THE POSTCODE LOTTERY
- There have been concerns since the late 1990s about the notion of the postcode lottery, rising from differences in access to NHS treatment throughout the country, and concerns that where you live can define the quality and availability of NHS services you can expect.
- The postcode lottery has become a big issue in the NHS, where the gap between the idea of a nationwide, comprehensive service and the reality of local decision making has been increasingly tense.
- Services which have been affected by the postcode lottery have included access to certain cancer drugs, fertility treatments, hernia repair, hip and knee replacements, cataracts and varicose vein surgeries, as well as variations in waiting times, access to cancer screening programmes and availability of drugs for mental health conditions.
- The postcode lottery came about largely from the practice of GP fundholding during the 1990s, a system which enabled GPs to receive a fixed budget from which to pay for primary care, drugs, and non-urgent hospital treatment for patients. The concept of a postcode lottery is also a by-product of patients and consumers becoming more aware: patient groups have become more adept at lobbying for their consumer "rights" to drugs and services.
- In 2008, Gordon Brown vowed to end the NHS postcode lottery, to mark the 60th anniversary of the NHS, and the issue of the postcode lottery has continued to come under much scrutiny in the context of the 2012 Health and Social Care Act.
- The increase in rationing within the NHS has led to an increase in the effects of the postcode lottery, in determining which patients have access to certain treatments. In April 2013, the NHS published generic commissioning policies, in order to ensure fair and consistent decision making across the board. with the aim of reducing the impact of the postcode lottery by making treatments available to all, regardless of where they live.
Charity nurses warn of ‘postcode lottery’ in specialist children's care (Nursing Times: 23 May 2016)
Expert children’s nurses have highlighted wide variations in services and standards for children with complex health needs as the ground-breaking charity nursing scheme celebrates its 10th anniversary.
Services provided by its nurses have made a dramatic difference to families including reducing distressing emergency hospital admissions and cutting lengthy stays in hospital.
However, nurses and managers involved in the scheme warn that many children with complex health conditions still face a “postcode lottery” when it comes to getting all-round support. Problems include reductions in children’s community nursing teams, huge variation in the types of services available and a lack of emotional support and training for parents caring for seriously ill children....read more
Jeremy Hunt urged to act against avoidable deaths from epilepsy (The Independent: 12 March 2016)
The Epilepsy Society has launched a new campaign calling on the Health Secretary Jeremy Hunt to act against avoidable deaths from the condition.
Although sufferers are at greater risk of premature death, almost four in 10 of those deaths are avoidable, according to the charity, which says better care, treatment and services are urgently needed. It has also launched an online campaign urging MPs to write to Mr Hunt requesting that a National Clinical Audit into the condition take place – for the first time since 2002.
The Epilepsy Society said the most worrying aspect is the postcode lottery for the 500,000 people in England living with the condition. Data from the Office for National Statistics shows that rates of premature death vary vastly: for example, someone with epilepsy is 49 per cent more likely to die prematurely in West Yorkshire than in Cheshire...read more
Prestigious teaching trust restricts access to heart service (HSJ: 1 March 2016)
A prestigious teaching hospital trust has temporarily restricted access to its outpatient cardiology service for out of area referrals, a leaked letter has revealed.
Cambridge University Hospitals Foundation Trust said the move was driven by its waiting list for routine cardiology outpatients rising by 50 patients a week and staff shortages. A leaked letter from the trust and its lead commissioner Cambridgeshire and Peterborough Clinical Commissioning Group said it made the move to avoid “potential safety concerns associated with excessively increased waiting times”.
The trust has told commissioners outside its main Cambridgeshire catchment area that their GP practices should send patients to “a different cardiology provider with immediate effect”...read more
The postcode lottery of new mothers' mental health services (The Guardian: 10 February 2016)
The arrival of a baby is supposed to be one of the happiest times of a woman’s life. But for a sizeable minority, it takes a heavy toll on their mental health, posing a risk to the welfare of mother and baby alike.
More than one in 10 women develop a mental illness while expecting a child or in the first year after giving birth. For about 40,000 women it is severe and in extreme cases necessitates admitting mother and baby to a specialist unit...read more
Diabetes care 'varies hugely' across England (Independent: 22 January 2016)
The Department of Health and NHS England paint an “unduly healthy picture” of the state of diabetes services in England, MPs have said.
The Public Accounts Committee said weaknesses in the approach of both organisations - and a lack of focus on preventing long-term complications from the condition - mean “the costs of diabetes to the NHS will continue to rise”.
MPs found that while evidence suggests the UK performs well compared to other countries, there are still “unacceptable variations” in how people with diabetes are able to access education about their condition. Furthermore, only 60 per cent receive the annual checks recommended to keep them healthy and prevent long-term complications.
The report said diabetes specialist staffing levels in hospitals “are not keeping pace” with the increasing percentage of beds occupied by diabetes patients.
It said: “The percentage of beds in acute hospitals in England occupied by people with diabetes continues to rise, from 14.8 per cent in 2010 to 15.7 per cent in 2013.
“However, the level of diabetic specialists has not significantly changed over this period. In 2013, nearly one-third of hospitals in England taking part in the audit had no diabetes inpatient specialist nurse and 6 per cent did not have any consultant time for diabetes inpatient care. “NHS England told us that an increase in nursing numbers isn't likely in the next year or two.” ... read more
Plan to force councils to raise more money to pay for elderly care 'could spark a postcode lottery' (Independent: 29 November 2015)
George Osborne’s plan to force local councils to raise more of their own money to pay for elderly care could spark a “postcode lottery” that determines much help the vulnerable can expect to receive at home, Town Hall leaders have warned.
In the Spending Review on 25 November, the Chancellor gave councils new powers to levy an extra 2 per cent on council tax bills to directly fund social care.
However, local government chiefs have warned that the change could widen the gap in care standards. The LGA calculated that, even where the 2 per cent surcharge was applied, it would be worth more in wealthier areas with more expensive homes – adding 15 per cent to those councils’ budgets by 2020 compared with just 5 per cent in disadvantaged towns.
LGA deputy chair David Simmonds, the Tory leader of Hillingdon, said that depending on individual circumstances, “you are not going to get any help at all” in some areas.
GP funding withdrawn as direct result of Government public health cuts, says local council (Pulse: 21 September 2015)
Public health commissioners were forced to cap funding of GP-run NHS Health Checks as a direct result of the Government’s mid-year cuts in funding, a local authority has said. Hertfordshire County Council told Pulse it needed to make savings as a result of the cuts – and hoped GPs would come to an agreement with them over how to achieve this. The Government introduced a £200m cut in the public health budget in June as part of a raft of measures to ‘bring down public debt’ – although it insisted this was on projected underspends and would not affect frontline services. As revealed by Pulse, public health commissioners in Hertfordshire recently wrote to GP practices to request the change to their contracts – meaning they will be paid only for the health checks they have already completed so far this year. Local GP leaders have vowed to fight the contract change, warning that it will force practices to lay off staff and cut other GP-run services, but say they have been accused of putting GPs’ ‘personal interests’ ahead of the need to sustain other public health services such as those for drug and alcohol misuse...read more
Revealed: Shocking NHS postcode lottery for elderly care (The Telegraph: 18 September 2015)
Elderly people in some parts of the country are nine times more likely than in others to be admitted to hospital as emergency cases - for lack of the right care in their local communities. Charities said the new official figures are a “troubling” insight into a growing crisis in care of the elderly, with hundreds of thousands of pensioners being admitted to hospitals via casualty in cases which could have been avoided with the right help earlier. The statistics also reveal a three-fold difference in the chance of cancer sufferers being diagnosed early enough to have a good chance of successful treatment, depending where they live. The figures, published by Public Health England, are among more than 100 measures assessed today in an “NHS atlas” exposing enormous variations in NHS care. They also show major disparities in dementia care, the chance of receiving stroke treatment quickly, or receiving treatment at all for a host of common health complaints such as cataracts. Over 75s living in Canterbury were the most likely to be admitted to hospital as an emergency for a stay of less than 24 hours, with 11,000 cases per 100,000 population.
English people with rare eye condition may be forced to move to Scotland to 'save their sight', says charity (The Independent: 25 July 2015)
English people living with a rare eye condition may be forced to move to Scotland or Wales to “save their sight”, the country’s leading charity for the blind has said, after the NHS refused to fund routine access to treatments.
The Royal National Institute of Blind People (RNIB) said it was considering legal action over NHS England’s decision not to recommended routine use of the drugs Humira and Remicade for patients with a severe form of the inflammatory eye condition, uveitis.
Both drugs are routinely available in Scotland and Wales and their use is standard practice in many other countries. A trial of Humira for one group of paediatric uveitis patients, taking place in the UK, was stopped early because overwhelming evidence of the drugs’ benefit meant it was deemed unethical to continue giving some children placebo.
However, NHS England concluded there was “not sufficient evidence” to recommend routine use.
Slashed budgets and STIs: The painful truth about birth control services in Britain today (The Independent: 16 June 2015)
‘Very worrying for sexual health, as well as other services: Government announces £200m cuts to public health budget.’
So tweeted the All-Party Parliamentary Group on Sexual and Reproductive Health last week, after George Osborne’s announcement that the Department of Health must make £200 million pounds worth of savings from public health budgets.
The news was met with alarm from the UK’s sexual and reproductive health (SRH) services.
Already a ‘Cinderella service’, SRH care has historically been less well funded or supported than other areas of health, and often finds it hard to attract and retain staff.
The proposed cuts could make huge differences to whether you can get an appointment when you need it or even the contraceptive you want.
NHS treatment cuts 'lack consistency' (Laboratory Talk: 2 March 2015)
During 2011, England’s NHS was tasked with finding £20 billion of efficiency savings over four years, in part by reducing the use of ineffective, overused or inappropriate procedures.
However, a report published today by researchers at Imperial College London (ICL) has found that an absence of clear national guidance about which procedures to perform less has caused inconsistency among NHS commissioning groups.
“Our research revealed a lack of consistency between commissioning organisations regarding which procedures were cut,” said Sophie Coronini-Cronberg, from the School of Public Health at ICL, who led the study.
“With little national guidance about which procedures to remove or restrict funding for and under which circumstances, commissioners may be turning to locally developed, unofficial lists and criteria of low-value treatments,” Coronini-Cronberg said.
“This urgently needs to be addressed to avoid local variations. Arbitrary decision-making needs to be replaced with objective, consistent, evidence-based policies.”
Cancer victims face postcode lottery for NHS care (Daily Mirror: 15 January 2015)
Thousands of cancer patients are dying needlessly every year because of an “unacceptable” postcode lottery of care, MPs warn.
A damning National Audit Office report warns almost 20,000 deaths a year could be avoided if patients from deprived areas fared as well as the richest in society.
Elderly cancer patients are also suffering from outcomes in particular.
The House of Commons Public Accounts Committee - which ordered the report - slammed the “astounding” survival rate differences within England and “shocking disparities” with other countries in Europe.
Some GP commissioners pay twice as much for IVF as others, review finds (BMJ: 11 September 2014)
Fertility Fairness is a multidisciplinary umbrella organisation that represents the major patient and professional bodies working in the field of infertility. It used freedom of information requests to map the fertility services offered by clinical commissioning groups (CCGs) in England. The audit found that the average prices paid for IVF ranged from £2900 to £6000. Fertility Fairness added that costs varied widely across the country because there was no national tariff for IVF treatment on the NHS—leaving it up to CCGs to negotiate locally with clinics on how much they should pay for each cycle.
The research also found that the number of commissioners offering the full three cycles of IVF that the National Institute for Health and Care Excellence recommends had fallen from 27% in 2011 to 18% (38 of 208 CCGs) in 2014. More than half of CCGs (110; 53%) offered just one cycle of IVF, up from 39% in 2011, and nearly a third (29%) offered two cycles (up from 26% in 2011). One CCG—Vale of York—offered no funding for fertility treatment.
The research also found that CCGs continued to restrict access to fertility treatment by using arbitrary age criteria that did not reflect NICE’s recommendation that treatment should be offered to couples where the female is under 42. For example, CCGs in Hampshire and the Isle of Wight continued to restrict access for couples where the female was 35 or over.
Last year an investigation by The BMJ found that only four of 195 CCGs had altered their IVF policy to reflect NICE guidelines published in February 2013, which advised that the age limit for women undergoing IVF should be raised from 40 to 42 and that IVF should also be offered to single women and same sex couples.
Cancer patients dying early because of postcode lottery (The Guardian: 15 August 2014)
Thousands of people are dying early of cancer every year because of an "inexcusable postcode lottery" in how quickly the NHS diagnoses and treats the disease, a leading charity warns.
Delays mean that cancer patients in some areas of England have up to a 61% higher risk of dying within a year of their diagnosis than those in other places, simply because of where they live.
While one in four (24%) of newly diagnosed cancer sufferers in north-east Hampshire and Farnham in Surrey die within a year, 38% of those in the London borough of Barking and Dagenham do so, according to a new Macmillan analysis of data from the Office for National Statistics.
About 6,000 more people a year would still be alive 12 months after being diagnosed if average survival across England could be made as good as that already achieved by the top 10% of England's 211 local CCGs, the charity says.
"This analysis shows an inexcusable postcode lottery, which is responsible for 6,000 patients dying needlessly every year within 12 months of being diagnosed with cancer," said Juliet Bouverie of Macmillan.
No NHS funding for fertility treatment in York (BBC News: 7 August 2014)
NHS bosses in York have decided to continue a policy of not funding fertility treatment.
The NHS Vale of York Clinical Commissioning Group (CCG) is currently the only area in England not to support IVF treatment. Funding was suspended in 2010 by the former primary care trust as part of a bid to save money.
Dr Tim Hughes, a GP member at the CCG, said the decision had been made "with a heavy heart."
Dr Hughes said the governing body had "voted to temporarily defer the commissioning of IVF services" but hoped to provide fertility treatment sometime in the future.
Patients denied vital operations by NHS bodies, surgeons report (The Guardian: 15 July 2015)
Patients are being denied access to vital surgery by NHS bodies, which are ignoring guidelines and choosing to ration some operations, according to an investigation by the Royal College of Surgeons.
The surgeon's report said that 73% of Clinical Commissioning Groups (CCGs) –the GP-led organisations involved in the delivery of a range of NHS services – do not follow rules set down by the National Institute for Health and Care Excellence and clinical guidance on referral for hip replacements, or have no policy in place for this procedure.
It also found that more than a third of CCGs (44%) require patients to be in various degrees of pain and immobility – with no consistency applied across the country – or to lose weight before surgery.
Criticism over NHS Down's syndrome test availability (BBC News: 14 July 2014)
A new screening test for Down's syndrome is still not available across the Welsh NHS, six years after guidelines said it should be.
In 2008 the National Institute for Health and Care Excellence (NICE) said all pregnant women should be offered the ultrasound scan and blood test. But currently only patients in north Wales are offered screening.
The Welsh government said introducing the test across Wales had been "challenging".
The guidelines recommended that all pregnant women are offered a combined ultrasound and blood test which identifies the risk of having a baby with a genetic condition caused by abnormal chromosomes, including Down's syndrome
Royal College of General Practitioners raises concerns over funding levels and postcode lottery for patient appointments (RCGP: 1 June 2014)
The Royal College of General Practitioners (RCGP) has voiced its concerns over the level of funding for general practice and the postcode lottery facing patients wanting to visit their local GP.
Up to four times as many people are reporting that they cannot get an appointment at their local surgery in places where access to a GP is worst, compared to the best performing areas. The RCGP analysis, based on the GP Patient Survey, also highlights that those patients who experience the most difficulty in getting to see a GP tend to live in the most deprived areas.
This survey data was allied to warnings over the proportion of health spending going to GPs, which is now at a historic low of 8.5% of the overall health budget; the RCGP argues that the increasingly stretched resources available to the general practice sector will lead to 34 million requests for consultations not being met this year amid increasing demand from the public for GP appointments.
NHS trusts told to end postcode lottery of IVF treatment. (The Telegraph: 15 May 2014)
Most couples who have not conceived after a year should be given three full cycles of IVF treatment on the NHS for free, the National Institute for Health and Care Excellence has said.
The first guidance on the issue was delivered ten years ago but NHS trusts have never fully implemented it across all areas meaning patients faced a postcode lottery. Gosport MP Caroline Dinenage told the Commons last week that women in her area are only being offered one cycle of IVF treatment up to the age of 35.
Earlier this year, campaign group Infertility network UK said three quarters of NHS organisations were not offering three full cycles as the Nice guidance intended.
Thousands of patients suffering from cancer and other serious illnesses are being denied the drugs they need from the NHS, according to a report. Even though the treatments have been approved by the health service rationing body, at least 14,000 patients a year are not receiving them. As many as one in three of those suffering from some types of cancer are going without medication that could extend their lives, the figures show. Experts said the report, from the Health and Social Care Information Centre, a government quango that provides NHS statistics and analysis of trends in health and social care, exposed an “endemic and disastrous postcode lottery” of care within the health service. Charities said the findings were “alarming” and meant patients were being condemned to an early death because local NHS bodies were failing to fund drugs even though they had been proven to work.
Surgeons criticise postcode lottery in weight loss services (The Guardian: 9 January 2014)
A postcode lottery is denying obese people in some areas access to intensive weight loss programmes, which are a prerequisite for bariatric surgery, the Royal College of Surgeons has said. NHS England's clinical commissioning policy requires individuals to have tried and exhausted all non-invasive treatment options, including weight management services, prior to potentially higher-risk surgical approaches. But based on evidence from its surgeons, the RCS says such weight loss services are not being made available to some people, putting their health at risk. It says north Cumbria stopped seeing patients for such programmes in September, and no funding is now available for them. In November Channel 4's Dispatches reported that fewer than one in four NHS clinical commissioning groups were funding weight management (tier 3) services.
Patients needing hip or knee replacements face a "lottery" over when their operations will be carried out, according to a new report. Nearly 11,500 more knee and hip replacements were performed by the NHS in March compared with April over the last 10 years, coinciding with the end of the financial year, researchers found. The figures suggested health trusts forecasting an under-spend were carrying out more procedures in March because they were "incentivised" to spend their budget limit to avoid losing those funds, the report said. The Medical Technology Group, which conducted the research, also found a "pronounced postcode lottery" over surgery waiting times, with a difference of up to 30 days in some parts of the country for hip and knee replacements.
‘Postcode lottery’ for knee and hip surgery (Age UK: 6 November 2013)
People needing a knee or hip replacement face significantly different waiting time lengths depending on where they live and when they begin their wait, a new report suggests. Researchers from the Medical Technology Group have reported a 'pronounced postcode lottery'; with patients in some areas waiting up to a month longer for operations than others elsewhere.
Patients in London typically waited 121 days for surgery last year, compared to the 91 or 93 days people in the East Midlands waited for a hip or knee replacement respectively.The last decade has seen a 92% increase in the number of NHS-conducted hip and knee replacement operations, the report found, with 140,000 carried out last year alone. This makes them among the most common medical interventions now seen in the UK. However, the report also found that over the last 10 years 49,351 knee replacements have been performed in March - 13% more than the 42,944 undertaken in April. It suggests health trusts forecasting an end-of-year under-spend are 'incentivised' to spend up to their delegated limit and carry out additional procedures in March.
It adds: 'This financial-calendar led allocation of procedures is highly unlikely to be the best model through which to fund equitable and consistent healthcare.'
Elderly at mercy of postcode lottery in 'ageist' NHS (The Telegraph: 2 September 2013)
Treatment statistics obtained by the former health minister Paul Burstow show dramatic variations between the availability of surgery for people over 75 in different parts of England. It amounts to alarming evidence that older people’s lives are being placed at the mercy of an unfair postcode lottery in the health service, Mr Burstow said. Patients over the age of 75 are six times as likely to be allowed cancer surgery in some areas as in others, according to the figures obtained in response to a Parliamentary question tabled by Mr Burstow. Michelle Mitchell, director general of Age UK, said: "The clear implication of these figures is that many older people, particularly in certain areas of the country, still face unfair, discriminatory and potentially illegal practice in the NHS. Everyone deserves fair access to medical care, yet older people's health and even their lives are at risk if arbitrary decisions are being made about their care based on their age, rather than their individual clinical need."
Dementia stats down but postcode lottery drives uneven care (The Conversation: 18 July 2013)
Dementia has been described as a ticking time bomb, with the number of those affected predicted to double in the next two decades, however a new study suggests that the prevalence of people with dementia in the UK has actually fallen over the past 20 years.
The findings, based on data from participants aged over 65 and living in Cambridgeshire, Newcastle and Nottingham, appears to be in line with a much larger Europe-wide study published by Alzheimer Co-operative Valuation in Europe. The researchers in England looked at 7,000 people randomly chosen between 1989 and 1994 and asked them about their lifestyle, health and socio-economic status. Nearly 8,000 more were recruited again between 2008 and 2011. Around 1,500 were tested for dementia.
Based on the estimated prevalence of dementia 20 years ago, the researchers then estimated that some 880,000 within the UK would be expected to have dementia by now (about 8% of people aged over 65). But this local study suggests a national prevalence of around 670,000 people (6.5% of the over 65 population). Overall, this is a fall of nearly a quarter in the number of people expected to have dementia.
The statistics about dementia are arguably the same all across the UK, and we can compare how four sets of policy makers have responded in England, Scotland, Wales and Northern Ireland. Each of the four health departments has a different policy. Based on the same statistics on prevalence of dementia, each country made a different policy at a different time and got hugely different outcomes. In Northern Ireland, for example, you have a 63% chance of being diagnosed by the health system, but in England it’s 42%. This postcode lottery is a scandal but averaging out the figure for England, Wales and Northern Ireland easily buries such differences.
Report reveals postcode lottery for cataract surgery (Optometry Today: 17 July 2013)
NHS England publishes generic commissioning policies (NHS England: 4 April 2013)
'Stark variation in NHS surgery due to rationing' (BBC News: 8 March 2013)
Hospitals in new cancer drugs postcode lottery amid fears some doctors prefer to stick with tried and trusted treatments (The Daily Mail: 24 January 2013)
IVF 'postcode lottery' to worsen, Lord Winston warns (The Telegraph: 2 January 2013)
Patients with rare conditions face postcode lottery (Guardian: 20 October 2012)
Mother attacks NHS 'postcode lottery' on pupil's hearing aid (This is Cornwall: 27 May 2012)
NHS postcode lottery survey reveals wide UK disparities (The Guardian: 9 December 2011)