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Now, the suggestion that the Guardian makes is that the NHS is wasting money on hundreds of websites, many of which are out-of-date, misleading or just wrong.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.

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

Yesterday I attended an Infectious Disease Research Network (IDRN) course on “Use of mapping sofware and systems in health research“. The broad remit of this event was to draw attention to the use of mapping software, such as GIS, and geospatial technologies, such as GPS, in health related research. The event was chaired by Professor Graham Moon, who seemed interested in the subject matter despite the fact that his work is not strictly in infectious diseases, rather health-related behaviours.

The way in which i think about health geographies is very much related to the individual, and the condition of a person being healthy or not, the likelihood of certain groups having a certain level of morbidity etc. Thus the first few presentations were actually quite strange, coming from an infectious disease angle, the focus is not the person but the disease and how it spreads. Therefore several talks predominantly featured the preponderance not of people, but of frogs, larvae or snails. The upshot of such analysis is that mapping is really quite important, these creatures can only exist in certain conditions, temperatures, soil types, moisure levels etc. and so spatial analysis helps directly map their habitats and delineate the sites of highest risk.

This type of analysis coupled directly to the extensive Malaria Atlas Project (MAP) based in Oxford which trawls for contemporary research on malarial prevalence globally and uses the subsequent huge data source to inform stakeholders of where certain types of malaria are likely to exist. The MAP project uses an impressive set of workflows through PostgreSQL and Python to create nice maps (cairo, mapnik and reportlab) and web maps (Django (python), Java and google web toolkit). Their most interesting element is the bayesian modeling framework which takes malarial influences such as temperature, elevation and other environmental factors, creates a malarial range and is then able to say where you are likely to find certain malaria forms. All the work coming out of MAP is cross checked by a panel of experts.

In the first session there was also a talk from the guys at spatialepidemiology.net who clearly have an extensive knowledge-base set up. Most interestingly they are pushing the contribution of ‘citizen scientists’ through their Android-based software for collecting field data – called epicollect – however the extent to which they are actually engaging citizen- or ‘street-’ science is negligable. they seem to subscribe to the idea that collation of data from many sources counts, even though the ‘citizen scientists’ they envision are all fully trained epidemiological researchers, hardly ‘Joe Public’.

The other presentations came from the Health Protection Agency (HPA) who reopened the onrunning debate on patient identifiable data, dynamic and time conscious data and the rights and ownership of data ‘masehed-up’ in a google maps interface. Subsequently we learnt of the incredible work being done  by MapAction, who let us know that maps were also a form of aid like food, water and medicine.

In spite of this, the general sense of cartographic technique from the health mapping was weak excluding perhaps map action and the malaria maps. In general representation choices weren’t that intuitive, and there was an overreliance on points in webmapping. Further the almost ubiquitous use of binary red-green schemes is unintelligable for the colourblind. Generally cartographic design could have been improved for most projects. There were some interesting uses though, such as time-lapse tracks of women and children in Uganda who had been tracked using GPS.

Unfortunately (or perhaps fortunately) the open session provided some more interesting papers than the health-based session did. Particularly the fascinating work on the Legible London project, I was particularly taken with their treatment of neighbourhoods in London. The concurrent poster session provided some interesting comment, including excellent work on cycles and rhymes in the city from Urbantick Fabian Neuhaus, who also provides an extensive review of the talks on his blog.

Finally the keynote, Mikaela Keller involved in the Health Maps project, deserves a mention. The scope of the site, which is well worth visiting is incredible, the level of technical expertise that goes into the site in terms of natural language recognition and machine learning is enormous. Again though, the mapping seems to struggle with overpopulation of point sources, overwhelming the slippy map surface. Still, a valuable resource based upon collecting and displaying media reports of disease outbreaks from diverse news media and health agency websites – roughly 20,000 of them resulting in 200 new alerts per day.