and St Helens PCT
| -115.4 | -3.7 |
| Herefordshire PCT | -54.7
| -3.7 |
| S | Lincolnshire PCT | -213.5
| -3.6 |
| S | Coventry Teaching PCT |
-106.3 | -3.5 |
| Bedfordshire PCT | -108.2
| -3.4 |
| S | Bolton PCT | -85.7
| -3.4 |
| S | Ashton, Leigh and Wigan PCT
| -97.9 | -3.3 |
| S | Newham PCT | -97.1
| -3.3 |
| S | Stoke on Trent PCT |
-85.2 | -3.3 |
| S | Walsall Teaching PCT |
-79.7 | -3.2 |
| Norfolk PCT | -193.2
| -3.2 |
| S | Middlesbrough PCT | -46.2
| -3.2 |
| Derby City PCT | -72.8
| -3.1 |
| S | Rotherham PCT | -72.5
| -3.1 |
| S | Tower Hamlets PCT | -75.3
| -3.0 |
| Medway Teaching PCT |
-64.8 | -2.9 |
| S | Northamptonshire PCT |
-160.0 | -2.9 |
| S | Derbyshire County PCT |
-176.2 | -2.9 |
| S | Hartlepool PCT | -27.1
| -2.9 |
| Cornwall and Isles of Scilly PCT
| -132.0 | -2.8 |
| S | South Staffordshire PCT
| -129.4 | -2.8 |
| S | Manchester PCT | -143.4
| -2.7 |
| Dudley PCT | -72.8
| -2.7 |
| S | Birmingham East and North PCT
| -104.8 | -2.7 |
| Milton Keynes PCT | -47.0
| -2.6 |
| Southampton City PCT |
-55.8 | -2.6 |
| Mid Essex PCT | -68.2
| -2.6 |
| Somerset PCT | -107.5
| -2.5 |
| S | Nottingham City PCT |
-68.4 | -2.4 |
| S | Bury PCT | -39.0
| -2.4 |
| South West Essex PCT |
-81.0 | -2.4 |
| Peterborough PCT | -31.9
| -2.3 |
| S | South Tyneside PCT |
-37.0 | -2.3 |
| S | Blackpool PCT | -35.4
| -2.3 |
| S | Nottinghamshire County PCT
| -125.9 | -2.3 |
| S | Heywood, Middleton and Rochdale PCT
| -47.3 | -2.3 |
| Worcestershire PCT | -97.6
| -2.2 |
| S | Heart of Birmingham Teaching PCT
| -62.9 | -2.1 |
| Isle of Wight Healthcare PCT
| -28.5 | -2.1 |
| North Lincolnshire PCT |
-28.1 | -2.1 |
| S | East Lancashire PCT |
-70.0 | -1.9 |
| Suffolk PCT | -87.8
| -1.9 |
| Leicestershire County and Rutland PCT
| -89.0 | -1.9 |
| S | Tameside and Glossop PCT
| -33.8 | -1.5 |
| S | City and Hackney Teaching PCT
| -39.7 | -1.5 |
| S | Redcar and Cleveland PCT
| -19.9 | -1.5 |
| South East Essex PCT |
-41.1 | -1.4 |
| S | Hull PCT | -37.5
| -1.4 |
| Shropshire County PCT |
-32.9 | -1.4 |
| S | Bradford and Airedale PCT
| -58.1 | -1.3 |
| East and North Hertfordshire PCT
| -54.1 | -1.3 |
| S | North East Lincolnshire PCT
| -18.2 | -1.2 |
| S | Gateshead PCT | -24.7
| -1.2 |
| Eastern and Coastal Kent PCT
| -70.2 | -1.1 |
| S | North Tyneside PCT |
-17.3 | -0.9 |
| East Riding of Yorkshire PCT
| -17.0 | -0.7 |
| Portsmouth City Teaching PCT
| -10.9 | -0.7 |
| Warwickshire PCT | -25.7
| -0.6 |
| Kirklees PCT | -19.3
| -0.6 |
| S | Northumberland Care Trust
| -15.9 | -0.6 |
| North Lancashire PCT |
-16.6 | -0.6 |
| S | Warrington PCT | -8.8
| -0.5 |
| S | Sunderland Teaching PCT
| 15.1 | -0.5 |
| Plymouth Teaching PCT |
-11.5 | -0.5 |
| Swindon PCT | -5.0
| -0.3 |
| North Staffordshire PCT |
-4.1 | -0.2 |
| S | Cumbria PCT | -5.2
| -0.1 |
| S | Central Lancashire PCT |
-1.2 | -0.0 |
| Dorset PCT | -1.0
| -0.0 |
| S | Salford PCT | 0.3
| 0.0 |
| Waltham Forest PCT | 1.2
| 0.1 |
| Havering PCT | 2.5
| 0.1 |
| Devon PCT | 11.5
| 0.2 |
| Enfield PCT | 7.6
| 0.3 |
| S | Wirral PCT | 10.5
| 0.3 |
| West Kent PCT | 24.8
| 0.5 |
| S | Haringey Teaching PCT |
11.6 | 0.5 |
| South Gloucestershire PCT
| 8.7 | 0.5 |
| North Yorkshire and York PCT
| 34.0 | 0.6 |
| S | South Birmingham PCT |
19.0 | 0.6 |
| Redbridge PCT | 13.2
| 0.7 |
| Cambridgeshire PCT | 29.8
| 0.7 |
| Solihull PCT | 11.9
| 0.7 |
| Western Cheshire PCT |
17.7 | 0.8 |
| Wiltshire PCT | 30.0
| 0.9 |
| Bexley Care Trust | 16.1
| 0.9 |
| Buckinghamshire PCT |
33.6 | 0.9 |
| Sefton PCT | 25.2
| 0.9 |
| Berkshire West PCT | 37.3
| 1.1 |
| Gloucestershire PCT |
53.2 | 1.2 |
| Hastings and Rother PCT |
23.0 | 1.4 |
| Bournemouth and Poole PCT
| 39.0 | 1.4 |
| Bristol PCT | 49.4
| 1.4 |
| Hampshire PCT | 150.2
| 1.6 |
| Central and Eastern Cheshire PCT
| 56.7 | 1.6 |
| Bath and North East Somerset PCT
| 24.0 | 1.7 |
| Calderdale PCT | 29.9
| 1.7 |
| Stockport PCT | 42.5
| 1.8 |
| Brighton and Hove City PCT
| 44.4 | 1.8 |
| West Essex PCT | 43.5
| 2.0 |
| Leeds PCT | 135.9
| 2.1 |
| Croydon PCT | 64.5
| 2.2 |
| Oxfordshire PCT | 105.1
| 2.3 |
| Berkshire East PCT | 69.5
| 2.4 |
| Sheffield PCT | 134.5
| 2.7 |
| West Sussex PCT | 179.6
| 2.8 |
| S | Newcastle PCT | 77.1
| 3.0 |
| East Sussex Downs and Weald PCT
| 85.6 | 3.0 |
| S | Greenwich Teaching PCT |
74.4 | 3.2 |
| Brent Teaching PCT | 93.2
| 3.4 |
| S | Southwark PCT | 91.4
| 3.4 |
| Hounslow PCT | 76.4
| 3.8 |
| West Hertfordshire PCT |
189.0 | 4.5 |
| Hillingdon PCT | 99.6
| 4.9 |
| Darlington PCT | 44.0
| 4.9 |
| Bromley PCT | 129.2
| 5.2 |
| Trafford PCT | 103.4
| 5.7 |
| Ealing PCT | 188.7
| 6.5 |
| Sutton and Merton PCT |
200.6 | 6.6 |
| Harrow PCT | 112.2
| 6.8 |
| Barnet PCT | 209.7
| 7.6 |
| Surrey PCT | 640.9
| 8.0 |
| Camden PCT | 206.3
| 8.8 |
| S | Islington PCT | 208.3
| 9.7 |
| S | Lewisham PCT | 248.9
| 9.9 |
| S | Hammersmith and Fulham PCT
| 172.8 | 10.3 |
| Kingston PCT | 135.2
| 10.6 |
| S | Lambeth PCT | 324.2
| 11.1 |
| Kensington and Chelsea PCT
| 227.8 | 13.4 |
| Wandsworth PCT | 322.2
| 13.5 |
| Richmond and Twickenham PCT
| 234.3 | 17.7 |
| Westminster PCT | 445.3
| 21.2 |
| |
| |
| 
