Stuart Carroll: The NHS Postcode Lottery – It Could Be You

Stuart Carroll is a senior health economist, policy advisor and researcher for the Bow Group. Here he summarises the research paper he has co-authored for the Bow Group on the NHS Postcode Lottery which is published today and can be downloaded here.

The National Health Service is the number one priority for David Cameron’s Conservatives.  A key policy challenge concerns access to services as based on need.  As my research paper (co-authored with brother Ross) just published by the Bow Group shows, access is often not based on need due to the persistence of the “postcode lottery” – random countrywide variations in the provision, delivery and quality of healthcare services.

Contrary to government rhetoric, where you live remains a major determinant of the healthcare you receive.  There are geographical variations in virtually all aspects of healthcare, including charges for patient home care, waiting times, and diagnostic screening.

Our research reveals three key areas where the postcode lottery is particularly prominent and problematic:  1) the implementation of National Institute for Health and Clinical Excellence (NICE) guidance; 2) access to life-saving drugs and treatments; and, 3) the provision of end of life care.

1) Implementation of NICE guidance

For multiple sclerosis (MS), only 19 out of 156 PCTs are routinely following NICE guidelines for the use of Beta-interferon.  Furthermore, the MS drug Tysabri is inconsistently available across the NHS, despite being NICE approved and subject to the 3 month legal requirement.  As the recent parliamentary inquiry into NICE commented:

“…NHS bodies respond to NICE guidance at different rates. This means that new technologies are not available to all patients and the highest standards are not used throughout the NHS."

These problems of implementation do nothing to advance NICE’s stated aim.  If anything, irregular implementation is likely to compound existing health inequalities, widening the “accessibility gap” in priority disease areas and across target populations.  The perversity could not be greater. 

2) Access to life-saving drugs and treatments

There are huge inconsistencies in access to treatments for heart disease.  Only 45% of eligible patients are receiving access to cardiac rehabilitation, far short of the government’s 85% target.  In the case of stroke, according to Dr Jonathan Boyce of the Healthcare Commission, “there are still too many variations, too many places and regions that are not responding as well as they could to minimise the harm done by this serious and common condition”.  Our findings unearthed the fact that 81% of hospitals continue to use generic or standard admissions for stroke patients, which is considered clinically “second best”.    

IVF treatment, although often overlooked, is subjected to a horrendous postcode lottery.  A Department of Health survey noted variations in assessment criteria, whilst differences in the number of cycles of IVF offered to patients ranges from one cycle to three cycles depending on area. 

3) End of life and palliative care

One of the most neglected areas within the NHS is the provision of end of life care for critically ill and dying patients.  PCT spending on palliative care varies from a low of £154 to a high of £1,684 per death.  For example, the Isle of Wight PCT spends £13.39 per head of population on end of life care and, with a death rate of 1,227 per 100,000 of the population, spends £1,091 per death.  Nearby East Sussex Downs PCT spends just £1.94 per head of population and, whilst having a similar death rate of 1,253 per 100,000, spends just £154 per death. There is no logical or justifiable reason for such extreme differences.   

Such dramatic disparities are inconsistent with the founding principles of the NHS.  Although there will always be natural differences in the precise healthcare requirements of different areas and sub-group populations, ready, consistent and open access to treatment should never be a question of geographical location.  The popular post-modern aphorism of “location, location, location” should have no place in a modern health service.

So why is this important you may question?  When broken down, the postcode lottery is a social injustice and incompatible with any rational understanding of fairness.  Stamping it out is therefore vital to increasing public confidence in the NHS; improving patient health outcomes; and ensuring the enshrined values of the NHS are actively upheld.   

Solutions

The persistence of the postcode lottery must be understood in the context of the current framework defining the NHS.  Increasing funding to target the problem can help, but is essentially limited in scope. Moving away from the current culture of centralised targets and prevailing “command and control” approach is fundamental to any sustainable policy resolution. 

Although important for performance assessment, targets need to be patient-orientated and linked to actual health outcomes on the ground. This is the only way to dynamically motivate the right provider behaviour and instill a framework of direct accountability to the patient.  Such a framework would place added scrutiny on those providers failing to provide ready access to the healthcare local patients need. 

Instead of “saving the world”, Gordon Brown should focus on saving the NHS as originally pledged.  It is a moral and social disgrace that the healthcare you receive depends so heavily on where you live.  Patients and the public surely deserve better.  The next Conservative government must take note.