- by Catherine Max
- Independent consultant specialising in sustainable health and social care
Catherine Max attended “Is a ‘postcode lottery’ in health ever justified?”, a panel debate hosted by the Nuffield Trust and Royal College of Surgeons on 19th February 2015. You can see information about all the speakers and watch the webcast here.
I attended “Is a postcode lottery in health justified?” because of my interests in health inequalities, sustainable development and ethics, as well as experience in a prior PCT non-executive role dealing with Individual Funding/Exceptional Treatment requests. As I tentatively raised my hand, I was shocked to find myself the only person at the Nuffield Trust/Royal College of Surgeons #NHSRationing debate claiming to represent public health (I have no formal qualifications as such).
But I was also struck, in a positive sense, that it was a GP asking whether public health was in the room. Dr David Jenner, Chair of the Eastern and Mid Locality of North Eastern and Western Devon CCG was rather brave, I thought.
Not only was he willing to admit to the realities of local variation in treatment on offer (including between individual GPs in the same practice), he was happy to remind an audience of clinicians and special interest groups that it is housing and employment that reduces health inequalities. Not, that is, a nationally standard menu of treatments for those who are already ill nor a funding allocation designed to meet the health needs of the current crop of over 65s.
This last thought was echoed by Nigel Edwards, the Nuffield Trust’s Chief Executive, who reflected that it is both a value judgement and a political calculation whether to incorporate funding for unknown, non-voting future generations into the NHS budget distribution.
Decisions can only be made on an objective and scientific basis up to a point, as they embody societal and personal values which are often fundamentally irreconcilable … Trade-offs and compromises are inevitable…
Edwards N. Crump H. and Dayan M., ‘Rationing in the NHS‘. Nuffield Trust Policy Briefing #2. February 2015.
The event began with a presentation by Ben Page of IpsosMORI. His research exposes the inconsistencies the British public are willing to tolerate and the inequalities that result. That includes you and me, lest we are tempted to feel smug. Overwhelmingly, we lack trust in central institutions, with a whopping 79% of us trusting local government instead to make decisions about local services.
But this view sits in tension with a three to one preference for a uniform offer in health as well as the distinctively high value we place on the NHS as a national institution. It’s what makes us proud to be British, apparently, more so than the royal family and our system of democracy. We justify this preference in terms of the slippery concept of ‘fairness’, which, of course, means different things to different people. Are we talking about equality of access here or ‘each according to their need’?
As Nigel Edwards pointed out, we are also beset by a path dependency problem: where we are now in terms of health provision is shaped by history and that’s not something we can ever completely escape. Everyone on the panel agreed that governments of all stripes fail to face up to these inconsistencies because they want to avoid the tough decisions about funding and access that would otherwise result. The political fudge that is the Cancer Drugs Fund is a case in point. Dr Jenner made an admirable but unlikely plea for more political certainty. Leadership, in other words. No fans of the CDF either (see Helen Crump’s blog here), the Nuffield Trust’s take on the issue is nevertheless more pragmatic.
Their Rationing in the NHS pre-election briefing calls for greater transparency and rigour in decision-making, and moots an enhanced role for NICE whose technology appraisal methodology is internationally admired. Personally, I’m inclined to say that transparency and consistency are necessary but not sufficient for ‘fairness’, and the local NHS accountability lacuna left by the Health and Social Act 2012 continues to trouble me.
In that spirit, I welcome the opportunity presented by the decision to devolve the £6bn NHS budget to Greater Manchester. But if we want local, responsive and democratically legitimated services, then inconsistency may well be the price we have to pay. If ‘fairness’ is the goal, then what’s needed are upstream interventions to reduce inequality of need in the first place. A panel of clinicians, pundits and a former government Minister had the humility to acknowledge that, and I salute them for it.