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.
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' (2 March 2015: Laboratory Talk)
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.”
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 9th 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.
‘Postcode lottery’ for knee and hip surgery (Age UK, 6th 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: 02 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: 04 April 2013)
NHS England has published a number of interim generic policies ensuring fair and consistent decision-making across its direct commissioning function. The 14 policies cover all aspects of NHS England’s direct commissioning responsibilities including specialised services, primary care, screening, military and offender health.
The policies, agreed by the Clinical Priorities Advisory Group (CPAG), set out NHS England’s approach on a variety of funding issues including Individual Funding Requests; access to treatments for patients moving between different sets of commissioners and services providers, and the process that NHS England will adopt for implementing guidance produced by the National Institute of Clinical Excellence (NICE). Other policies include the Ethical Framework for Priority Setting and Resource Allocation which sets out a fair and consistent approach to decision-making.
The policies are being adopted on an interim basis to enable NHS England to carry out further engagement with patients, carers and the public over the next 6-12 months in refining and agreeing final versions. NHS England plans to bring together a steering group which will lead development of the policies, working in partnership with a range of stakeholders. This group will test the principles on which the policies are based and will revise them, where appropriate, in order to make them more accessible.
'Stark variation in NHS surgery due to rationing' (BBC News: 08 March 2013)
Local NHS rationing has led to a "postcode lottery", say researchers: the number of patients undergoing common surgical procedures varies widely across England because of funding restrictions, figures show. The Department of Health said access to services should not be decided on cost, but rather on suitability for surgery, which should be judged by clinical experts on the basis of individual need.
A comparison of hospital data with primary care trust (PCT) policies on rationing of surgery showed a significant difference in the number of operations being done depending on local rules. For example for cataract surgery, PCTs with rationing in place were admitting about 48% fewer patients than those with no such policy in the first year restrictions were introduced, the figures showed.
Significant variations had been seen in access for almost every year looked at since rationing. The type and number of procedures rationed by PCTs varied considerably and only 17 of 119 respondents had no policy for all five of the procedures looked at.
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)
Hospitals are denying patients the latest cancer drugs, a report reveals today: many are refusing to give patients life-extending new treatments approved by NHS rationing body NICE. Research has uncovered a 40-fold variation between hospitals offering the highest numbers of drugs and those providing the least.
Charities warn that patients are at the mercy of an ‘unjustifiable postcode lottery’, with their chance dependent on where they live. There is also concern that hospitals are deliberately holding back highly effective treatments because they are more expensive than ones they already use. The stark variation may also be partly due to doctors in some hospitals preferring to give patients drugs they have used for years, rather than trying new treatments.
Research by the Rarer Cancers Foundation analysed NHS figures showing how often hospitals were prescribing new cancer drugs approved by NICE. The charity looked at 25 treatments recommended by the watchdog within the last ten years to treat cancers including breast, bowel, stomach, pancreatic, prostate, kidney and leukaemia. Some of these drugs have been shown to boost survival rates by as much a quarter while others can extend the lives of terminal patients by a year.
Andrew Wilson, chief executive of the Rarer Cancers Foundation, said: ‘For the first time these figures expose the highest and lowest users of cancer drugs. ‘Patients have a right to know. Some variation may be explained on clinical grounds, but others could reveal an unjustifiable postcode lottery: the NHS owes it to patients to investigate these variations and account for why they occur.’
IVF 'postcode lottery' to worsen, Lord Winston warns (The Telegraph: 02 January 2013)
IVF treatment will be down to a “postcode lottery” this spring when doctors take control of NHS spending, Lord Winston has warned. The fertility expert said the availability of in vitro fertilisation treatment was already unfair, with many Primary Care Trusts (PCTs) denying women the recommended three cycles of treatment.
The introduction of Clinical Commissioning Groups in April will widen the regional disparity as panels of doctors gain control of local budgets and target spending towards the most pressing needs in their area, he said. While women in some areas may see the availability of IVF increase, others living in regions with different priorities — such as those with more elderly patients — could find treatment harder to come by, Lord Winston said. This could force more women to seek private fertility treatment, driving up the cost of the procedure, he said.
The change in how NHS services are commissioned was dictated by the Health and Social Care Bill, which put spending in the hands of smaller, localised groups of doctors rather than PCTs.
Patients with rare conditions face postcode lottery (Guardian: 20 October 2012)
Research shows that patients with rare conditions have less chance of accessing 'orphan' medication if they live in England. "Orphan" drugs treat patients with a condition affecting fewer than five in 10,000 people. Figures contained in a new report by the think-tank 20:20 Health, claims the NHS is providing an unequal service. Seriously ill patients with life-threatening rare diseases are being denied vital drugs because of a postcode lottery across the NHS that campaigners say is frustrating and unfair.
New research reveals that patients with a rare condition have much less chance of accessing "orphan" medication if they live in England rather than Scotland or Wales. While the European Medicines Agency (EMA) has approved 68 drugs for use with patients with rare conditions such as unusual forms of cancer and epilepsy since 2000, the National Institute for Health and Clinical Excellence (NICE) has assessed only 18 of them, recommending that seven become available on the NHS in England and Wales, and another five under certain restrictions. In contrast NICE's equivalents in Scotland and Wales have made 28 and 21 respectively available in some way.The Scottish Medicines Consortium (SMC), has examined 56 of the 68 drugs and made 14 fully available and 14 more in some circumstances. Similarly, the All Wales Medicine Strategy Group (AWMSG) has looked at 51 and made 12 available and nine others in some cases.
The figures are contained in a new report by the think-tank 20:20 Health, which claims the disparity between the Celtic countries and England shows the NHS is providing an unequal service.
Mother attacks NHS 'postcode lottery' on pupil's hearing aid (This is Cornwall: 27 May 2012)
Ellie Sanders, four, was born with a rare condition called hemifacial microsomia which affects the development of the lower half of the face, and is being denied a hearing aid because of where she lives. Ellie has just one ear and desperately needs a special device so she can hear teachers and follow lessons on her first day of school in September.
Her mother Kelly, 31, applied for the bone anchored hearing aid (Baha) implant which transmits sound directly through the skull and reaches the inner ear, but she says Ellie is the victim of a "postcode lottery" with two NHS trusts arguing about who should pay the £3,000 bill. And while other children elsewhere in Britain get the aid little Ellie, from Truro, Cornwall, faces starting school without one.
Kelly said: "Other families in the same situation elsewhere in the UK have been offered a Baha. They don't have to go crawling around to other trusts. Kelly first tried unsuccessfully to get a Baha from the former Cornwall and Isles of Scilly Primary Care Trust which later became NHS Kernow. When she asked NHS Kernow for the device she was told she couldn't have one and was instead directed to NHS England, which has also failed to deliver: a spokesman for NHS Kernow said: "This particular type of equipment is funded by NHS England. We have written to the consultant caring for Ellie to advise him of this".
NHS England refused to comment on individual cases but a spokesman said: "From April 1, 2013, there was a new national commissioning policy in place providing guidance on bone anchored hearing aids for hearing loss: "This now ensures patients have the same access to treatment irrespective of where they live in the country".
NHS postcode lottery survey reveals wide UK disparities (The Guardian: 09 December 2011)
The NHS Atlas of Variation, a government analysis of regional healthcare treatment which shows assesses data on quality, quantity and costs, reveals huge variations in treatment and costs around the UK. The Atlas exposes what is a 'postcode lottery of treatment' in the NHS by revealing wide regional disparities in patient treatment.
The NHS Atlas of Variation, a copy of which has been obtained by the Guardian, lays bare the tension between the health secretary's vision of a "localised" health service and the need to impose basic minimum standards of acceptable care. While ministers accept that "some variation is warranted because different populations have different levels of need", the differences in cost, quality and patients outcome mean that "unwarranted" inequalities need to be ironed out.
The most stark contrast shows up in the rate of prescribing anti-dementia drugs, with patients in some parts of the country – such as North Lancashire – prescribed 25 times as many treatments and tablets to help "temporarily improve or stabilise symptoms" than in Kent. There is also concern that some women suffering with breast cancer are staying too long in hospital in certain parts of the country. In parts of south Wales, patients can stay for days whereas in Hertfordshire the same surgery warrants an overnight stay. The report states that most patients undergoing breast cancer surgery can be "safely managed as day cases or with a single overnight stay" but it adds: "At present, over 20 primary care trusts (PCTSs) have (average) lengths of stay in excess of three days".
Covering 71 key indicators – including hospital admission rates, what treatments health trusts choose to fund and how children are managed in NHS – the atlas attempts to map the "utilisation of healthcare services that cannot be explained by variation in patient illness or patient preferences". The government is aware that its plans are being tarred as increasing health inequalities and last week Andrew Lansley, the health secretary, told GPs that "the degree of variation is considerable, and unexplained by simple differences in population".