Re: Dismantling the signposts to public health? NHS data under the Health and Social Care Act 2012
Michael Soljak has failed to understand how the Health and Social Care Act, in abolishing area based structures and transferring most health service responsibilities to non-geographically based CCGs, as well as some to local authorities, will limit the availability of routine data to monitor the health service and the population, including inequalities in access, services, and outcomes. His narrow focus on well documented problems with the decennial census suggests that he is unaware of the increasing extent to which Neighbourhood Statistics and the Index of Multiple Deprivation (IMD) draw on a range of more timely population-based administrative and survey data, to which we alluded.1 Even this fuller range of data and readily available look-up tables to convert postcodes to output areas and IMD scores cannot compensate for variation within output areas and the potential for practices to game the system by cherry picking the most healthy patients from the more deprived output areas.
Some estimates of list inflation, to which he referred, compare general practice registrations with ONS’ population estimates and show not only that the average list inflation was around 5% but it varied up to 30% in some PCT areas2 but the picture is no better when other population-based comparators are used. In Manchester, the PCT has been working with the City Council to match addresses held on GP registers with those in the Local Land and Property Gazetteer which is essentially a composite of the Council Tax and Electoral Registers. Only 78% of names and addresses held on GP registers could be matched with equivalent records held on the Council Tax system.3 Based on this level of accuracy, they estimated that there were about 117,000 patient records where the accuracy of the data was questionable. This has significant financial implications, given that both local authority and NHS funding formulae are based to some degree on population estimates or counts.3
In contrast, the substantial differences of up to 18% between the two sets of population estimates used in London, produced by ONS and the GLA, are well recognised. This situation, which is far from ideal, arises because they use different methods and assumptions.4, 5 For example, ONS uses the International Passenger Survey to factor in the impact of migration, whilst the GLA uses local authority housing capacity plans in its method of forecasting. When the first results of the ONS 2011 census are published in July this year, it will be possible to assess which sets of estimates are closest to the actual new count. However estimates based upon practice registered populations where the incentives are in place for risk selection and cherry picking will see a radical departure from a comprehensive population focus.
Soljak’s account is not of ‘new data sets’. Instead it is a description of developments in the use of current data from general practice systems, mainly for research purposes. These data do not supersede data collections which have been lost or deteriorated following cuts in ONS and NHS expenditure and which Soljak appears to be unaware of. It may be that general practices could provide additional data, some of which are more up to date than the census but this ignores the fact that these data will be seriously incomplete in respect of the local residents living in an area. Moreover, they will only be recorded when people register and updated when they consult, with data being missing or out of date for those who do not consult. The Scottish study he cited is completely irrelevant as it was a register-based study in which South Asian ethnicity was identified retrospectively from surnames rather than being self-reported.6 Furthermore, the fact that GP and hospital systems all use classifications based on ICD10, is no guarantee that the systems will allocate or derive the ICD codes in the same way, as Hendrik Beerstecher points out.7 His picture of the realities of local primary computing shows that there is some way to go before facilities in routine practice catch up with research.
It is essential to be able to continue to measure and monitor populations on a consistent basis, over time and in a way that is comparable for different population groups. The abolition of the NHS and the switch from contiguous administrative areas to a system where nobody has ultimate responsibility for monitoring and meeting the health care needs of all residents and where GP practices are incentivised to dump high risk patients has consequences for data collection. It means that, as in low income countries, those who do not receive care will no longer be counted or measured.8, 9
1. Department of Communities and Local Government. The English Indices of Multiple Deprivation 2010. London: Department of Communities and Local Government, 2011 http://www.communities.gov.uk/documents/statistics/pdf/1871208.pdf. Accessed 13 June 2012.
2. Primary Care Commissioning. Tackling list inflation, 2012. http://www.pcc.nhs.uk/tackling-list-inflation.
3. Getstats. Health data under threat, May 2012. Response from Neil Bendel. http://www.getstats.org.uk/2012/05/02/will-nhs-stats-be-less-reliable-in....
4. Greater London Authority. London Datastore. 2011. Link: http://data.london.gov.uk/taxonomy/categories/demographics.
5. Office for National Statistics. Annual mid year population estimates 2010. Newport: ONS, 2011. http://www.ons.gov.uk/ons/rel/pop-estimate/population-estimates-for-uk--.... Accessed June 13 2012.
6. Fischbacher CM, Bhopal R, Steiner M, Morris AD, Chalmers J. Is there equity of service delivery and intermediate outcomes in South Asians with type 2 diabetes? Analysis of DARTS database and summary of UK publications. J Publ Health 2009;31(2):239-49. Link: http://jpubhealth.oxfordjournals.org/content/31/2/239.abstract .
7. Beerstecher H. All that glitters. Rapid Response to Pollock AM, Macfarlane AM, Godden S. Dismantling the signposts to public health? NHS data under the Health and Social Care Act 2012 BMJ 2012;344:e2364.
8. Setel PW, Macfarlane SB, Szreter S et al. A scandal of invisibility: making everyone count by counting everyone. Lancet 370 (9598) 1569-1577, 2007.
9. Guardian. 31st May 2012. GP practice ‘offloaded vulnerable patients to save money’. http://www.guardian.co.uk/society/2012/may/31/gp-health-reform-cost-cut
Alison Macfarlane, City University London A.J.Macfarlane@city.ac.uk
Allyson Pollck, Sylvia Godden, Queen Mary University of London