The writer is chief analyst at The King’s Fund, a health think-tank
The clue is in the name. The NHS is a national health service, implying that the services we receive should look and feel broadly the same wherever we live. And in many ways that is the intention.
While no one would expect the health service to be so uniform that it rode roughshod over the particular needs of local populations, NHS England’s national constitution still includes a series of important commitments that mean your wait for an ambulance, cancer diagnosis or hip and knee operation should be the same from in Sunderland to St Ives.
But the current crisis has emphasised what many have always known — that the NHS is more akin to an industry than a single entity. Variation, rather than standardisation, is one of its defining features.
So, what does this look like in practice? Let’s take the example of how long patients wait in A&E departments.
Headlines focus on the gradual decline in national performance figures for these services as austerity and staffing crises started to bite in the 2010s, then turbocharged by Covid-19. In January 2013, 94.6 per cent of people were seen within the target four hours within A&E departments. By January 2023, that had fallen to 72.4 per cent.
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But the growing variation in performance is even more striking. Ten years ago, less than 20 percentage points separated the top performing A&E department (with 99 per cent of patients seen in four hours) from the worst performer (82.4 per cent). Now, the worst performers see only 47.2 per cent of patients in four hours compared to the top performing trusts, at 93.5 per cent.
Like an outgoing tide uncovering hidden rocks, the unprecedented pressures from Covid, low funding growth and staff shortages have revealed local problems. While some NHS organisations have world-class infrastructure and modern facilities, others operate out of buildings that predate the NHS, with old, unreliable equipment. Some are in thriving communities with buoyant labour markets; others, in dying towns and cities, fail to attract staff.
Three things might help. The first is to create incentives so that the NHS’s best people can support struggling organisations. As one former NHS leader observed, in other industries the top brass earn their stripes working in the most challenging circumstances. In the NHS, however, some locations are avoided because they are “career killers”. Tackling this stigma could help prevent the downward spiral.
Second, it must be made as easy as possible to share resources to improve overall performance. As collaboration gradually replaces competition as the organising principle of the NHS, we need shared staff rotas, pooled “staff banks” and equipment. The assets of the NHS must be seen as a collective resource rather than the spoils of individual fiefdoms.
Finally, we need to change how we measure and monitor results. I have spoken to several high-performing organisations who have taken on additional work from struggling neighbours, only to see their own metrics suffer — even as the overall figures for the region start to improve. A new framework should reward organisations that make the right decision for patients in their patch.
The NHS “postcode lottery” is often taken to mean that the range of services and treatments — from IVF to new drugs — depends on where we live. But a more obvious form of postcode lottery concerns the quality of care.
This reflects an underlying truth about the NHS: it is not a “supertanker” that can be turned and redirected slowly by national directives. Instead, it is a flotilla of ships of varying shapes and sizes that are, at best, loosely tethered. Strengthening the ties between those ships, making it easier to exchange knowledge, skills and resources, could be a big part of the answer to the pressures the NHS and its patients face.