The NHS ‘postcode lottery’

Does a postcode lottery exist in healthcare delivered by the NHS?  The British Medical Association is in no doubt that it does.  Its spokeswoman says: “The BMA believes that every patient should have access to the same high quality health care, wherever they live.

“Unfortunately access to certain services, and in some cases the quality of the service being provided, can vary in different parts of the country. This is unacceptable and we believe action should be taken to address variation where it exists, including by providing extra funding and resources as necessary.”

There is plenty of evidence to support the BMA’s view.  A recent survey conducted for GP magazine found 71% of GPs believe there is local rationing of healthcare and that this has increased since April last year.  GPs report that in some localities they have difficulties in accessing community nursing care, counselling services, IVF and cataract surgery.

Even a government agency, the Health and Social Care Information Centre, has described access to cancer care as being subject to an “endemic and disastrous postcode lottery”.  It reported that perhaps one of three patients with cancer were not being prescribed medications that could extend their lives and which have been approved by NICE.

A recent report in the British Medical Journal found differential local pricing for IVF treatment means that different clinical commissioning groups pay widely varying prices.  This in turn leads to reluctance to pay for the treatment in some areas.  An audit by Fertility Fairness found that average prices ranged between £2,900 and £6,000.  Just 18% of CCGs provide the level of IVF – three cycles – recommended by NICE.  One CCG – the Vale of York – does not provide any IVF treatment.

At the end of last year, Dr Foster’s annual Hospital Guide reported that various treatments most commonly associated with ageing are becoming increasingly difficult to obtain in those areas where trusts are in financial difficulty.  A quarter of the English population now live in areas where the number of hip, knee and eye operations has fallen in the last five years.

It seems inevitable that CCGs which are struggling to balance their books are particularly likely to ration treatments, or adopt a tougher line to cost control by seeking cheaper treatments.

The Nuffield Trust has looked in detail at local variations.  Its analysis of the old Primary Care Trusts indicated big differences in how much work was contracted-out to the private sector according to region.  In London, PCTs contracted out 6.3% of secondary care spending to independent providers and slightly more was contracted out in the North West. But more than 10% of PCTs’ spend went to the independent sector in the South East, the South West, the East Midlands and the Yorkshire and Humber region.

Perhaps even more significantly, a joint report from the Nuffield Trust and the Health Foundation earlier this year found substantial variations across regions on the spend on anti-depressants.  Even where the social demographics of areas were similar, there were very substantial differences in the prescribing practices of GPs.  The population of Blackpool consume four times’ as many anti-depressants as those in Brent, adjusted per capita.

At the very least, this research shows massive variations in approaches taken by GPs in different regions across England.  Professor Nick Barber, director of research at the Health Foundation, says: “A crucial finding for doctors and patients to consider is that there is real variation in prescription rates across GP practices.  These differences imply that certain practices have a propensity to over or under prescribe.”

Another issue of concern is the impact of variable access to social care.  While the NHS is a national service – with a theoretically standardised principle of access to health care – there is no such pretence at uniformity with social care.  This is a local authority service, with vastly differing policies for the provision of services to residents in need.  It seems very likely that those variations will themselves have different impacts on the local NHS – and perhaps increase cost pressures in areas where councils provide less social care support.

A recent report from the King’s Fund called for more uniformity of access to social care.   A New Settlement for Health and Social Care concluded that access to social care should operate on the principle of “equal support for equal need”.  That report considered the greater assistance provided for people suffering from some illnesses, such as cancer, compared to other, dementia.  It urged reform of the social care system provided by both the NHS and local government, saying: “The consequences of doing nothing are that fewer people will receive publicly funded social care as further cuts are made to local authority budgets and more NHS organisations find themselves unable to provide timely access to acceptable standards of care within budget.”

It seems clear that while there has always been local variation and localised choice in how to tackle health problems, this trend towards local differences has accelerated in recent years. This in part reflects a more decentralised NHS, but also the pressures from tight budgets which have led to localised differences that amount, in practice, to locally agreed policies of rationing.

But it can be argued that local variations are not necessarily a bad thing.  The circumstances that apply in Berwick, for example, are likely to differ from those in Dover or Penzance.  The Department of Health seems to agree.  Its spokeswoman says: “We don’t really have any involvement in the decisions made on the ground.  Clinical commissioners are responsible for what services they need to provide based on the needs on the ground.”

Colin Talbot, professor of government at the University of Manchester, believes that the concept of a uniform NHS is unrealistic.   “You are inevitably going to get some variation in any large organisation,” he argues.  “It can potentially be a laboratory of learning for what works and what doesn’t.  But if you have a policy of everything being the same you will have people hiding differences – and then you won’t learn from it.”

But there is also a fundamental problem about the concept of responding locally to local situations.  That problem is that there is no structure of democratic control or accountability over the decision-making process.  Trying to address this issue leads to a challenge to the principle of a National Health Service.  Professor Talbot suggests: “The logic is that you will have to move the NHS acute and other care into local authority control, or some other form of local democratic control.”