26 October 2007
Health experts have long bemoaned England's North-South divide.
The Health profile of England 2007, published by public health minister Dawn Primarolo on October 22, found 'poorer health in the North of England in comparison to the South in almost all cases'.
Northerners experience higher obesity and diabetes rates, smoke more and have a lower life expectancy of at least two years for both men and women. The proportion of men in the Northeast who define themselves as in 'poor health' is double that of those in the Southeast. It's grim up North – or is it?
Last week's annual NHS performance assessments by the independent Healthcare Commission paint a different picture. Once inside ambulance, hospital or mental health trust, the average 'northerner' is likely to receive better services, supported by superior local health care finance, than people in London, the Southeast or Southwest.
The HC's Annual health check 2006/07 showed an overall improvement across England's NHS trusts, with one in three recording a higher score than the previous year on measures including cancer treatment and accident and emergency waiting times. Famously, the study also exposed poor hygiene standards at 28% of NHS trusts (111 out of 394 organisations).
However, dig a little deeper and what one Department of Health official calls 'the untold story' of the health service emerges: the significantly better performance of trusts in what could broadly be described as 'northern' strategic health authorities.
The HC's findings were substantiated by an Audit Commission report, published on October 23, which showed that the divide is as much about financial management as the quality of services. Drawing on Auditors' Local Evaluations, the commission found that the use of resources across the NHS generally improved last year – turning the NHS's £547m deficit into a £515m surplus.
However, trusts in the South were over-represented among the 31% of organisations (104 trusts) whose financial management was considered 'inadequate'.
Andy McKeon, the commission's director of health, tells Public Finance that 21 of the 27 organisations that 'failed' each of the assessments – financial standing, financial management and value for money – are broadly 'southern'. There are, he admits, 'serious concerns about this hardcore of under-performing trusts'.
Although the geographical divide has existed for some time, the extent of it has taken experts by surprise. Anna Walker, HC chief executive, admits to being 'struck by the difference'.
Under the HC's assessments, three-quarters of northern trusts received 'excellent' or 'good' ratings for service quality or use of resources, whereas three-quarters of southern trusts were rated as 'fair' or 'weak'.
Following the report, Health Secretary Alan Johnson threatened to intervene at four organisations that received a 'double weak' rating for the second year running. All four – North Devon Healthcare, Royal Cornwall Hospitals, Surrey & Sussex Healthcare and West Hertfordshire Hospitals – are in the South.
Specific assessments show that the divide operates across most NHS bodies. Of the 55 acute and specialist trusts that scored a 'weak' rating for use of resources, 35 (64%) were in southern SHAs. Nine of the 12 acute and specialist trusts rated 'weak' for service quality were in the South, as were all five of the trusts that failed to meet any of the government's core standards.
Of the 18 primary care trusts rated 'weak' for service quality, 11 (61%) were southern.
There are, however, few explanations for this performance gap. Walker says that it is 'historic' but offers little analysis.
Nigel Edwards, policy director at the NHS Confederation, cites several probable causes: the growth in size of northern PCTs; the way that NHS resources are allocated; reconfiguration; staff recruitment and retention issues; and the way that health care performance is measured.
The resource issue, he says, is likely to be the most important. NHS funds are allocated according to population and specific local needs, so the higher the rate of growth in a PCT, for example, the more cash they receive. In basic terms, this means that disproportionate health problems in the North convert to higher funding levels – but Edwards says that would not necessarily explain the performance gap.
'That said, northern PCTs have grown at a faster rate in recent years, so it follows that if they have a little bit more cash all round, then they should perform a little better and they are less likely to have historic deficits,' he adds.
'Additionally, with the North inclined to higher growth, the South has to be more inclined to find development money from within [their budgets], rather than new cash allocations. It is probably easier to use new money to make change happen than to try to get managers to disinvest in other programmes – creating further hurdles for the South.'
But Edwards dismissed claims that southern trusts should receive short-term additional funding.
Another explanation, he suggested, is linked to recent 'political' hospital or PCT reconfigurations, which have changed the way services are delivered and finances used. 'There are a lot of hospitals in the South with big problems, particularly to do with unresolved reconfiguration changes, and one wonders whether their proximity to decision-makers in Whitehall also makes necessary changes difficult to achieve.'
The Audit Commission found that 69% of trusts met the requirements for use of resources – an eight percentage point rise on last year.
But Steve Bundred, the organisation's chief executive, expresses concern about the 'considerable variation' in SHAs' regional performance. He adds that some trusts appear unable to 'get out of trouble themselves' and warns that a lasting effect could embed service delivery problems.
'Managing money well goes hand in hand with providing good services,' he says. Local managers needed no reminder.
As far as service provision is concerned, Edwards says that, despite improvements in recent years, there remains a link between the larger distances that people in the South travel to receive services compared with those in the North.
A Department of Health spokeswoman said Johnson would seek to bridge the performance divide 'as part of his reaction to the wider health inequalities' outlined in Primarolo's study.
Of course, all experts agree that the North-South divide is a crude measurement. One notable area where geography appears not to undermine performance is at the government's flagship foundation trusts.
Each of the 19 trusts that scored 'excellent' for both service quality and use of resources under the HC's assessment in 2006/07 had been granted foundation status: of these ten were in the South and nine in the North.
McKeon warns, however, that action must be taken to remedy failings that act as a 'drag' on trusts' performance. Longer term, he suggests, this could 'include changes to the funding distribution formula to reflect specific demands' on southern organisations.
In the meantime, managers and doctors face an immediate challenge to improve local performance against rising public expectations for health care.
It's grim down South – isn't it?
PFoct2007
