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Geographic reform of the NHS is not new: region, district, area, and locality are all familiar terms in NHS history, and notions of “place” as an organising principle retain an intrinsic appeal for policy-makers.  Recently, the English NHS has now been reorganised along spatial lines with the creation of 44 geographically-defined STP (Sustainability and Transformation Plan) footprints, to ‘deliver the right care, in the right place, with optimal value’. This is in the spirit of the King’s Fund argument that “place-based systems of care offers the best opportunity for NHS organisations to tackle the growing challenges that they are faced with.”

Critics have argued that far from being a neutral, technocratic process, the creation of arbitrary geographies delivers “spatial closure,” shutting down argument and marginalising debate about the fundamental political choices which determine the nature of our public services. Recent research examining STPs goes further, suggesting their geographic focus enables the “highly resource-constrained management of health systems.”

It is argued here that, unlike previous reconfigurations, STPs deliver outcomes which systematically undermine the national in the national health service. In contrast to Beveridge-era concerns with equity, fairness, and collaboration, STPs privilege the superiority of “local choice” over national ambition which, in the context of austerity,  enhances and accentuates the geographic variation of care provision,  undermining the principle of universality.

The NHS should ensure the achievement of equitable access to health care regardless of region of residence. Policymakers have sought to minimise geographic variation, but it remains a persistent and ubiquitous problem, and the NHS Atlas of Variation maintains that much of this variation is “unwarranted.” However, rather than identifying NHS funding restrictions, geographic fragmentation of the NHS, or the disruptive role of the private sector as causative, it argues that “limited professional knowledge” and “disparate organisational performance” are the drivers.

The reality is that STPs areas are forced to make hard choices about the services they provide, and to whom, and they make these choices without regard to national consistency. Responding to fixed financial resources and increasing demand their approach has been six-fold, characterised by the King’s Fund: Deflection; Delay; Denial; Selection; Deterrence; and Dilution, each of which can be seen in action within STPs.

GP referral management schemes  delay, defer, and deflect patients away from secondary care; the explicit exclusion of certain groups (smokers, the obese) denies care; blaming patients for presenting inappropriately deters the future expression of need; the tightening of referral criteria (for hip replacements, IVF, or continuing healthcare funding) selects patients; and increasing variation in the funding of community nursing services dilutes quality.

Rather than making transparent the boundaries of care and seeking national agreement on acceptable variation, risk, or quality thresholds, STPs are developing and implementing their own local criteria and priorities, the effects of which compound geographic variation and institutionalise the postcode lottery of care: the decision whether care is “warranted” or “unwarranted” is one fully for local determination.

Further, this variation has been exacerbated by the marketisation of the NHS. Expedited by the “any qualified provider” test , the application of competition law, and the diffusion of accountability which has made effective public challenge more difficult, local markets in healthcare  have been exploited by private providers, specifically in community services  and  primary care.  As Birch and Siemiatycki note, private contractors negotiate deals on a case-by-case basis, and this splintering leads to uneven development: some places end up better served than others.

Evidence from Italy’s decentralisation of healthcare suggests the end result is a zero-sum game, where the gains for the stronger are counterbalanced by the reductions in performance of the weaker, which can lead to greater inequalities. In England, there is emerging evidence from the Care Quality Commission that spatial variation has intensified, variation which will only be intensified through the new regime of inter-spatial competition for funding, with funding held back until health systems develop acceptable plans.

The NHS in England can now be viewed analytically as no more than a set of contiguous places, in each of which problems that were forged nationally are required to be owned and solved. Variation raises important policy questions: within a marketized, fragmented NHS how will policies and governance tools ensure that the reduction of unwarranted variation is prioritised? When the mantra of local choice is paramount, how will solutions to critical, national problems such as the care of the elderly be found when parts of the system are owned by different actors, each with competing goals and values, and the assessment of local needs is separated from the provision of services.

Increasing “warranted” variation in care provision across England challenges the idea of a national health service providing universal coverage through a universal funding system (taxation). In a multi-speed, variegated, health service where national accountability is constrained and national funding limited, localised funding solutions to meet local needs may be sought. Do personal ‘year of care’ budgets, and Greater Manchester’s consideration of local funding for social care portend a plural healthcare funding regime?   There is a need for future research to investigate the impact of NHS fragmentation and local choice upon accountability, equity, and variation across the NHS, and for citizens concerned about the survival of the NHS to be alert to the wider impact of these upon the founding principles of the NHS.