I’m thinking about starting a list of unhelpful phrases about the NHS and top of the list is going to be “post code lottery”.
“London NHS care is postcode lottery” screamed the Evening Standard recently in response to a study from the Kings Fund showing variations in what London PCTs spend on cancer, heart disease and other things. Cue tabloid shroud waving and health-campaigner handwringing: funding differences = dreadful unfairness to people in areas where spending does not match the highest levels = heartless NHS bureaucrats putting people’s health at risk (shame!).
Simplistic league tables comparing health spending in uncritical ways don’t help public understanding, whether it is between London boroughs or between so called “developed” economies. The US spends more than anyone to achieve often mediocre outcomes and high wastage in their health transactions.
Is there really any significance for the health of their respective populations that Ealing comes “bottom” in England for cancer spending per patient and Redbridge is the highest spender? If that level of spending reflects an analysis of health needs and an allocation of resources according to population characteristics and desired outcomes, then the local spend is probably right for each place. It is the job of PCTs as commissioning bodies to do just this kind of localised analysis and investment to meet health needs and improve health outcomes. This point is sadly lost on most people and our politicians fear trying to explain it even when it has robust justification. No politician – Town hall or Whitehall – wants to put their neck on the media block for what the public perceives to be “unfair” even when it really is equitable.
Self-styled health campaigners and quite a few politicians wallow in emotive “death sentence” language claiming differential spending always means differential quality of care. On the contrary, it could just mean that all areas are not the same. We don’t have homogenous, equal-sized populations with identical needs. The fact is that uniformity of spending would be inequitable because it would smother action to meet local needs and reflect local views.
Local decision making – reflecting what patients and the public want and what public health intelligence says is needed and effective – is incompatible with national uniformity of spending. I don’t want Whitehall dictating how Wandsworth PCT should spend its resources on meeting the health needs of our population. I want local people to have an informed say about it and for clinicians, public health specialists and managers close to the issues who know the data and the effectiveness of the interventions to inform the PCT’s decisions for investment.
With this in mind, I was cheered this week to see well known South London GP Brian Fisher tackle this politically charged subject head on in a succinct letter in Health Services Journal on “local socialism” – certainly an attention grabbing title on a very serious topic.
“Unplanned and irrational differences in provision may be unacceptable”, but Ministers need to get over their fear of “planned differences” as Dr Fisher terms them. Rational and robust “differences” show that the NHS commissioners are doing their job, not the reverse. We need the health literacy and political maturity to understand and welcome that. And the thing that would make it much better is when local communities get involved in decisions about levels of health and social care funding. The participatory budgeting pilots reported in a recent issue of the HSJ point the way to greater local decision making, not less.
So here is my “Memo to Ministers”: stop taking your cue from the tabloid sub-editors and the self-interested campaigners. Get the facts first and then support the people taking the tough decisions at the front line.
As Brian Fisher sums it up: “We need to reassure Ministers and the Department of Health that localisation is usually the result of good practice.”