issues Distributing health care . Economic and ethical

Sundquist et al present a care need index for allocation of primary health care resources. Unfortunately, their paper rests on an erroneous description of the allocation model presently used in Stockholm, a blurred conception of need, and a mistake in the handling of data. The model used by Stockholm County Council to distribute funds between areas to purchase health care consists of four different components: (1) hospital based care, (2) private specialist care, (3) primary health care, and (4) pharmaceutical drugs. The primary health care model gives extra weight to neighbourhoods with high proportions of low income earners, immigrants, and single persons; and according to the proportion under 16 and over 64 years as they use primary health care more. This approach is as likely to capture health care needs in the population as the care need index (CNI) model, and it is not based on prior health care utilisation as suggested by Sundquist et al. In the CNI model ‘‘need’’ is defined on the basis of a set of pre-defined indicators that general practitioners have weighted according to their impact on GP work load. Models of health care utilisation usually differentiate between need and demand, as the probabilities to show up in the GP’s waiting room differ between persons and social groups, given the same need. GP’s experienced workload, however, is only affected by the patients in the waiting room; thus the theoretical basis for the CNI is demand rather than need. The empirical analyses are based on the annual surveys of living conditions. In these surveys the number of response alternatives to the self rated health question was changed from three to five in 1996, but the authors seem to treat the data as if there were three response alternatives throughout the period. As a consequence those with ‘‘good’’ health have been counted as ill in a third of the sample. This will cause the illness prevalence for 1996–97 to be overestimated and introduces a bias in the relation between health and other variables. The main practical consequence of applying the CNI rather than the existing model would be to ‘‘take from the poor to give to the poor’’. Although the SS area is more deprived than the SW area according to the CNI a reallocation from the first to the second is suggested. There must be more useful tools for allocation of primary care resources.