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Thursday, 15 March, 2001, 14:27 GMT
Health inequalities
Heart disease and cancer death rates
Heart disease and cancer death rates
Controversy over 'post-code' or 'lottery' access to health care has dogged the NHS.

Health is a devolved matter dealt with domestically by the Scottish Parliament, and the Welsh and Northern Ireland assemblies. Westminster retains UK-wide powers over medical regulation and safety.


The "postcode lottery" is a phrase often bandied about when people talk about access to NHS care.

People may receive different levels of care dependent on where they live.

Expensive procedures, such as fertility treatment come under most pressure, with different areas having different rules.

The NHS ... has never, or will never, provide all the care it theoretically might be possible to provide

Alan Milburn,
Health Secretary
The NHS has been plagued by the need to ration services ever since its inception over 50 years ago.

Its founders made care free at the point of delivery, in the belief that the population's health would improve and demand fall.

Instead demand has risen and the development of expensive new treatments and drugs means the limited pool of resources available has to be rationed.

In December 1999, Health Secretary Alan Milburn said: "The NHS - just like any other health system in the world, public or private - has never, or will never, provide all the care it theoretically might be possible to provide."

Labour in government made ending the "postcode lottery" one of its key health policies.


One of the main questions for politicians is how resources should be allocated.

Money is currently allocated to health authorities, based on a formula that takes into account the size and characteristics of the area's population.

Cancer deaths in 1996
Cancer deaths in 1996
By 2003, the way allocations are made will change, with reducing inequalities a key consideration.

Services are commissioned from GPs and hospitals.

New bodies called primary care groups and primary care trusts, run by health professionals, have been introduced by the Labour government.

They can commission varying levels of health services, dependent on how powers have been devolved from the local health authority.

In Wales, local health groups have been introduced, and in Scotland health management is organised into primary care trusts and local health care co-operatives.

The government has promised a review of how funds are allocated by 2003.

These arrangements superseded the Conservatives' system where GPs were divided into fundholders, who held their own budgets, and commissioners who's budgets were still controlled by the health authority.

The Tories also introduced the "internal market" in 1990, with split purchasers, health authorities and some GPs, from providers, hospitals, ambulance services and community health services.


Many studies have argued that elderly patients are worst affected, and denied expensive treatments by doctors on the grounds of their age.

A National Service Framework (NSF) for Older People was published in March.

In it, the government promised 120m to boost the number of cataract, hip and knee replacement, and heart operations carried out on the elderly.

The NSF also sets out national standards for services in areas such as stroke care, social and hospital care. It also called for an "end to discrimination within the NHS on the grounds of age".

Prior to the NSF, the government appointed an 'Ageism Czar' to oversee elderly people's services.

But some experts say as the population ages, some sort of rationing of services is likely to be necessary.


In 1999, the government set up the National Institute for Clinical Excellence, made up of health professionals, managers and patient representatives.

NICE evaluates the effectiveness of drugs or treatments for their clinical and cost effectiveness.

The guidance NICE produces is not legally binding, but health authorities are 'expected' to implement its guidance.

But decisions from NICE can be controversial.

Its first clinical decision was to not recommend the flu drug Relenza to be prescribed on the NHS. That decision was later reversed. Similarly, its deliberations over the multiple sclerosis drug beta-interferon have been scrutinised.

And critics say if the body backs expensive treatments, but fails to support recommendations with extra funding, other pots of money will be raided to fund them.


The differences between the health of the rich and poor have also exercised governments.

Heart deaths in 1998
Heart deaths in 1998
In the Black Report, 1980, Sir Douglas Black linked poor health to poverty. But the Conservative government of the time failed to act on his recommendations.

In 1998, former Chief Medical Officer Sir Donald Acheson wrote a follow up report, recommending increasing benefits, better health education, improved school meals, and action to tackle smoking levels.

The Labour government's white paper, Saving Lives: Our Healthier Nation required targets to be set locally to eradicate health inequalities.

In 2000, the Labour government launched the Health Development Agency, which took over from the Health Education Authority.

Its job is to reduce the inequalities in health between the rich and poor, particularly in diet, and the prevention of killer diseases such as cancer, heart disease and stroke.


The latest figures for cancer show there were 155,000 deaths from cancer in 1998. The top three cancer killers are lung, colorectal and breast.

Cancer deaths in 1996
Cancer deaths in 1996
At last year's Labour Party conference, Alan Milburn launched the NHS Cancer Plan - and promised cancer survival rates would be among the best in Europe within ten years.

He said the number of cancer specialists would increase by one third over the decade.

The government has pledged to cut cancer deaths in under-75s by a fifth by 2010.

From this year, breast cancer patients will receive treatment within a month of being diagnosed, a target which will be extended to cover all other cancers.

There will be 50m of investment in hospices and palliative care, plus investment in cancer services from lottery money.

A Cancer Research Network, doubling the number of patients in treatment trials, and a Cancer Services Collaborative will streamline cancer care in different kinds of units.

NICE will assess anti-cancer drugs and cancer care.


Cardiovascular disease kills around 250,000 people a year. Half of those deaths are from coronary heart disease and a quarter are from strokes.

Heart deaths in 1998
Heart deaths in 1998
A National Service Framework on coronary heart disease, published in 2000, aims to save 20,000 lives a year.

It sets out a ten-year programme to improve prevention, diagnosis, treatment and care.

Labour in government promised 230m a year for heart disease services and 120m from 2002 to improve services.

By 2003, rapid access chest clinics would be set up across the UK, it said.

It promised waiting times for operations will be cut, with a maximum six month wait for routine cardiac surgery by 2005 and a three month maximum wait by 2008.

Mental health - which has also been the subject of a NSF - is promised 300m of investment by 2003/4, much of which will be in community mental health services.

An NSF on diabetes is also planned.


The NHS Plan published last summer, laid out plans for preventative care to be extended.

Breast cancer screening will be extended from screening women aged 50 to 64, to cover women up to the age of 70.

Screening programmes for colorectal and prostrate cancer may also be introduced, with programmes for other cancers, including ovarian are also set to be considered.

From this year, local efforts to address health inequalities will be assessed by the NHS Performance Assessment Network.

Smoking - the leading single cause of avoidable ill health and death - is also being tackled.

A smoking cessation service is to be introduced on the NHS this year.

The measures are aimed at encouraging at least 1.5m people to give up smoking by 2010.

In 2004, a scheme to give nursery and infant school children a free piece of fruit each day will be introduced.

SureStart, a project which cover young children's health, will be expanded.


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