Can we tolerate a postcode lottery?

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An intriguing question faces all the political parties: how can the inherent tension between the desire for a National Health Service be balanced with a devolved model of decision making which will make local variation more likely?

Variation in standards of care can be addressed through regulation, commissioning standards and contracts, but a more devolved model of decision making may increase variation in the availability and access to services between areas.

In a debate at The King's Fund yesterday, Jonathan Nicholls from Ipsos MORI reported that even members of the public who said they didn't want a 'postcode lottery' of care were nonetheless willing to engage in meaningful debate about local priorities based on local need, meaning different services in different areas.

But in social care, which is run by local authorities and therefore subject to more local democratic control, the tide appears to be turning against localism. Our work to engage people around the country in a debate on the funding of social care (Caring Choices) suggested that people were much more interested in national entitlements than local services, and that they were willing to trade localism for an end to the postcode lottery of care.

Variation has of course existed since the NHS began – a universal service does not have to be a uniform one – but it will be interesting to see how a greater commitment to localism will play out in practice.

Politicians find it difficult to stand back from the fray when a constituent is not able to access a particular service because a local process has decided that it is not a priority for their area. As the funding squeeze takes effect, will there be greater demands to define a 'national' package of care for the NHS, or will the public be willing to allow local areas to decide for themselves?


Richard Marsh

Comment date
17 March 2010
It is a sober comment on the withered state of local democracy that it is within its sphere of influence that "localism" appears most swiftly in retreat. Government policy - which either in secret or openly has received broad cross-party support - for a "national care service" can only hasten the decline in the reputation and raison d'etre of local authorities, certainly so far as social services are concerned.

This is a point for all the political parties to consider going into the election, but perhaps mostly so the Liberal Democrats who are the only big party to favour locally elected bodies organising healthcare.

Suzy Awford

Comment date
17 March 2010
Obviously, we won't be hearing a politician saying that local freedom of choice is a bad thing.  Or that a rapid growth of the 'postcode lottery' is a good thing.  It's interesting that the localism rhethoric is gaining much traction at a time when we need to get more for less from health and social care spending. The CQC's recent report on health and social care emphasised that a reduction of repeated admissions and length of time spent in hospital to that of the best performing areas would result in an annual saving of up to £2 billion.  I hope that localism and promoting best practice can go together.

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