Can we tolerate a postcode lottery?

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?