During the recent general election, the NHS featured as one of the most important political issues in the public mind. Indeed, Ipsos MORI found that it polled significantly higher than even the army or the monarchy as the institution which made people most proud to be British.1 Clearly, it’s the ‘National’ in the ‘National Health Service’ that resonates: not only is the NHS a safety net, but it’s free at the point of use for all, and is available regardless of means or any other discriminatory variable.
And yet this national service has always been shaped by the judgement of clinicians and local level commissioning decisions. What is fearfully spoken of as a ‘postcode lottery’ has always been a feature of the NHS.2 Growing haphazardly since 1948, both individual health authorities and powerful medical consultants have shaped local decisions on treatments and drugs. For instance, in the nineteen-nineties, GP ‘fundholding’ meant patients of ‘budgetholding’ general practices had faster access to hospital treatment than patients of nonfundholding practices, producing a clear, two-tier system.3 In response to concerns about this inequality of access, the 1997 Labour government promised to “renew the NHS as a one nation health service”,4 establishing national service frameworks and enforcing national standards of care to “further tackle the lottery of care”.5
However, public concern about ‘postcode lotteries’ in health seems stronger today than ever, due to the funding pressures the NHS faces and the process of ‘rationing’ being pursued by Clinical Commissioning Groups (CCGs). These processes, currently in operation across the country, restrict access to treatments in order to balance budgets, either through excluding ‘low value’ procedures (such as weight loss surgery) or excluding patients from surgery on grounds of lifestyle choices (such as excluding smokers from receiving hip replacements).6 Furthermore, the government’s decision to devolve health powers to Greater Manchester raises the question of how much divergence from national consistency in the NHS should be tolerated.
There are well-known examples where local variation has been deemed unpalatable. Northern, Eastern and Western Devon CCG was forced to back down on its plans to limit access to surgery for severely obese patients and smokers in the face of a public backlash.7 However, there are also examples of variation in the NHS which might be understood as reasonable. GPs make decisions everyday based upon their individual, professional judgement of patient need. Decisions at CCG level combine an assessment of local needs and ‘path dependency’: the legacies of previous spending decisions.
Indeed, as NHS England has stated, “England is too diverse for ‘one size fits all’”,8 so while NICE guidance and national priorities can shape decisions, there is no strict, objective way of allocating resources across different programmes of care throughout the country. In the case of health devolution in Manchester, supporters see the reform as enabling decisions to be taken much closer to the population served, mirroring the experience in Nordic countries where regional and local politicians often have a more significant role than their national counterparts in running health and care services.9 However, leaders in Manchester have also recognised the need for adequate resources to manage this devolved responsibility. Some have called for a proportion of the rebate paid by the pharmaceutical industry to government (under the Pharmaceutical Price Regulation Scheme) to be passed downwards to help fund improved local care.10
There are different sorts of variation within the NHS. In many places non-statutory NICE guidelines (to be distinguished from its binding technical appraisals) are not being followed, leading to an inequality of NHS provision across the country. In the case of IVF, for example, NICE recommends three full cycles for women aged under forty who have not conceived after two years of trying. However, eighty per cent of CCGs are failing to commission three full cycles in line with these recommendations, with the Vale of York CCG failing to offer any IVF cycles at all.11
The potential for unfairness in these ‘postcode’ disparities is clear. However, while the NICE guidance on IVF is ‘elective’ and not mandatory, the NHS is legally obliged to fund and resource medicines and treatments recommended by NICE’s technology appraisals. Yet, even with these statutory appraisals, there seems to be evidence of significant variation and non-compliance, leading to inequality of provision across the country. In response to this, an ‘innovation scorecard’ was established in 2013 to monitor NHS compliance with NICE technology appraisal decisions, increase transparency and overcome variation.12
The scorecard’s data demonstrates considerable variation across the country in the use of a range of medical technologies: for instance, in 2013-14, the Derbyshire and Nottinghamshire Area Team purchased twenty-two times fewer drugs for the prevention of thrombosis and strokes as recommended by NICE than the Area Team of Bristol, North Somerset, Somerset and South Gloucestershire.13 While some divergence can be explained by medical need and legitimate professional judgement, slow uptake of NICE technology appraisals may also be responsible. (It should be noted that the provision of accessible data and information is a welcome step, but more must be done to make it more user-friendly and better at highlighting variation.)14
However, variation in terms of mode of service delivery is not necessarily always detrimental, as in the case of the devolved nations. For example, while health inequalities between the devolved nations has been well-documented, Health Foundation and Nuffield Trust research has shown that despite differences in structures, organisation, competition, patient choice and the use of non-NHS providers, there is no evidence (based upon the data available) linking these policy differences to a divergence of performance.15
Different sorts of variation, then, produce different degrees of divergence. Come what may, the NHS has finite resources so ‘rationing’ will always exist. Tie this to commissioning and policy-making to reflect local need, and variation becomes inevitable, and possibly even desirable. However, to date, the public has not been part of this conversation. Polling from 2009 for the Social Market Foundation indicated that almost three quarters of the public believe that ‘treatments should only be available on the NHS if they are available to everyone and not dependent on where you live’, with only a quarter agreeing that NHS treatments should be based on ‘local need’.16
Public opinion offers an additional layer of complexity. The polling also found that people want a say on issues that affect them directly and frequently (such as GP access) or on issues where their participation was being sought (such as national health campaigns). Indeed, more recent analysis from The Patients Association has suggested the NHS should imbibe this ‘no decision about me, without me’ idea via CCGs, strengthening their use of patient and public engagement, and developing a clear sense of who should be responsible for patient engagement.17 However, to complicate matters, the public seems to prefer health specialists taking a lead on areas where the NHS is perceived to be performing well, and where decisions need to be made using complex clinical evidence (such as in screening): for these areas, the public sees its own participation as chaotic. In these instances, the public prefers ‘information’ over ‘involvement’, with decisions made openly with transparent rationale. So, despite broad support for the principle of engaging with citizens during decisionmaking, a nuanced approach to local participation and involvement is needed.
It is clear that establishing a health system that avoids the extremities of either a ‘one size fits all’ or a ‘let a thousand flowers bloom’ approach, as NHS England puts it, is complicated and prone to difficulty.18 As such, creating a truly ‘national’ offer in a locally and regionally devolved health and social care system generates a range of issues to consider for the future. Different local needs require different local approaches. As Nuffield Trust research has demonstrated, geographic variation in ‘rationing’ is now a fact within the NHS: yet, despite this, most CCGs ‘muddle through’ on an ad hoc basis, rather than develop a considered and transparent approach to priority setting, which is seemingly what the public would like to see.
While CCGs continue to establish how to set local priorities in the face of public disapproval of local variation, devolution of health powers must be founded upon a strong national framework. CCGs need to have the capability and resources to deliver on national frameworks and guidelines. They also need to understand fully ‘what the rules are’. By the same token, national leaders must be clear in setting out what they consider to be ‘acceptable variation’, what the national minimum standards across the country are, and what should and should not be within CCG powers.19
Notes
- Ipsos MORI, Maintaining Pride in the NHS (2014) – www.ipsos-mori.com/Assets/Docs/News/Blogs/ nhs-maintaining-pride-health-slides.pdf
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See the Black Report, Inequalities in Health (1980) for more information about ‘social and geographical disparities’ in the NHS – www.soc health.co.uk/national-health-service/publichealth-and-wellbeing/poverty-and-inequality/ the-black-report-1980/
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King’s Fund, Le Grand et al., Learning from the NHS Internal Market (1998)
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Department of Health, The New NHS: Modern and Dependable (1997) – www.gov.uk/government/ uploads/system/uploads/attachment_data/file/ 266003/newnhs.pdf
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Labour Party, Ambitions for Britain: Labour’s Manifesto (2001) – www.politicsresources.net/area/uk/ e01/man/lab/ENG1.pdf
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For more information see Nuffield Trust, Rationing in the NHS (2015) – www.nuffieldtrust.org. uk/sites/files/nuffield/publication/rationing_in_ the_nhs_0.pdf
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Michael White, ‘Why plans to ‘ration’ surgery in Devon were too politically unpalatable’, LGC Plus – www.lgcplus.com/opinion/health/moreon-health-and-social-care/why-plans-to-rationsurgery-in-devon-were-too-politically-unpalatable/5077868.article
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NHS England, Five Year Forward View (2014) – www.england.nhs.uk/wp-content/ uploads/2014/10/5yfv-web.pdf
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Chris Ham, ‘What Devo Manc could mean for health, social care and wellbeing in Greater Manchester’, The King’s Fund – www.kingsfund.org. uk/blog/2015/03/devo-manc-health-social-carewellbeing-greater-manchester
10.Nick Renaud-Komiya, ‘Manchester commissioners to lobby over pharma deal’, Health Service Journal – www.hsj.co.uk/hsj-local/ccgs/nhsnorth-manchester-ccg/manchester-commissioners-to-lobby-over-pharma-deal-money/5084460.article
11.‘NICE calls for an end to postcode lottery of IVF treatment’ – www.nice.org.uk/news/article/nicecalls-for-an-end-to-postcode-lottery-of-ivftreatment
12.NHS England’s Innovation Scorecard website – www.england.nhs.uk/ourwork/innovation/innovation-scorecard/
13.Data sourced from website – http://ccgtools. england.nhs.uk/innovation/ISKeyATSecondaryCareMedicinesOctober2014/atlas.html
14.Terry Harrison, ‘Innovation Scorecard: Innovation, Adoption and Diffusion?’ (2014) www.ghp. org.uk/ContentFiles/PDIG%20Terry%20Harrison%20presentation%20-%20June%202013.pdf
15.The Health Foundation and Nuffield Trust, The four health systems of the United Kingdom: how do they compare? (2014) – www.health.org.uk/ public/cms/75/76/313/4746/revised_four_countries_summary.pdf?realName=h0IYEn.pdf
16.Social Market Foundation, Local Control and Local Variation in the NHS: What do the public think? (2009) – www.smf.co.uk/wp-content/ uploads/2009/06/Publication-Local-controland-local-variation-in-the-NHS-What-do-thepublic-think.pdf
17.The Patients Association, Involving Patients in Commissioning: No decision about me, without me? (2011) – www.patients-association.org.uk/wpcontent/uploads/2014/07/Involving-Patients-inCommissioning.pdf
- NHS England, Five Year Forward View (2014)
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Nuffield Trust, Rationing in the NHS (2015)
This was first published by the Fabian Society