Health resources: who decides who gets what

World and stethoscope

Clock with years on itIntroduction

Published by The King’s Fund, this briefing discusses how to improve the allocation of health resources in England. It is aimed at commissioners and local authorities, and other key decisions-makers regarding health care delivery.

This is an important document, as it explains clearly the changes taking place from April 2013, as a consequence of the coalition reforms resulting from the Health and Social Care Act. Since 1948, when the NHS was first established, decisions about how the health care budget would be distributed have been made by the Secretary of State for Health (SSH). As of 1st April 2013, however, this has changed, and the responsibility of distributing more than £95 billion pounds now goes to the National Commissioning Board, now referred to as NHS England, independent from the Government. This document starts by providing a very useful and comprehensive background to resource allocation in the NHS, and describes the possibilities for future, which The King’s Fund hope will inform the changes planned by NHS England. A mandate was drafted which states that “While decisions about allocating funding to commissioners are for the Board [NHS England] to make, the Department [of Health] is responsible for managing the overall NHS budget, and therefore will need to understand the Board’s approach to allocations.” It is assumed that as the NHS Commissioning Board becomes NHS England, this mandate will still apply.

Power buttonResponsibility for allocating resources

The SSH will need to make the initial decisions about how much is allocated to public health and how much to the NHS. NHS England will then need to decide how much to allocate to:

  • themselves and the clinical commissioning groups
  • primary care services
  • specialised services, clinical commissioning groups for secondary and community services

The SSH will now be responsible for deciding who gets what in public health; these decisions were previously made by PCTs, but now some public health functions are being transferred to local authorities, and a new organisation has been set up called Public Health England to oversee this work. This means that decisions will need to be made about how much of the public health budget should be allocated to Public Health England, and how much to local authorities.

Open tablet with question marks falling outRisks involved

At the start of the briefing, there is a description of all the different stages of resource allocation in the NHS, explaining the resources available at the start of the NHS and how things have adjusted, as governments have changed. This is followed by an explanation and a critique of the current approach, emphasising that while there is risk with these changes, there are also some ideal opportunities for dealing with longstanding problems. The authors do discuss the risks in great depth, looking at:

  • “increasingly fragmented and complex decision-making process,
  • lack of transparency and consultation,
  • inadequate measurement of need, and
  • the slow pace of change.”

Pie chartResource distribution

The King’s Fund wants to see resource allocation supporting bigger changes. In this document, they propose supporting the following options and discuss the pros and cons:

  • Outcomes – for example, allocating resources using the NHS Outcomes Framework.
  • Localism – via the Health and Wellbeing Boards and local authorities.
  • Integrated provision – using person-based resource allocation methods.
  • Mandated services through bottom-up costing – so, distributing programme budgets via national bodies or local commissioning groups.

Finally, there are recommendations for how public health resources could be fairly shared out.


This is a thought-provoking and useful paper as it explains thoroughly the background to health resource allocation in England and provides an important discussion on how best to manage the distribution of the health budget.

It is important for commissioners and providers, and everyone involved in health care decision-making to understand the implications of these new reforms and to think about how they are going to influence local decision-making practices.


Improving the allocation of health resources in England: how to decide who gets what (PDF)
D Buck, A Dixon
The King’s Fund
April 2013

Additional resources

The King’s Fund

NHS England (National Commissioning Board)

Public Health England

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Caroline De Brún

Caroline De Brún

Caroline has been a medical librarian in a variety of NHS and academic roles since 1999, working in academic, primary and secondary care settings, service improvement, knowledge management, and on several high profile national projects. She has a PhD in Computing and currently develops resources to support evidence-based cost and quality, including QIPP @lert, a blog highlighting key reports from health care and other sectors related to service improvement and QIPP (Quality, Innovation, Productivity, Prevention). She also delivers training and resources to support evidence identification and appraisal for cost, quality, service improvement, and leadership. She is co-author of the Searching Skills Toolkit, which aims to support health professionals' searching for best quality clinical and non-clinical evidence. Her research interests are health management, commissioning, public health, consumer health information literacy, and knowledge management. She currently works as a Knowledge and Evidence Specialist for Public Health England, and works on the Commissioning Elf in her spare time.

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