Then of course there is the issue of how health services are paid for and equity of access. Is it generally available free at the point of access? Do you have to pay a fee? Is there a social or private insurance system? To what extent is there a private market? How regulated is it? Now all this dizzying array of variations is enough to make you feel that health is a lottery, even when considering mainstream need. Move toward less popular areas of health provision and things get rapidly patchier. There are many countries where access to treatment for drug use is almost non-existent. This is not limited to countries with low incomes and poor infrastructure. The Russian Federation is ideologically opposed to substitute prescribing and favours abstinence-based approaches, despite the toll in deaths and disease this creates.    

Across the globe access to sexual health services varies massively based on morality, perceptions of deserved need and, dare I suggest, electoral calculation. By which I mean the lobbying power of certain groups, such as drug users, are extremely limited.   This influences decisions in all kinds of health systems, even those with a strong national system and a commitment to providing access to all, free at the point of need.

In 2013 England devolved public health responsibilities and budgets to local authorities. In many ways this was a bold move, reflecting the important role the latter play in improving health and preventing illness. It was also intended to allow local areas to commission and shape services to best match the need to their communities. In terms of the principle behind this kind of approach I was very supportive. It is not possible to determine what services should be run across 150 local authorities from a government ministry in London. While many raised concerns about the risk of variations in services, termed a postcode lottery, I reflected that there were already differences from area to area and the benefits of being able to tailor local provision would outweigh the negatives. There remained central bodies to provide a degree of oversight and specialist input.  

Of course, this was taking place against a backdrop of reducing budgets and increasing demand for local authorities. I was also guilty of forgetting just how good some areas were at deciding “we don’t have that kind of problem”, regardless of any evidence to the contrary. When I first started in the drugs field I had to ring a London local authority to contact their Drug Action Team (DAT). Now I knew the DAT had been in existence for around two years but ended up talking to many individuals around the organisation until I ended up speaking to a senior officer there, who assured me they didn’t have a DAT “as we don’t have that kind of problem here”. Safe to say you could have deleted problem and inserted “person” and not changed the meaning or understanding, although in fact the borough had a significant drug problem.

I was reminded of this recently by two things. One was an English local authority (not in London!) being in trouble over whether it used its public health money to prop up other areas of expenditure. This seems unlikely to be the last case of its kind. There was also a recent report from Public Health England expressing concerns over reductions in sexual health services at a time when serious infections and the threat posed by antibiotic strains is increasing.

There are clearly huge benefits in having local areas involved in designing and overseeing services appropriate for their communities. But there needs to be mechanisms to prevent unpopular or marginalised services being neglected. It can be hard for local politicians and policy makers to ensure that services for drug users and other groups are not overlooked. Local areas may lack the specialist knowledge to know how to respond to complex issues or the consequences of not having certain services.

This doesn’t mean that central health ministries need to set out and determine every aspect of local delivery. What it does mean is that there needs to be strong central data, accurately reflecting local, regional and national issues. There needs to be good central advice pointing out how problems identified can be addressed in an evidence -based fashion. An overview needs to be maintained on how funding is being used. Networks to support peers can be invaluable in supporting knowledge transfer and providing confidence in tackling the less popular issues.   I will be looking at aspects of this, and its impacts on access to services, during my presentation at City Health 2018.

If local areas are not supported in the move towards devolved and local delivery the odds are firmly stacked that more and more lose out on the lottery of good health.