Mapping choice in the NHS: cross sectional study of routinely collecte
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《英国医生杂志》
1 Policy Directorate, King's Fund, London W1G 0AN, 2 Department of Economics, University of Bristol, Bristol BS8 ITH
Correspondence to: C Propper carol.propper@bristol.ac.uk
Abstract
One aim of the UK government is to introduce more choice into the NHS in England. Several key policies exist on this theme. The supply of providers (public and private) in secondary, particularly elective, care and primary care is being boosted. For example, 30 new diagnostic and treatment centres are now open and a further 15 are planned as of December 2004.1 Competition, or at least contestability, among secondary care providers is being enhanced.2 The choice of secondary care provider for patients waiting more than six months for elective care is to be extended, and a national consultation exercise on choice has taken place.3 These changes are underpinned by a new system—essentially a cost per case mechanism—of financial flows around the NHS.4
Increasing patient choice of provider is integral to these policies.3 Since 2002, two groups of patients—those waiting longer than six months for cardiac surgery, and those in London waiting longer than six months for treatment in selected specialties—have been offered a choice of provider that can supply treatment more quickly. Early results show that choice seems popular—for example, over 70% of 5000 patients involved in pilot schemes in London chose to be treated by another provider. A MORI poll for the BMA showed that if faced with a long wait 27% of people would travel anywhere in the United Kingdom for treatment by the NHS.5 The government expanded the model for choice to all patients waiting longer than six months for treatment across all specialties by August 2004, with more choice to be offered in the future.
Choice encompasses several dimensions. The current policy focuses on choice as a means of decreasing waiting times, but patients are also concerned about other dimensions of care, in particular quality.6 Regardless of dimension, expanding choice of provider to patients is a challenge to systems such as the NHS in which supplies are limited. We focused on the time it would take patients to travel to a provider. We used routinely collected data to examine the extent to which travel time would increase choice given the existing pattern of NHS and private facilities, ignoring differences in quality. If patients are to be given a choice of provider, are there differences in the time those seeking care will have to travel? If so, where in the country will people have to travel furthest to exercise this choice? Will increased use of private facilities, in addition to those in the NHS, change the amount of time people will have to travel?
Methods
Figure 1 shows the location of each NHS trust dealing with acute conditions in England. For most areas of England, an acute NHS trust was accessible within 100 minutes' travel time, and for large parts of the country a NHS trust was accessible within 30 minutes. Overall, 25% of the population had one hospital within 15 minutes' travel time and 41% had up to two hospitals. Fifteen per cent had no hospital within 30 minutes' travel time, but 98% had one hospital and 92% had two hospitals within 60 minutes' travel time.
Fig 1 Travel time (gradation of colour) to nearest NHS trust dealing with acute conditions, England, 2001
In three areas of England people have to travel relatively further to reach an acute NHS trust: the north of England close to the border with Scotland, East Anglia and parts of Lincolnshire, and parts of Devon and Cornwall.
The map did not adjust for population density, and so demand. To the extent that long travel times reflected low population densities, then some of the long travel times affected relatively fewer people.
Figure 2 shows the number of NHS trusts within 60 minutes' travel time. We found that areas with high and low access to hospitals were relatively similar when we considered 30 minutes' travel time instead of 60 minutes. The longer the travel time we considered, the greater the blurring of boundaries between areas of low and high access. As 60 minutes is reasonably long for a one way journey, we used this time for the rest of the analysis.
Fig 2 Number of NHS trusts within 60 minutes' travel time, England, 2001
Most people in England have access to at least one trust within 60 minutes' travel time. Areas with least choice of supply were the Scottish and Welsh borders and parts of East Anglia, Lincolnshire, and the south west. When considering choice in the Welsh borders we did not account for facilities in Wales.
Figure 3 shows travel time when private facilities are taken into account. This map is similar to figure 2, except the number of facilities within 60 minutes' travel time has increased, particularly in areas of relatively low supply. The proportion of the population with access to NHS and private facilities within 60 minutes' travel time was only 1% higher than the proportion with access to the NHS alone, however, because of the relatively small number of private facilities and because most are located near NHS facilities.
Fig 3 Number of NHS trusts and private facilities within 60 minutes' travel time, England, 2001
Hospitals vary in size, so the pattern of potentially available beds may differ. Figure 4 shows the number of available and unoccupied NHS beds within 60 minutes' travel time in England in 2001. Access to these beds resembles the pattern of access to facilities shown in figure 2. Within 60 minutes' travel time, 98% of people in England have access to up to 100 unoccupied NHS beds and 76% have access to up to 500 unoccupied NHS beds. The number of available and unoccupied NHS and private beds within 60 minutes' travel time is almost identical to that depicted in figure 4, due to the relative paucity of private beds (data not shown). People in England therefore have a large potential for choice of provider, with most people having access to a bed within 60 minutes' travel time.
Fig 4 Number of available and unoccupied NHS beds within 60 minutes' travel time, England, 2001
Our maps do not account for demand. Figure 5 shows demand relative to supply. We chose as a measure of the potential for choice, the number of patients waiting longer than six months for elective inpatient care per available and unoccupied NHS bed within 60 minutes' travel time.
Fig 5 Number of patients waiting longer than six months for elective inpatient care per available and unoccupied NHS bed within 60 minutes' travel time
The demand per unoccupied bed was greatest not only in some of the areas of low supply—parts of East Anglia, the area near the Welsh border, part of Cornwall—but also in areas of relatively high supply—the south east except for London, and south of Bristol. In contrast, other low supply areas (for example, the Scottish borders) also had low demand, so demand relative to supply was low and the potential for choice was high.
Adding in the number of available and unoccupied beds in the private sector (fig 6), shows the effective competition for available and unoccupied beds in different parts of the country.
Fig 6 Number of patients waiting longer than six months for elective inpatient care per available and unoccupied NHS bed, and private beds within 60 minutes' travel time
The pattern was similar to that without private beds. The areas with high competition for beds were concentrated in the south east, particularly outside London, parts of the south west (Cornwall, Bristol), East Anglia, and an area alongside the Welsh border. People in these areas need to travel further than those living in other areas of England to access available beds.(Mike Damiani, visiting senior analyst1, )
Correspondence to: C Propper carol.propper@bristol.ac.uk
Abstract
One aim of the UK government is to introduce more choice into the NHS in England. Several key policies exist on this theme. The supply of providers (public and private) in secondary, particularly elective, care and primary care is being boosted. For example, 30 new diagnostic and treatment centres are now open and a further 15 are planned as of December 2004.1 Competition, or at least contestability, among secondary care providers is being enhanced.2 The choice of secondary care provider for patients waiting more than six months for elective care is to be extended, and a national consultation exercise on choice has taken place.3 These changes are underpinned by a new system—essentially a cost per case mechanism—of financial flows around the NHS.4
Increasing patient choice of provider is integral to these policies.3 Since 2002, two groups of patients—those waiting longer than six months for cardiac surgery, and those in London waiting longer than six months for treatment in selected specialties—have been offered a choice of provider that can supply treatment more quickly. Early results show that choice seems popular—for example, over 70% of 5000 patients involved in pilot schemes in London chose to be treated by another provider. A MORI poll for the BMA showed that if faced with a long wait 27% of people would travel anywhere in the United Kingdom for treatment by the NHS.5 The government expanded the model for choice to all patients waiting longer than six months for treatment across all specialties by August 2004, with more choice to be offered in the future.
Choice encompasses several dimensions. The current policy focuses on choice as a means of decreasing waiting times, but patients are also concerned about other dimensions of care, in particular quality.6 Regardless of dimension, expanding choice of provider to patients is a challenge to systems such as the NHS in which supplies are limited. We focused on the time it would take patients to travel to a provider. We used routinely collected data to examine the extent to which travel time would increase choice given the existing pattern of NHS and private facilities, ignoring differences in quality. If patients are to be given a choice of provider, are there differences in the time those seeking care will have to travel? If so, where in the country will people have to travel furthest to exercise this choice? Will increased use of private facilities, in addition to those in the NHS, change the amount of time people will have to travel?
Methods
Figure 1 shows the location of each NHS trust dealing with acute conditions in England. For most areas of England, an acute NHS trust was accessible within 100 minutes' travel time, and for large parts of the country a NHS trust was accessible within 30 minutes. Overall, 25% of the population had one hospital within 15 minutes' travel time and 41% had up to two hospitals. Fifteen per cent had no hospital within 30 minutes' travel time, but 98% had one hospital and 92% had two hospitals within 60 minutes' travel time.
Fig 1 Travel time (gradation of colour) to nearest NHS trust dealing with acute conditions, England, 2001
In three areas of England people have to travel relatively further to reach an acute NHS trust: the north of England close to the border with Scotland, East Anglia and parts of Lincolnshire, and parts of Devon and Cornwall.
The map did not adjust for population density, and so demand. To the extent that long travel times reflected low population densities, then some of the long travel times affected relatively fewer people.
Figure 2 shows the number of NHS trusts within 60 minutes' travel time. We found that areas with high and low access to hospitals were relatively similar when we considered 30 minutes' travel time instead of 60 minutes. The longer the travel time we considered, the greater the blurring of boundaries between areas of low and high access. As 60 minutes is reasonably long for a one way journey, we used this time for the rest of the analysis.
Fig 2 Number of NHS trusts within 60 minutes' travel time, England, 2001
Most people in England have access to at least one trust within 60 minutes' travel time. Areas with least choice of supply were the Scottish and Welsh borders and parts of East Anglia, Lincolnshire, and the south west. When considering choice in the Welsh borders we did not account for facilities in Wales.
Figure 3 shows travel time when private facilities are taken into account. This map is similar to figure 2, except the number of facilities within 60 minutes' travel time has increased, particularly in areas of relatively low supply. The proportion of the population with access to NHS and private facilities within 60 minutes' travel time was only 1% higher than the proportion with access to the NHS alone, however, because of the relatively small number of private facilities and because most are located near NHS facilities.
Fig 3 Number of NHS trusts and private facilities within 60 minutes' travel time, England, 2001
Hospitals vary in size, so the pattern of potentially available beds may differ. Figure 4 shows the number of available and unoccupied NHS beds within 60 minutes' travel time in England in 2001. Access to these beds resembles the pattern of access to facilities shown in figure 2. Within 60 minutes' travel time, 98% of people in England have access to up to 100 unoccupied NHS beds and 76% have access to up to 500 unoccupied NHS beds. The number of available and unoccupied NHS and private beds within 60 minutes' travel time is almost identical to that depicted in figure 4, due to the relative paucity of private beds (data not shown). People in England therefore have a large potential for choice of provider, with most people having access to a bed within 60 minutes' travel time.
Fig 4 Number of available and unoccupied NHS beds within 60 minutes' travel time, England, 2001
Our maps do not account for demand. Figure 5 shows demand relative to supply. We chose as a measure of the potential for choice, the number of patients waiting longer than six months for elective inpatient care per available and unoccupied NHS bed within 60 minutes' travel time.
Fig 5 Number of patients waiting longer than six months for elective inpatient care per available and unoccupied NHS bed within 60 minutes' travel time
The demand per unoccupied bed was greatest not only in some of the areas of low supply—parts of East Anglia, the area near the Welsh border, part of Cornwall—but also in areas of relatively high supply—the south east except for London, and south of Bristol. In contrast, other low supply areas (for example, the Scottish borders) also had low demand, so demand relative to supply was low and the potential for choice was high.
Adding in the number of available and unoccupied beds in the private sector (fig 6), shows the effective competition for available and unoccupied beds in different parts of the country.
Fig 6 Number of patients waiting longer than six months for elective inpatient care per available and unoccupied NHS bed, and private beds within 60 minutes' travel time
The pattern was similar to that without private beds. The areas with high competition for beds were concentrated in the south east, particularly outside London, parts of the south west (Cornwall, Bristol), East Anglia, and an area alongside the Welsh border. People in these areas need to travel further than those living in other areas of England to access available beds.(Mike Damiani, visiting senior analyst1, )