The government is set to release a bill detailing how it is they expect the proposed GP Consortia to work. GP Consortia, groups of GPs working together, are set to replace the current structure of Primary Care Trusts (PCTs) and Strategic Health Authorities (SHAs) as the mechanism through which primary healthcare is provided to the public, and services are commissioned. Recently, the planned wholesale changes to the NHS have come under a sustained attack from the media, professional bodies and MPs, meanwhile the plans for GP consortia have moved into a trial phase in which different setups are being tested for their effectiveness. The trial consortia demonstrate the extent to which the plans represent a completely new venture, with a broad spectrum of possibilities being tested in terms of consortia templates, from a ‘consortia’ of a mere 3 GP practices, to a vast group of 83 GP practices. There seems little reasoning behind how Consortia are allowed to form at the moment, thus I saw an interesting opportunity to consider the ‘GP Consortia Problem’ as a geographic question. This is most evident in the fact that the NHS is mandated to provide an equitable and universal service, and an unmetered potential for GPs to ‘consort’ may well lead to increasing inequities in healthcare provision.

I see the ‘GP Consortia Problem’ as solvable through a zone-design approach. To do this, I identify contiguity between all English GPs and employ spatially constrained clustering. The following assumptions are made:

• Distance is important, GP consortia should be space covering without holes or islands, therefore a ‘neighbour’ approach to contiguity is advocated using graphs.
• As a preliminary test, GPs are considered to be equal, although there is scope in the future to develop measures of dissimilarity and homegeneity which will provide better, or more appropriate solutions to the GP Consortia problem.
• Based on the trials, I assume that Consortia must consist of at least 35 GPs, the average number of GPs per consortia in the trial phase.

I have used two approaches to creating contiguity amongst the English GP practices, both of them graph theoretical concepts based upon geometric analyses: the delaunay triangulation, and the gabriel graph. I believe that the gabriel graph is a sub graph of the delaunay triangulation, as such it is sparser than the delaunay graph. The two graphs are defined as:

• Delaunay Triangulation – for a set of nodes (GP practices) the delaunay triangulation is the set of triangles created by drawing a circle with 3 nodes (which define the triangles edges) on the circle’s perimeter, in which the circle does not contain any other points- iterated for all sets of 3-points.
• Gabriel Graph- 2 nodes are connected if they form the start and end-point of the diameter of a circle, and the circle does not contain any other points – iterated for all pairs of points.

In this sense, both the Delaunay triangulation and the Gabriel graph are nearest proximity measures. Having obtained the graph, the differences can be seen below. Note both graphs have been constrained for the English boundary.

Having created the ‘contiguity’ graphs, I wrote a short python script to extract the realtionships between GPs and write the output as a ‘.gal’ file for use with pySAL. I utilised the pySAL regionalisation module to compute the consortia solutions, I have used this previously in my blog, so I won’t go into detail on it. I paramterised the solution using the contiguity matrices created, assuming equality amongst GP practices, and looking for groups of at least 35 GPs. The regionalisations were then joined to a special areal geography I created for visualisation, this is simply the Voronoi diagram of the English GPs clipped to the English boundary. The results are below:

In these results it is notable that the Gabriel graph gives a cleaner result, the density of the delaunay-based contiguity matrix means that the result is subject to some sliver-like polygons in the regionalisation, and ‘spikier’ regions in general.

Of course, this is just a test, but it does point at the potential to create a rationalised system fo GP Consortia. Naturally, the biggest issue with these maps is that they only establish an areal depiction of consortia, one that is largely irrelevant. This is because the actual service areas of GPs tend to overlap and extend beyond any given GP’s voronoi defined footprint. Therefore the geography of patients requires a subsequent treatment once a geography of COnsortia has been established, and only in the interaction of the two can issues pertaining to equity be understood.

A comment I received by a chap called Bob Stott, on a previous post, got me thinking. I want to pick up this part of the comment in particular:

This set of a couple of neurons firing, firstly, I was reminded that the Guardian recently had a piece lamenting the state of NHS websites, and secondly I remembered some critique I wrote a while ago suggesting that NHS Choices wasn’t up to scratch.

What I thought was: community informatics! What a great term! Here is a concept that might actually work under the new NHS structure! However, rather than Bob’s truly ambitious idea about communicating policy and strategy, what if we keep it simple at first and thought about communicating effectively with local communities about their care choices?

Now, the suggestion that the Guardian makes is that the NHS is wasting money on hundreds of websites, many of which are out-of-date, misleading or just wrong. In fact many of these website actually relate to primary care doctors surgeries, who, it could be argued, have better things to do than maintain a website. In fact there are numerous GPs who do not even have a web presence outside of the NHS Choices search page. Likewise, NHS Choices is an improving website – it has added several search filters and patient feedback methods since I last cast a critical eye over it, but it still acts as a centralised inforamtion portal. This is fine on the one hand, because the NHS is a national system of care, and such a system needs a centralised presence to some extent, however it may be limited when dealing with local issues. This is largely the thinking behind proposed changes to the NHS, the Conservative-Liberal government believe that previously too much power was centralised within the NHS system through explicit heirarchies. This, they claim, meant that central government had too much control over health spending, despite the fact that around 80% of funding was left to the lowest level authority- the primary care trust- to spend. The conservative-liberal system remotes the explicit national-regional-local linkage in favour of local consortia, groups of GPs, and instills a shadowy national body – the NHS commisioning board- about which we do not know too much at the moment, to oversee the consortia. Whilst there are numerous critiques one might make, upon reflection this seems like a potentially advantageous position from the vantage of ‘community informatics’.

Clearly a well maintained website for individual surgeries, or GP consortia, will be highly advantageous to the local users of the service, and as well as providing general information it could provide highly personalised insight that is tailored to the specific issues faced by either the communities, or the individual themselves. These websites were traditionally the responsibility of GPs who may not have kept them updated, as opposed to the PCTs, who had more important things to do, and perhaps were somewhat inefficient with respect to information dissemination and web media. However, a consortium, which is responsible for a group of local GPs, and which has a more marketised responsibility to provide tailored care may gain an advantage from the potential for several GPs to bring together resources and collaborate on providing community-based information and online services. This is simply because the shifting situation will mean that it is increasingly in the interest of the GPs and the consortia to advertise access to care and provide effective local solutions. Of course, whether this is a realistic possibility remains to be seen, I certainly hope that it could be a positive upshot of the NHS plans, but again there seems potential for the system to become increasingly inequitable for patients across the social scale.

Amongst other things, I’m beginning to tap into a data source I have acquired for my research known as Hospital Episode Statistics (HES). These are datasets which record the particulars of hospital service by patients. Generally they have a bit of a learning curve, and require the gathering of several additional datasets in order to make them useful. Having gathered all this data and put in all within a MySQL database I decided to conduct a basic analysis, using my study site of Southwark as a guinea pig. Essentially I wanted to known whether more people from Southwark were using hospitals of outpatient appointments than we would expect from national (England) figures. There are many reasons why any given area might be using health care services at a greater or lesser rate than other areas, but for the moment I simply wanted to see whether there was any interesting patterns.

In the HES data it is simple to calculate the total number of people using outpatient care, what is more complex is deriving an expected score from the national data. I went about it in the following way:

Firstly, I took the ONS experimental population projections from mid-2008 and calculated the number of people in each Southwark LSOA, and at the national (England) level, for each of the available age bands by men and women. The population projection age bands are quite coarse, giving totals for 5 population groups: 0-15, 16-29, 30-44, 45-64 (for men) or 45-59 (for women) and 65+ (for men) and 60+ for women. This isn’t ideal, but the age bands do roughly correlate with the different groups of mortality causes in the Grim Reaper’s road map (Shaw, Thomas, Smith and Dorling, 2008). Then I calculated the admission totals for all of the age-sex bands nationally (England), with this I could create a ratio of admissions against popualtion nationally. By applying this ratio to the Southwark LSOA population projects I could create an expected value for number of admissions per areas. Finally it is simply a case of dividing the observed admissions by the expected and multipling by 100 to get a score.

I mapped the results as follows, a score of 100 suggests that the area is not different from the national picture, whereas a value higher than 100 suggests that the area has more people using hospitals than we would expect and a value lower than 100 suggests the converse.

In the case of Southwark, the pattern seems to follow those that are often observed in my work on Southwark, in that the Bankside areas, and the southern part of the borough, in addition with the north-eastern former docklands area have levels of admissions that are equivilant too, or lower than what we would expect nationally, whereas the central areas have admission numbers higher than the national level.

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.

The Marmot Review on health inequalities was released last week and is available at: http://www.ucl.ac.uk/marmotreview/ named ‘Fair Society, Healthy Lives’. I attended a lecture on it given by Prof. Peter Goldblatt which sought to details some of the process, evidence and outcomes that arose from the review. I will aim to briefly outline the nature of the report before sharing a few thoughts I had that arose from the session.

The report develops from a previous Marmot report called “Closing the Gap in a Generation” commissioned by the WHO. This report details the neccessity for Social Justice; Material, psychosocial and political empowerment; and, critically, the need to create conditions for people to have control over their lives. Health inequality is the situation in which different social classes can expect to have different health outcomes, the following graph from the Marmot Review demonstrates just this; that there is a social gradient in health from most deprived to most advantaged and that there is evident stratification between those that are healthy and those with Limiting Long Term Illness.

Life expectancy and disability-free life expectancy (DFLE) at birth, persons by neighbourhood income level, England, 1999–2003

It is interesting to note that the report is using the Index of Multiple Deprivation (I assume 2004) at MSOA (not LSOA) to define the axis ‘Neighbourhood Income Deprivation’. It is notable that the social gradient of health inequality in terms of life expectancy is greater for those with disabilities than without. Other graphs in the Marmot review confirm that the social gradient in health inequalities is not closing. Additionally there is also evidence for regional gradients. It is not just within the quantitative data that these gradients exist, but there is further evidence that social gradients in health inequalities are evident even in subjective questions in the Health Survey for England (HSE).

Having made health inequalities most evident, the review sought to collate as much evidence as possible, investigate measurement, indicators and targets that would be useful to this end, and finally suggest a strategy for implementing a reduction in health inequality. To this end it is important to note that the review was written under a philosophy of ‘progressive universalism’ – the authors believe in intervention across the social gradient, but put a greater focus on the least well-off areas. The review’s impetus is to create a greater sense of social justice and lower health inequalities by creating an enabling society; one in which there exists a sense of ‘Health Equity’ in all policy and in which benefit systems are used properly so as to maximise links between health and social protection and hence provide an adequate minimum income for healthy living. The 6 major recommendations, aimed at intervening along the entire life course, but specifically targetted at earlier stages where more good can be done, are:

• Give every child the best start in life
• Enable all children, young people and adults to maximise their capabilities and have control over their lives
• Create fair employment and good work for all
• Ensure a healthy standard of living for all.
• Create and develop healthy and sustainable places and communities
• Strengthen the role and impact of ill-health prevention.

It is clear from even a basic summary of the review that it is far reaching, this is the nature of my first observation: health no longer simply means an absense of disease as dictated by a Doctor, rather it is an incredibly complex, multi-dimensional concept. Health has seen a shift from something that is solely related to the body and the mind in terms of illness and mental health, to something that is far more pervasive. We now talk of the health of society- a collective health, the ‘wellbeing’ of people – a broader social aspect of health, the presence of healthy places – places that promote health, and the differential effects of health needs and access to healthcare. The Marmot review deals more with social conditions that with health per se, as such the report is reminiscent of the attitudes of Victorian philanthropists and social reformers advocating the clearing of slums and publishing on the state of the poor and the need for social uplift. The breadth of the question of health really calls into question how such recommendations as noted above could be adequately implemented, despite the fact that the Department of Health is one of the most well funded government departments, many of the recommendations of the Marmot review are multi-disciplinary in the sense that they seek to act on aspects of society as a whole through diverse channels at multiple levels.

I’ve previously commented on the nature of policy to develop interventions at the local/community/neighbourhood/place level without having an adequate definitions of what these levels constitute. I think it is clear that, again, this review picks up these current tendencies in government policy without really stopping to ask what they actually are, or why they are important. Health geographers talk a lot about health and place, and often the meaning behind this is very nuanced. This is something which is is very difficult to account for in policy which is quantitatively driven, or requires concrete indicators of performance and success, and a universal toolkit applicable nationally, even regionally.

Finally, I pick up the comment about ‘Health Equity’. Asthana and Gibson (2008) define both health equity and healthcare equity. Health equity is the condition of equal “opportunity to be healthy” whereas healthcare equity is more targeted than health equity, specifying “equal opportunities of access to healthcare for equal needs” (2008 p.4). Health Equity is a deficient term because it supposes a uniformly distributed population across space, essentially it fails to account for the spatial dimensions of health. When one considers the one-dimensional space of healthcare inequalities in which inequalities are dictated by universally applicable socio-economic characterisitics such as social class or wealth is is easy to see how a logical conclusion to reach would be health equity, but this is because the inequalities of access to health and the patterns of environmental quality are not adequately assessed. Distribution of people over space is an implicit indicator of likely health inequalities that is most evident in the persistence of ‘postcode lotteries of care’.

Reference

Asthana S and Gibson A 2008 Health care equity, health equity & resource allocation: Towards a normative approach to achieving the core principles of the NHS. Radical Statistics 96: 4-28

One of the most popular media narratives regarding care in the NHS is based around the concept of a ‘postcode lottery’. It is however something that is also acknowledged by the Department of Health in some areas of health care, for instance in the NHS Cancer Plan it is noted in chapter 1 that:

“In addition to relatively poor survival rates, the NHS also suffers from unacceptable variations in access to high quality cancer services.” (DoH, 2000)

The term ‘postcode lottery’ thus refers to a situation in which there exists geographic variation in the quality and type of treatment that prospective patients receive. As such the care any given patient receives is connected to where they live, thus the term ‘postcode lottery’ arises. The existence of such a situation is attributable to any number of factors including NHS resource allocation, insufficient numbers of specialist staff in a given area, accessibility to key services, and the possible presence of another postcode lottery centring around prescribing and access to pharmacy services. Connected to this idea is the proven fact of the ‘inverse care law’ first described by Julian Tudor Hart in 1971 which shows that communities most at risk from bad health tend to have the worst levels of access to the required NHS services. Wealth is often a factor in this function, in that the areas most at risk from poor health are likely to be those areas which are more deprived (as per the IMD) or from neighbourhoods which are again less-desirable or well-off (as per OAC).

The particular findings of the Royal College of Surgeons (RCS) relates to access to surgery to combat obesity, a particularly popular topic within the NHS at the moment:

“Access to NHS weight-loss surgery is ‘inconsistent, unethical and completely dependent on geographical location’, say senior surgeons” (RCS, 2010)

The RCS goes on to make a somewhat sinister claim that in some areas where budgets and resources are stretched, NHS decision makers are ignoring guidelines and denying patients’ access to surgery. Whilst in others, patients who already meet the criteria are forced to wait until either they become more obese or develop life-threatening illnesses like diabetes.The RCS calls for a basic tenent of the NHS systems to be upheld – universal service and the values that surround it that are enshrined in the NHS Constitution (2009) regarding fairness:

“Surgeons want to see consistency and transparency across the NHS so that patients are clear about what they are entitled to and doctors can treat all patients equally.” (RCS, 2010)

The main findings from an anonymous survey of UK bariatric surgeons (surgeons with a specialism in obesity related surgery) reveals that:

• Approximately two thirds of surgeons said patients who are eligible under guidelines are refused surgery in their centres.
• Criteria for surgery varies dramatically depending on geographical location and within the same Strategic Health Authorities.
• Some centres are treating patients with referrals from multiple Primary Care Trusts (PCTs) with different eligibility criteria meaning that patients with a BMI of 60 + are being refused surgery in the same hospitals that are treating patients with a BMI of 40 or less.
• Some Primary Care Trusts are refusing to commission any obesity surgery.

English Strategic Health Authorities acts as containers for Primary Care Trusts. The RCS has reported that even within some SHAs there exist PCTs which have a different policy towards obesity care. Thus the postcode lottery exists at a number of scales.

Guidelines set out by the National Institute for Clinical Excellence (NICE) were intended to herald the end of postcode lotteries, but in this case it seems that the power of local commisioning has meant that the national guidelines haven’t been followed. This has led to a call for the Department of Health (DH) to invest further in a strategy that will uphold patients right to not be subject to unequal access to treatment.

Finally, one wonders about the merits of refusing access to treatment, when, as Dr David Haslam (Chair of The National Obesity Forum), states:

“Bariatric surgery is amongst the most clinically-effective and cost-effective specialities in any field of medicine, preventing premature death, and transforming lives, whilst saving vast amounts of money for the NHS and the economy. Even the most cynical taxpayer should support bariatric surgery, alongside clinicians, in opposing the unethical and immoral barriers to surgery imposed by NHS purse-string holders.” (RCS, 2010, emphasis added)

Acknowledgements

The post is derived from the RCS website here

The map image is from data subject to: Crown Copyright 2009 UKBorders, an Edina/JISC supplied service.

In conjunction with my colleague Catherine Jones, soon to be of Portsmouth University, I am arranging a session at the coming years RGS-IBG 2010 annual conference. The session is jointly sponsored by the Geography of Health Research Group (GHRG) and the Quantitative Methods Research Group (QMRG) of the RGS. The details by way of a call for papers are:

The Spatial Dimensions of Health

Session Abstract

There is little doubt that geography and health are linked. Whether geography is considered in terms of the ‘geographies’ of individuals; communities and neighbourhoods; services and resources; or diseases- the linkage persists. In light of this, Gatrell and Elliot (2009) state ‘the subject of “health” is a rich source of material that bears study by the geographer’ (p.3). The importance of such study is highlighted by the steadfast presence of spatial disparities in health and healthcare nationally.

The intention of this session is to bring together research on the spatial dimensions of health, for the purpose of highlighting ongoing and nascent challenges within the diverse spectrum of health and health geography.

The session organisers invite proposals for papers that present empirical contributions within the spatial dimensions of health, ideally with focus on the UK. We welcome proposals that explore:

• The spatial dimensions of health inequalities and health behaviours
• Place, community and neighbourhood health and healthcare
• Spatial methods for developing health statistics
• Web 2.0 and health mapping

Reference
Gatrell, A. C. and Elliot, S. J. (2009) “Geographies of Health: An Introduction”, 2nd Edition, Wiley-Blackwell, Chicester

Key Words: Health, behaviour, inequality, quantitative, space.

Deadline for submitting abstracts is Monday 1^st February 2010

Please send abstracts up to a maximum of 250 words and proposed titles (clearly stating name, institution, and contact details) to Daniel Lewis (d.lewis@ucl.ac.uk) and/or Catherine Jones (kate-emma.jones@ucl.ac.uk).

Details of the full call for papers here.

In a nod to my colleague James Cheshire‘s fascination with cartograms, I’ve created one from the Spatial Equity data I used in the previous post. A cartogram is a map in which the value of each spatial unit’s area is replaced with a thematic mapping value; thus the mapped representation is warped and distorted to reflect the new thematic variable. Danny Dorling has been particularly active in this field, writing up work on Dorling Cartograms in the CATMOG series, and laterly using the Gastner Newman method to create cartograms for his interesting work in the book: The Atlas of the Real World.

Figure 1: Cartogram of Spatial Equity by Gravity Potential Model

It is clear from figure 1 that the south of Southwark suffers in terms of accessibility to a Southwark GP, whereas the central areas, characterised by a higher population density and more social housing have greater accessibility to healthcare services.

Whilst I’m not sure whether such a representation is entirely appropriate in this context, it does tell an interesting story- the same as the previous post but in a different manner, using the size of areas as well.

NB the map is subject to Crown Copyright 2009 Ordnance Survey. An UKBorders/JISC supplied service.

A little while ago I created some basic measures of spatial equity for my main study site in Southwark, London. Spatial equity in this case relates to a measure of the ‘fairness’ of spatial distribution of services. The NHS as a public institution has a requirement in its universal terms of service to provide a fair service to all.

The following maps aim to show how different areas in Southwark, in this case output areas (OAs), have different characterisitics in terms of: the level of primary care provision available, and the distance to centres of primary healthcare. Following Truelove (1993), Talen and Anselin (1998) and Ricketts et al (1994) the first 3 maps use a buffer-approach to spatial equity, whilst the final shows a gravity model approach.

Figure 1: Spatial equity measured with a 500m buffer around GPs

This first map (figure 1) demonstrates that large parts of Southwark do not have access to healthcare services within 500 metres (euclidian distance), whereas the best served areas have access to more than one GP surgery and as many as 24 individual doctors.

Figure 2: Spatial equity measured with a 750m buffer around GPs

Figure two demonstrates that with a 750m buffer most areas are served, although there are still unserved areas, particularly in the south of the borough. The most well-served areas not have access to as many as 48 doctors.

Figure 3: Spatial equity measured with a 1000m buffer around GPs

A 1km buffer still shows areas of Southwark which are unserved, particularly in the south. My recent working paper features a map which confirms that residents of these areas are less likely to use Southwark services than those in the more core areas in the centre of the borough.

Figure 4: Spatial Equity measured by Log of the Gravity Potential

This final map uses a distance decay function rather than a buffer to represent spatial equity and is specified thusly (Talen and Anselin, 1998 p.600):

where Sj is the size of a facility (measured by number of doctors, operating capacity etc.) at location j and d is a distance decay factor between area i and facility j with a friction parameter alpha, here set to 2.

The result is not hugely different to the buffered approaches, giving a similar account of affairs. It is notable that in all cases the spatial equity correlates with provision of social housing. In the UK context Southwark is a special case, being amongst the most deprived Local authorities by IMD07 rank, in which fair access to services is skewed towards the needs of the more deprived, whether or not uptake, or ability to uptake actually reflects this is another question.

References

]]> http://danieljlewis.org/2009/12/08/basic-equity-maps-for-southwark/feed/ 0 http://danieljlewis.org/2009/12/07/nhs-it-cuts-some-thoughts/ http://danieljlewis.org/2009/12/07/nhs-it-cuts-some-thoughts/#comments Mon, 07 Dec 2009 16:55:17 +0000 Daniel Lewis http://danieljlewis.org/?p=86

Over the past week it has become apparent that Alistair Darling, the British Chancellor, is to cut funding for IT in the NHS. In particular, Darling highlights the NHS IT system and the scheme to make all patient records electronically accessible from any GP or Hospital in the country as not essential to the ‘frontline’. This is a terrible state of affairs; on a broader scale it is clear that government have become convinced that cuts in the public sector are required to manage the UK’s economy after the impact of quantitative easing and national indebtedness, but on a scale more local to the NHS it suggests an arbitrary characterisation of things the NHS do that are important and other things the NHS do.

Sure, to most people the NHS is the organisation that looks after the doctors that look after your health, thus the frontline function is healthcare. However as with all complex systems, of which the NHS is certainly one of the prime examples, the effective operation of the frontline is inextricably connected to the system’s ability to perform other core functions, particularly administration. Without wanting to sound facetious, administration drives the global economy and the performance outcomes of major companies, without this performance, efficiency, cost-effectiveness and attitude all go wanting. In the NHS sometimes it seems that the only way to standstill is to keep pushing forward, in light of new disease, the dynamic social situation of the UK, failing premises and reportedly falling standards. Thus, for a new centralised IT backbone that brings the NHS system upto a standard that most would consider essential, and possibly shocking that one was not already in place, to be cancelled in light of budget decisions is serious indeed.

In my personal experience it is evident that the NHS is not wholly blessed with technological innovation, in the past year I’ve still filled out paper-based forms for enrollment in doctors, seen my records passed around in a cardboard sleeve and had appointments recorded in a paper diary. On an academic level I’ve learnt of databases such as the NHSCR which records patient registrations to GPs and uses a language I believe called ‘MUMPS’ designed in some past time, and not at all accessible to a humble user of SQL, and had to reconfigure a template to read mortality registers into Microsoft Access. The research that I, and many others are conducting, could change the way in which public services operate but only if the data is available and accessible – who knows what kind of good could be achieved through spatial analysis of and data mining of a central database of NHS care records? The government aren’t looking ahead because it never pays to look ahead when an election is forthcoming.

Some news articles and comment on this topic: here, here, here and here.