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.

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.

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.