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.

Recent reports (for instance here and here) have indicated that the government is prepared to scrap the notion of catchment areas for General Practices in order to make it easier for patients to choose an appropriate doctor. The new NHS constitution allows patients increased freedom to choose, however the scrapping of catchment areas is an interesting proposition.

My work focuses on Southwark, London, so I can only really comment on the situation there, which as a densely populated urban area is likely to have a different set of issues than suburban or rural locations, however there are still a number of points to be made here.

Firstly, the idea is to promote ‘choice’ however the right to choose is captured primarily within a geographical context, i.e. proximity to a GP, or desire to use a GP that is close to work or school. However, research has shown that the majority of people (50% plus) do not actually care about their GP beyond it being ‘local’, most claim that they choose to use their closest GP. Those that do choose a GP still value accessibility, but more important factors tend to be related to the doctor’s ethnicity, or spoken language, and to the environment of the GP such as the neighbourhood it is within. Only in America, or Europe is the quality of service important; in the UK important metrics exist for assessing school and hospital quality, however an equivilent in the UK seems to be lacking. Prevalence statistics are available, but these are difficult for the layman to interpret, and they are given without context on the NHS choices website.

The main argument behind removing GP catchment areas seems to be that a) it will increase choice, and b) chocie is good. However, I offer some reasons why this might not be true.

• Catchment areas are primarily used to define the area within which a doctor is willing to make house calls. Thus it is not within a doctors interest to accept patients from too far away should this situtation arise.
• Often the catchment areas defined exogenously by a GP are much larger than the de facto catchment area defined endogenously by the pattern of patient registration (certainly the case in Southwark)
• The NHS pays doctors based on the size of their patient, and has a pretty weak structure for handling list data. A move such as this will make it much more difficult to handle registrations particularly if people want to register for convenience near where they work and then find themselves using a more local doctor on an ‘emergency’ basis when they have got something more than a cold.
• This may well create a hierarchical system of GPs based upon wealth, or some other measure of status. This may be evidenced by pronounced post-residential sorting, which will likely effect the performance of GPs in poor areas which can only attract chronically ill patients.
• How will choice be regulated, will GPs be able to close lists at will, or refuse ‘undesirables’?

My suspicion is that even if such a move went ahead it would be unlikely to create a massive upheaval, access to primary care is a very geographically limited problem as no one wants to travel great distances when ill just to go to the doctor. In many ways this approach seems to somewhat undermine the NHS rhetoric towards community health, in a situation in which everyone is choosing their GP you may find that GPs within a community do not actually reflect the needs of that community, or are not representative of the issues faced by that community because the patient register is itself a completely different community from outside of the immediate locality of the GP.

Finally, much of the agenda surrounding choice relies on the primary care commissioners within each Priamry Care Trust to ‘get it right’. I’m not confident that every PCT will be able to manage such a system, particularly if PCT boundaries become more porous and inequities between GPs develop.