Postcode Lottery Research Articles

A postcode lottery in education? Explaining regional inequality in multilevel systems

AbstractInequality is a challenge for societies around the globe. In addition to its socio‐economic and political dimensions, inequality also has a territorial dimension. Focusing on educational inequality across regions, this article explores factors that shape regional differences in student enrolment and educational attainment in 14 OECD countries. The findings of the article suggest that a strong level of regional authority over education increases regional inequality in education. Further factors are regional differences in education expenditures and variation in the population size of regions. Low regional inequality in education seems to be explained by a low degree of regional authority or low differences in education spending. By examining regional inequality in education, the article enhances our understanding of the way multilevel governance influences the quality of life within regions. In particular, it highlights the impact of decentralization on territorial inequality.

537VP Evaluation of the Scottish rhabdomyolysis and metabolic myopathy gene panel highlights limitations of genetic test criteria and a postcode lottery in access to testing

537VP Evaluation of the Scottish rhabdomyolysis and metabolic myopathy gene panel highlights limitations of genetic test criteria and a postcode lottery in access to testing

Losing the Postcode Lottery: An Observational Study Examining the Association Between Patient Address and Delayed Discharge in a Rehabilitation Centre

Abstract Background Quality and Fairness: A Health System for You published by the HSE in 2001 stated, as one of its core principles “Access to healthcare should be fair. The system must respond to people’s needs rather than have access dependent on geographic location or ability to pay.”1 Twenty years on, experience at our rehab unit suggests that inequality exists in accessing care in the community for older persons based on their residential address. The aim of our study was to examine and quantify this inequity of access. Methods A retrospective study was designed. Using the local patient information management system, all discharges in 2023 were identified. Baseline demographics, admission and discharge date and residential address were recorded. Delayed discharges were defined as patients for whom their rehabilitation programme is complete as agreed at the multi-disciplinary team meeting. Delayed discharge data was obtained from medical social work department who input this data to the HSE weekly. Patients were assigned a community healthcare organisation (CHO) based on address. CHO ‘A’ included two CHOs with predominantly rural areas whilst CHO ‘B’ comprised of one predominantly urban CHO. Results 167 patients were included. 24 discharges were delayed (14.4%). Median age was 84. Total bed days lost: 935 (mean 40.6, range 3 – 232). All nine CHOs were represented. Patients living in CHO A had increased likelihood of having discharge delayed (OR: 4.82, CI 2.86 – 8.13). Conversely, those living in CHO B were less likely to have had a discharge delayed (OR: 0.39, CI 0.15 – 0.96) Conclusion Our study demonstrates that health inequity does exist. Patients residing in rural communities are 4 times more likely to have their discharge delayed awaiting community supports compared to urban dwellers. Ending of the discrimination of patients based on their postcode and ensuring access based on need is the very essence of Sláintecare.

931 Core Surgical Training; a Postcode Lottery?

931 Core Surgical Training; a Postcode Lottery?

"It's a Postcode Lottery": How Do People Affected by Dementia in Wales Experience Their Diagnosis and Post-Diagnostic Support, and How May These Be Improved?

National dementia strategies are government policies that guide the provision of appropriate support for people living with dementia. These strategies, developed through extensive stakeholder engagement, should be tailored to the cultural and demographic needs of a country. Using a mixed methods survey design, this study explored the aims of the Dementia Action Plan (2018-2022) for Wales (UK) around assessment, diagnosis, and post-diagnostic support, and assessed whether these are being realized. Further, it sought to gain insight from people living with dementia and their carers around how the experience may be improved for others in the future, as the development of the next iteration of the Action Plan is anticipated. Respondents included 71 people, affected by typical and rarer types of dementia, living in both rural and urban areas. Findings suggest both positive and negative experiences, reflecting a 'postcode lottery' of service provision. Attainable recommendations for improvement were made by respondents, which would ultimately likely be cost-effective and reduce strain on formal services. The findings reported in this paper concur with those reported by people living with dementia in other countries, indicating their relevance for policymakers beyond Wales.

What is quality in long covid care? Lessons from a national quality improvement collaborative and multi-site ethnography

BackgroundLong covid (post covid-19 condition) is a complex condition with diverse manifestations, uncertain prognosis and wide variation in current approaches to management. There have been calls for formal quality standards to reduce a so-called “postcode lottery” of care. The original aim of this study—to examine the nature of quality in long covid care and reduce unwarranted variation in services—evolved to focus on examining the reasons why standardizing care was so challenging in this condition.MethodsIn 2021–2023, we ran a quality improvement collaborative across 10 UK sites. The dataset reported here was mostly but not entirely qualitative. It included data on the origins and current context of each clinic, interviews with staff and patients, and ethnographic observations at 13 clinics (50 consultations) and 45 multidisciplinary team (MDT) meetings (244 patient cases). Data collection and analysis were informed by relevant lenses from clinical care (e.g. evidence-based guidelines), improvement science (e.g. quality improvement cycles) and philosophy of knowledge.ResultsParticipating clinics made progress towards standardizing assessment and management in some topics; some variation remained but this could usually be explained. Clinics had different histories and path dependencies, occupied a different place in their healthcare ecosystem and served a varied caseload including a high proportion of patients with comorbidities. A key mechanism for achieving high-quality long covid care was when local MDTs deliberated on unusual, complex or challenging cases for which evidence-based guidelines provided no easy answers. In such cases, collective learning occurred through idiographic (case-based) reasoning, in which practitioners build lessons from the particular to the general. This contrasts with the nomothetic reasoning implicit in evidence-based guidelines, in which reasoning is assumed to go from the general (e.g. findings of clinical trials) to the particular (management of individual patients).ConclusionNot all variation in long covid services is unwarranted. Largely because long covid’s manifestations are so varied and comorbidities common, generic “evidence-based” standards require much individual adaptation. In this complex condition, quality improvement resources may be productively spent supporting MDTs to optimise their case-based learning through interdisciplinary discussion. Quality assessment of a long covid service should include review of a sample of individual cases to assess how guidelines have been interpreted and personalized to meet patients’ unique needs.Study registrationNCT05057260, ISRCTN15022307.

Comparing Leaving-Care Policy and Practice Across the Four Nations of the United Kingdom: Exploring Similarities, Differences, and Implementation Gaps

From an international comparative perspective, the four nations of the United Kingdom have robust legal and policy frameworks governing care leaving. Measures taken include access to aftercare workers; pathway planning; introduction of extended care arrangements (permitting young people to remain in placement beyond 18 years); and specific types of financial support. The paper explores commonalities and differences in approaches across the United Kingdom and illuminates how resource constraints, placement availability, workforce challenges and cultural norms may result in implementation gaps and a postcode lottery of provision. Findings lend weight to calls for attentiveness to and systematic evaluation of the implementation process to understand the challenges encountered in embedding effective support for care leavers. Findings also highlight the value of further comparative studies that explore the systems and subsystems of law, policy, and practice in the four nations to contribute to more-informed leaving care policy and practice.

“Deeply Rooted”: Abortion Federalism, Divided Citizenship, and Disability Reproductive (In)justice

ABSTRACT Laws structure people’s “lived citizenships.” This article considers the ways in which Dobbs v. Jackson Women’s Health Organization gave states the power to regulate reproduction in ways that have disproportionate consequences for pregnant people with disabilities. Specifically, Dobbs did not eliminate the right to bodily integrity, but rather put conditions on who can claim a right to bodily integrity in federal courts. Moreover, uneven changes to Medicaid financing of abortions have created a “postcode lottery.” People’s ability to receive care is determined by a politics of place – or even individual providers. These policies create structural inequalities.

P069 The hard-hitting facial trauma postcode lottery – the relationship between facial trauma and socioeconomic deprivation

P069 The hard-hitting facial trauma postcode lottery – the relationship between facial trauma and socioeconomic deprivation

Failing children with Special Educational Needs and Disabilities in England: New evidence of poor outcomes and a postcode lottery at the Local Authority level at Key Stage 1

AbstractThis paper sets out original findings from analyses of the English National Pupil Database of Key Stage 1 (KS1) attainment, to examine educational outcomes of children with Special Educational Needs and Disabilities (SEND). The schooling of these children has been entirely within the context of the current SEND system, defined by the 2014–2015 policy of the Children and Families Act and Code of Practice. With a strong focus on children's needs and outcomes, the policy intends to achieve high educational outcomes for children with SEND. Our new results show, however, that children with SEND are one of the most disadvantaged groups in education, and they are far less likely to meet expected learning standards than their peers at KS1. For instance, about 44%, 31% and 23% of children with SEND met the standards in phonics, reading and writing, respectively, compared to 88%, 83% and 78% of children with no SEND. Further, our spatial analysis shows for the first time that this disadvantage displays large spatial variability across Local Authorities: there is a postcode lottery in the education of children with SEND. The new findings provide strong evidence that the new SEND policy is failing many children with SEND, and that this performance varies markedly across space. This adds further weight and evidence to a growing recognition, even from government, that the SEND system needs to change, and that the ambitious aims of the transformation of education and care for children with SEND in 2014 and 2015 are not being realised.

What happens after an NHS Health Check? A survey and realist review.

The National Health Service Health Check in England aims to provide adults aged 40 to 74 with an assessment of their risk of developing cardiovascular disease and to offer advice to help manage and reduce this risk. The programme is commissioned by local authorities and delivered by a range of providers in different settings, although primarily in general practices. This project focused on variation in the advice, onward referrals and prescriptions offered to attendees following their health check. (1) Map recent programme delivery across England via a survey of local authorities; (2) conduct a realist review to enable understanding of how the National Health Service Health Check programme works in different settings, for different groups; (3) provide recommendations to improve delivery. Survey of local authorities and realist review of the literature. Realist review is a theory-driven, interpretive approach to evidence synthesis that seeks to explain why, when and for whom outcomes occur. We gathered published research and grey literature (including local evaluation documents and conference materials) via searching and supplementary methods. Extracted data were synthesised using a realist logic of analysis to develop an understanding of important contexts that affect the delivery of National Health Service Health Checks, and underlying mechanisms that produce outcomes related to our project focus. Our findings highlight the variation in National Health Service Health Check delivery models across England. Commissioners, providers and attendees understand the programme's purpose in different ways. When understood primarily as an opportunity to screen for disease, responsibility for delivery and outcomes rests with primary care, and there is an emphasis on volume of checks delivered, gathering essential data and communicating risk. When understood as an opportunity to prompt and support behaviour change, more emphasis is placed on delivery of advice and referrals to 'lifestyle services'. Practical constraints limit what can be delivered within the programme's remit. Public health funding restricts delivery options and links with onward services, while providers may struggle to deliver effective checks when faced with competing priorities. Attendees' responses to the programme are affected by features of delivery models and the constraints they face within their own lives. Survey response rate lower than anticipated; review findings limited by the availability and quality of the literature. The purpose and remit of the National Health Service Health Check programme should be clarified, considering prevailing attitudes about its value (especially among providers) and what can be delivered within existing resources. Some variation in delivery is likely to be appropriate to meet local population needs, but lack of clarity for the programme contributes to a 'postcode lottery' effect in the support offered to attendees after a check. Our findings raise important questions about whether the programme itself and services that it may feed into are adequately resourced to achieve positive outcomes for attendees, and whether current delivery models may produce inequitable outcomes. Policy-makers and commissioners should consider the implications of the findings of this project; future research should address the relative scarcity of studies focused on the end of the National Health Service Health Check pathway. PROSPERO registration CRD42020163822. This project was funded by the National Institute for Health and Care Research (NIHR) Health Services and Delivery Research programme (NIHR129209).

P138 Inequity in Clinical Commissioning Group funding across England for high-cost biologic drugs in rheumatoid arthritis

Abstract Background/Aims Biologic, and targeted, disease-modifying antirheumatic drugs (bDMARDs/tDMARDs) are recommended for patients in England with high disease activity score rheumatoid arthritis (HDAS-RA) who do not respond to two or more conventional synthetic DMARDs. To prescribe bDMARDs/tDMARDs in England, prescribers must apply for funding via their local clinical commissioning group (CCG). The project aim was to review whether CCGs across England had defined high cost drugs pathways for bDMARDs/tDMARDs use in HDAS-RA and if so, what this pathway looked like regarding drug choice, order of availability, and ability to prescribe as monotherapy. Methods We submitted a freedom of information (FOI) request in October 2021 to all CCGs within England to obtain their high cost drug pathway for bDMARDs/tDMARDs use in HDAS-RA. We then manually reviewed the pathways to determine whether the CCG specified an order of drug prescribing. Data was also gathered on whether CCGs allowed abatacept (ABT), rituximab (RTX), and golimumab (GOL) to be prescribed as monotherapy. Results All 107 CCGs in England responded to the FOI request. 69 out of 107 CCGs (65%) had a pathway for bDMARDs/tDMARDs prescribing. 60 out of 69 CCGs (87%) specified an order for drug prescribing in RA. Within their pathways, CCGs generally fell into 3 prescribing preferences. Table 1 summarises these pathway recommendations. 39 (57%), 59 (86%), and 6 (9%) CCGs allowed ABT/RTX/GOL to be prescribed as monotherapy respectively. RTX monotherapy was specifically allowed outside of special indications such as cancer, interstitial lung disease and multiple sclerosis. Conclusion These findings show there is significant variation across England regarding which bDMARDs/tDMARDs patients can receive for HDAS-RA resulting in a postcode lottery. Several studies support the use of ABT/RTX/GOL as monotherapy and registry data shows that 30-40% of RA patients are administered ABT/RTX/GOL as monotherapy for methotrexate intolerance/contraindication. Lack of NICE appraisal, however, means some CCGs mandate individual funding requests for monotherapy prescribing. We would like to use these results to help negotiate equitable access to bDMARDs/tDMARDs nationwide. Disclosure O. Buckeldee: None. R. Khanna: None. L. Snell: None. L. Attipoe: None.

A survey of adult respiratory and sleep services in Aotearoa New Zealand: inequities in the provision of adult respiratory and sleep services.

The New Zealand "Standards for Adult Respiratory and Sleep Services" were published by the Ministry of Health in 2004. A 2006 survey demonstrated major gaps in the staffing and service provision and significant variation between district health boards (DHBs). We repeated this survey in 2019/20 in order to highlight issues which should be addressed as part of health service reforms. Survey of all adult DHB respiratory services assessing staffing and service provision. There is marked regional variation in staffing levels for all specialist clinicians. There are 1.18 FTE/100,000 population respiratory physicians, which is well below Australian and United Kingdom levels. Two hundred thousand people in New Zealand do not have access to a local respiratory physician. For provided services we found a four-fold variation between DHBs for CPAP treatments, six-fold for oxygen services, and eight-fold for pulmonary rehabilitation. The place of residence of New Zealanders determines access to respiratory services. There are inequities in access, with little progress made since 2006. Data on health outcomes are required. The restructure of the health service must rectify this situation. The need to end a "postcode lottery" is demonstrated when reviewing current respiratory services in New Zealand.

Postcode Lottery in Healthcare? Findings from the Scottish National Comprehensive Geriatric Assessment in Secondary Care Audit 2019.

Comprehensive Geriatric Assessment (CGA) is provided differently across Scotland. The Scottish Care of Older People (SCoOP) CGA Audit was a national audit conducted in 2019 to assess this variation in acute hospitals. Two versions of audit questionnaires about the provision of CGA were developed (one each for larger hospitals and remote/rural areas) and piloted. The questionnaires were sent to representatives from all hospitals in Scotland using the REDCap (Research Electronic Data Capture) system. The survey asked each service to provide information on CGA service delivery at the ‘front door’. The questionnaire was open for completion between February and July 2019. Of the 28 Scottish hospitals which receive acute admissions, we received information from 26 (92.9% response rate). Reporting sites included seven hospitals from remote and rural locations in the Scottish Highlands and Islands. Significant variations were observed across participating sites for all key aspects studied: dedicated frailty units, routes of admission, staffing, liaison with other services and rehabilitation provision. The 2019 SCoOP CGA audit highlights areas of CGA services that could be improved and variation in specialist CGA service access, structure and staffing at the front door across Scotland. Whether this variation has an impact on the outcomes of older people requires further evaluation.

Consumption Responses to Income Shocks: Evidence from the British Postcode Lottery.

Consumption Responses to Income Shocks: Evidence from the British Postcode Lottery.

Clinical commissioning group funding of oculoplastic services: is there a postcode lottery?

Background/Aims Clinical commissioning groups have been responsible for commissioning healthcare services since 2013, allocating resources according to local needs. This has given rise to concerns about a ‘postcode lottery’. This study examined the variability of clinical commissioning group-imposed funding restrictions and access policies for oculoplastic procedures in England. Methods A freedom of information request was sent to all 206 clinical commissioning groups in February 2018 seeking information about their funding policies for common oculoplastic procedures. When signposted to online policies, these were reviewed. Results Significant funding variation exists across all procedures examined. Access criteria usually depends on visual function sequelae. Some clinical commissioning groups have adopted shared policies. Although many policies are publicly available online, the authors frequently found them unclear and thus suspect that practical implementation may be challenging. Conclusions Access policies vary significantly across England. Practical interpretation is difficult, leading to a postcode lottery. This has implications for patient access, and clinician workload.

Shifting from Fragmentation to Integration: A Systematic Analysis of Long-Term Care Insurance Policies in China.

Introduction:Long-term care is an effective intervention that help older people cope with significant declines in capacity. The growing demand for long-term care signals a new social risk and has been given a higher political priority in China. In 2016, 15 local authorities have been selected to pilot the long-term care insurance programme. However, the current implementation of these programmes is fragmented, with a measure of uncertainty. This study aims to investigate the principles and characteristics of long-term care insurance policies across all pilot authorities. It seeks to examine the design of local long-term care insurance systems and their current status.Methodology:Based on the 2016 guidance, a systematic search for local policy documents on long-term care insurance across the 15 authorities was undertaken, followed by critical analysis to extract policy value and distinctive features in the delivery of long-term care.Results:The results found that there were many inconsistencies in long-term care policies across local areas, leading to substantial variations in services to the beneficiaries, funding sources, benefit package, supply options and partnership working. Policy fragmentation has brought the postcode lottery and continued inequity for long-term care.Discussion:Moving forward, local authorities need to have a clear vision of inter-organisational collaboration from the macro to the micro levels in directional and functional dimensions. At the national level, vertical governance should be interacted to outline good practice guidelines and build right service infrastructure. At the local level, horizontal organizations can collaborate to achieve an effective and efficient delivery of long-term care.

Reducing fire risk in buildings: the role of fire safety expertise and governance in building and planning approval

Following the Grenfell tower incident, fire safety is being re-examined around the world. One key area is planning and building approval. It has been suggested that expert fire authority advice is being ignored in building and planning control. In this paper, freedom of information requests were submitted to fifty local government authorities (covering approx. one quarter of the England and Wales population), and three fire authorities, to examine their consultation process. No prior study has examined this relationship in detail. This work attempts to identify who is assessing fire safety, what expertise exists in the system, and what guidance is available from central government. The impact of austerity on the ability to effectively manage fire safety is also discussed. Results show local government authorities have a large degree of discretion with no guidance from central government on fire safety expertise needed to assess non-prescriptive building standards, and only limited guidance on how fire authority advice should be used by local government. The result is a dramatically different level of engagement of fire authorities, and implementation of fire safety advice. There does not appear to be any guarantee that fire expertise is being employed for the purpose of fire safety in building/planning processes. This means the building regulatory regime may be one of the many issues contributing to fire safety issues. Stronger legislation is required to prevent a post-code lottery of fire safety implementation.

The postcode lottery of safety: COVID-19 guidance and shortages of personal protective equipment (PPE) for UK police officers

The COVID-19 pandemic has caused significant changes to police working practices involving the enhanced wearing of personal protective equipment (PPE), and ways of working inside and outside of police stations. The safety guidance released by the various government agencies has been conflicting, confusing and unhelpfully flexible, and there are significant discrepancies between some of the 43 forces of England and Wales. This article draws on primary interview data with 18 police officers from 11 UK police forces to explore the problems that officers faced in accessing appropriate PPE and the difficulties in obtaining and understanding accurate coronavirus health and safety information.

P092 NICE biologics pathways for inflammatory arthritis exhibit regional variability due to modification by CCG’s: results from a national survey of pathways in England

Abstract Background/Aims NICE publishes guidance underpinned by act of Parliament and legally enforceable, on the use of biological therapies in the treatment of rheumatoid arthritis (RA), psoriatic arthritis (PsA) and ankylosing spondylitis (AS) which should allow harmonisation of access independent of region. However, sufficient guidance is not provided on the use of sequential biologics nor is a numerical cap placed on the number of biologics a patient can attempt if they have had an inadequate response. We have previously reported that in a limited sample, Clinical Commissioning Groups (CCGs) interpret NICE guidance variably and restrict access to NICE approved treatments depending on geography, the so-called “postcode lottery”. We determined the variability of biologics pathways in all CCG’s in England to examine whether a potentially unfair postcode lottery exists for sequential biologics use. Methods All 135 England CCGs covering over 55 million people, were sent Freedom of Information requests, for their biologic pathways for RA, PsA and AS. Where CCGs did not have this information, the relevant acute trusts were contacted, with responses recorded under that CCG. For every CCG the local biologics pathways were examined for detail on the number and type of biologics commissioned before an Individual Funding Request was needed. “No Cap” was recorded if CCG’s responded with no restriction on the number of biologics. Results Responses were obtained from 124/135 CCG’s for RA, 122/135 for PsA and AS, all covering an estimated population in excess of 45 million people. For RA, 55% CCG’s had no cap on the number of commissioned RA biologics. 45% had a variable cap from 3 to 6 commissioned biologics. For PsA, the figures were 54% with no cap and 46% with variable capping between 2-5 biologics allowed, for AS the figures were 51% and 49% respectively. In total this represented 41 different local pathways for RA, 29 different pathways for PsA and in AS where fewer biologics choices exist, 25 different pathways depending on CCG and location. Conclusion There is wide regional variation in the interpretation of NICE guidance by CCG’s resulting in many different local pathways depending on geography. Approximately 50% of pathways restricted biologics prescribing by mandating the type and sequence of biologics used, potentially compromising patient care and delaying treatment by requiring an IFR for a NICE approved biologic. Moreover, pathways varied as to which biologics could be used at any point of management by region as well. As exemplars of good practice, approximately 50% of CCG’s had no cap, allowing clinical freedom to prescribe the most appropriate biologic. The results of this national study demonstrate the variability of biologics pathways in many areas of England ensuring a postcode lottery still exists in many regions. Disclosure J. Mistry: None. D. Hill: None. A. Bosworth: None. A. Kaul: None.