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Michael White: When localism tips into a postcode lottery

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When three quarters of clinical commissioning groups fail to follow national guidelines, where does this leave the “N” in NHS?


Years ago, the newly departed coalition minister, David “two brains” Willetts warned me of a central paradox of politics in a country too small and too England dominated to develop a regional federal structure: voters want local decision making, but they don’t want the postcode lottery that is bound to arise from it.

‘When NICE’s evidence based guidance clashes with local clinical imperatives, localism prevails’

I thought again of “Willetts’ law” when the Royal College of Surgeons reported that 73 per cent of the clinical commissioning groups it had investigated do not follow the guidelines set down by the National Institute for Health and Care Excellence, the saintly NICE.

Well, there’s a shocker! Give those clinical commissioning groups some freedom and they’ll use it, eh? Doctors were meant to be the lead partners, if you recall, but that has proved difficult.

The CCGs’ motive may not be exclusively financial, concedes RCS president Clare Marx, whose report Access to surgery: a postcode lottery? is based on freedom of information data obtained about a range of procedures from hip replacement to glue ear.

Localism wins out

But the message is clear enough: when NICE’s evidence-based guidance clashes with local clinical imperatives, localism prevails, as the CCGs’ platform NHS Clinical Commissioners insists.

Rightly so, in my view, though MPs, the kind of people who always support “save our hospital” campaigns in their own back yard – “it’s suicide not to” – know it will cause political trouble. Even the former foreign secretary William Hague backed a hospital protest in Richmond.

‘The health secretary can ask NICE for guidance but he can’t tell NICE what to say, though only the tone deaf fail to hear the mood music’

So Labour’s Andy Burnham is already protesting that this localist development undermines the “N” in NHS. Though, as usual, Labour’s own record undermines his stance: the devolved administrations that Labour created in Cardiff, Edinburgh and Belfast are already taking their regions in different “N” directions.

The NHS monolith can learn from this diversity - especially from Scotland - just as it can from CCGs that insist on weight loss before sanctioning a hip replacement (seems sensible, yes?) or on “wait and watch” before spending money on a still-risky tonsillectomy.

There are good and bad lessons – Welsh waiting lists, anyone? – to be learned, such is the cash crisis enveloping the service.

Seeing red

All of which makes better sense of NICE’s announcement on Tuesday about nursing levels on the ward and how “red flag events” should be recorded, published and acted upon. Pain relief delays, medication errors, a lack of patient checks – they are all part of Jeremy Hunt’s drive to focus concern on patient safety and the patient’s wider experience of hospital.

‘NICE has retreated from the proposed 1:8 nurse-to-patient maximum requirement, a change that defers to local autonomy and discretion’

The health secretary can ask NICE for guidance but he can’t tell NICE what to say, though only the tone deaf fail to hear the mood music.

NICE’s safe staffing advisory committee has taken its cue from Mid Staffs and other horrors in much the same way that ministers have done in getting suspected unsafe hospitals put into special measures – with the imminent prospect that care homes and even GP practices may face the same “name and shame” treatment.

There’s a downside to all this, not least in terms of public confidence and staff morale, though I doubt Hunt needs reminding. But it’s worth noting that NICE has retreated from the proposed 1:8 nurse-to-patient maximum requirement set out in its draft guidance, a change that defers to local autonomy and discretion.

Different wards, different patient needs, we can call it a “postcode ward policy” if we or the Daily Mail want. Even as recommendations, it may add £200m (5 per cent) to the nursing budget.

Efficiency, in the shape of fewer bed sores and infections, will claw the money back, says Whitehall. Here’s hoping.

Michael White writes about politics for The Guardian

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