Since coming to government, new Conservative Health Secretary Andrew Lansley has sought to fulfil the pledge he made to put an end to local restructurings of NHS service delivery by authorities higher up the NHS hierarchy. Ostensibly he believes that local decision-making will have a better overall effect on the quality of outcomes for patients and hence lead to a better health service. Specifically he wants to provide GPs with an opportunity to work with community leaders and their local authorities to steer local services. The core elements actually do not differ greatly from the outgoing Labour policies, particularly with respect to patient choice; however I will argue that there is a clear danger in engaging to too great an extent with a purely ‘local’ approach, in general there seems to be something of a misconception in Government, particularly in the provision of local services (i.e. schools), that local approaches are somehow ‘better’.

Firstly, let us consider something that the Government seems to do without fail, something that I, as a Geographer, find to be a grave sin of omission. That is the apparently indiscriminate use of spatial qualifiers without so much of an explanation as to their meaning. The use of ‘local’ and ‘community’ are spectacularly misleading without qualification, and yet they are often used because people seems to think they understand what is meant by them – everyone considers themselves part of a community, and local to a service – but will these personal feelings about their socio-spatial connections actually translate to the ability to input on healthcare decision making? My investigation of access and registeration of patients to GPs in Southwark has shown that a) primary care is a very location based service and without fail each doctor exhibits a characteristic distance decay function that describes the pattern of registration with a GP suggest to some socio-economic criteria, but also that b) patients overlap to a large extent in a densely-populated urban context, the suggestion being that activity-spaces (i.e. retail areas, workplace and schools) has a distorting effect on patterns of registration for some people. To this end I suggest that a ‘community’ can be defined independently for individual GPs based upon the patterns of patient uptake unique to that service, although there may be some strong correlations with residential, workplace, educational etc. communities that overlap it (of course for some GPs the profile of its registered community may be greatly divergent from its observed local (defined by proximity to a GP) community). The following map is an example of this kind of complexity:

Here it is clear that any definition of locality or community based upon an arbitrary areal basis yields groups of people who could be registered to as many as 29 different Southwark GPs in only a very small area. This is in fact a very good, simple, illustration of patient choice in action. There are a lot of questions to ask Mr Lansley about how he views ‘local’ or ‘community’, and whether he is willing to enshrine that definiton in policy before we actually consent to doing anything with provision of services.

Further still, I have claimed that GPs are very much location based services – they are, over a certain distance (in Southwark this is about 6 -10km) no one is registered with a GP, choosing instead a closer service. In many ways this was constrained by the pre-existing system of ‘catchment areas’, however these were set to be removed by the end of the year in the quest for patient choice, thus the potential for registration is opened up to people using doctors near their place of work (for instance) rather than than near their home, thus should these people have a say in provison of services in the area within which they do not live – they are part of the GP’s ‘community’ but not of the residential one. A good illustration of this  is actually the polyclinic system – Southwark is geared up to introduce 3 polyclinics – one which already exists as a large GP-led health centre in the centr eof the borough, and two in the north connected to hospitals, the biggest difficulty faced at the moment is in estimating the daytime population (i.e. transient workforce) of the Southbank in order to account for likely polyclinic usage – a huge number of people who do not live in Southwark but will likely have some part of their healthcare provided for by Southwark PCT.

It is also unclear what Mr Lansley refers to when he talks about ‘top-down’: is it the Strategic health authorities and the DoH itself? It cannot be the PCTs as Mr Lansley claims that the new criteria will have the support of ‘GP commissioners’ and it is the PCTs that actually do the commissioning, further the idea of GPs working with local authorities is largely the same of GPs working with PCTs now, as PCTs and LAs are generally coterminous.

Whilst it is pleasing to see a politician quoting the need for an evidence based appraoch to restructuring, it is unclear what evidence he might base GP quality on, the current payment method (QoF) is based on GP reporting of pre-specified target outcomes to a centralised authority, surely GPs will simply follow these directives in order to bring in as much money as possible. Indeed, these stats are strong recommended not to be used as measures of GP quality as they are by-and-large patchy in what they cover, and include little demographic data. Indeed, had the previous government not already cut the NHS IT initiative that would have made reporting of outcomes actually feasible nationally, the new government would have no doubt cut it anyway.

The final worry I have is one of equity, something upon which the NHS is founded – the provision of a fair service contingent on those that need it, that is free at point of service. Surely such an atomistic approach to healthcare provision as Mr Lansley seems to specify, is liable to deepen the perceived ’social gradient’ in health care, as without a careful (top-down) hand, the GPs and communities best-equiped to play an active role in orchestrating GP services will get increasingly better provision: most likely to be the wealthier areas of the country. There needs to be at least some form of national accountability for a national health service.