Christmas Lottery

 Politicians hate variation in healthcare. Anything that hints of a postcode lottery inevitably means bad press. Labour’s 1998 White Paper – ‘A First Class Service’ – opened with a very bold promise. ‘All patients in the National Health Service are entitled to high quality care. This should not depend on the geographic accident of where they happen to live. The Government is determined that all patients should receive a first class service. The unacceptable variations that have grown up in recent years must end.’ Thirteen years later, the NHS Atlas of Variation has found that disparities in treatment and funding across the service are as wide as ever.

There will always be some variation in the NHS. By random chance alone, some services do better than others and at any point in time, half of all doctors/ nurses/ managers will be below average. What the NHS needs to do is to ensure all services reach defined standards of quality and – given the money that has poured into the NHS – what’s most unacceptable is that this has yet to happen.

There has been a longstanding time lottery in the NHS – if you’re fortunate enough to have your life-threatening illness ‘in hours’, the chances of survival are greater than if you have it ‘out of hours’.  The notion that there are designated hours for illnesses that predict whether you make it out of the NHS alive is ridiculous yet, even in the twenty first century, you don’t want to get sick at Christmas. Department of Health research has found that you’re 11% more likely to die on a Saturday and 16% more likely to die on a Sunday compared to being admitted on a Wednesday. As one DH source put it: ‘We’re thinking of renaming every day Wednesday.’

The major predictors of unnecessary death were the fact that diagnostic equipment and experienced, senior staff tend not to be used at the weekend. The NHS needs to concentrate resources in fewer hospitals with high tech equipment and senior staff available around the clock. London would be much safer if it had nine  properly funded super hospitals rather than thirty not-so-super ones struggling for survival , yet no politicians – least of all Lansley and Cameron before the election – have had the balls to argue for hospital closures. So the NHS is stuck with a few centres of  excellence in a sea of mediocrity.

At least it now publishes the Atlas of Variation to show just how mediocre care can be. Last year, the Atlas found that 70 amputations a week are carried out in type 2 diabetic patients in England, that 80% of them were probably preventable and that if you lived in the South West you were almost twice as likely to get one than if you lived in the South East. The variation in the treatment of mini-strokes was equally shocking, with some areas treated 100% of patients within 24 hours and some treating virtually none.

The treatment of strokes in London has at least improved dramatically, with patients going to eight designated centres of excellence offering round the clock expertise rather than any one of thirty variable quality hospitals. This rare example of life-saving hospital reconfiguration encountered some political opposition, and the equally important centralisation of child heart surgery services – something MD has been advocating for nearly 20 years – has been delayed by judicial review. But ask any doctor where they’d send their baby for heart surgery and they’d choose a unit with round the clock expertise, safe staffing levels and top of the range equipment, not some small unit that mixes adult and child surgery and where the survival of the child depends on who’s on holiday that week.

This year’s Atlas has found patients in North Lancashire are prescribed 25 times as many anti-dementia drugs as those in Kent. There were also wide variations across England and Wales in the length of hospital stay after breast cancer surgery, access to care homes and angioplasty. Understanding what the variations mean is more complex, as is knowing how to tackle them. America has even wider variations in healthcare which suggests that Labour’s experiment with a market system – and the government’s persistence with it – may not be the answer.  Benchmarking services, publishing the results and concentrating services in centres of excellence that remain excellent at weekends and bank holidays  is likely to do far more good.