Thursday 6 August 2009

You can't have localism without postcode lotteries

If David Cameron' were serious about localism and an enormous decentralisation of power being his big idea, then he would surely tell his frontbenchers never to throw around the phrase 'postcode lottery'.

On the other hand, if Conservatives are serious about ending postcode lotteries and ensuring equity of provision across different places, they should admit that this would place significant limits on how far local choices can be allowed to result in any differences on anything that matters.

That latter anti-local variation and pro-equity view appears to be the view of Tory frontbencher Grant Shapps, who is energetically touring the broadcast studios to promote his report on the postcode lottery in IVF treatment.

IVF is just too important an issue for different provision. Shapps even turns on his italicisation to point out it is a National Health Service, not a local one (though he does "not necessarily advocate" equitable provision either, perhaps because calling for more spending and spending cuts is another slightly tricky circle to square).

While not necessarily advocating that local Trusts offer the full NICE-recommended treatment, some degree of national, or even regional, standardisation would be fairest for all concerned, even if that means an effective tightening of the criteria in some areas. The continuation of this lottery means that couples are going so far as considering moving to areas in which their dreams of having a baby can be realised. Clearly that is an unfair situation for what should be a national health service.

So Shapps' report follows exactly the pattern observed by Matthew Parris, on this subject three years ago in The Times. Localism is all important - as long as it does not apply to anything that matters.

Post- code lotteries are bad — I think we’re all agreed on that. Which is curious. Because local choice is good. Most people seem to be agreed on that too. Odd, because if local choice makes a difference, you’ll get a postcode lottery.

... The argument for localism is disgracefully mushy; we should be more rigorous about what localism means ...

Whither, then, “local choice”? We English are hugely in favour of it of course, except when it makes a difference ... It is hard to avoid the conclusion that we think no citizen should be placed at a disadvantage by his address; from which, I’m afraid, flows the conclusion that no citizen should be placed at an advantage by his address; from which flows very limited scope indeed for local public bodies to make any difference at all. We are relaxed only about matters of branding, “local pride”, and control of the quaint or quirky as opposed to the useful functions of public administration.

The political problem which advocates of localism have not addressed is that the public do seem to largely think that the equity argument is trumps. A Fabian/YouGov poll in 2007 presented the options of more local decision-making, even if it led to variations in provision, or the same access to treatment and services nationwide, even if this meant little local choice, and found a margin of seven to one, as The Independent reported.

The YouGov poll also casts doubt on plans being considered by all the main political parties to devolve more decisions about health to a local level. There is deep public concern that this would create a "postcode lottery" within the NHS. More than 80 per cent of respondents said patients throughout Britain should have the same access to treatment and services wherever they lived, with rules decided nationally rather than locally. Only 11 per cent thought the NHS would work better if priorities were decided locally.

This does not rule out a case for more localism. But it is difficult to see how this could proceed without greater clarity about what national standards were guaranteed and what is subject to variation.

That means resisting the temptation to use whichever of two contradictory soundbites sounds most popular at any particular moment and admitting there is a trade-off. We might then have an open and informed debate about how much localism, how much variation, and how many postcode lotteries we want.


Newmania said...

I think thats rather smart arsed really. IVF is an issue without any obvious parallels. My wife and I went through cycles of IVF one intermediate procedure paid for by the NHS and then we were on our own. This was a cost of £10,000 or so which we did not have and was an ordeal to come up with. Of course we could have chosen not to have a family , ta , but then heres your problem. Why should working people who get very little form the State be denied just about the only major thing they ever ask for from the NHS when between us we would be paying for about £1000,000 of healthcare insurance over our lives.
This obvious injustice is felt deeply especially by women whose working patterns sought or not often make early children difficult and the withdrawal from the deal already underway carries on. Is this what you want ?
The use of the “Post Code Lottery “ is only to draw attention to the fact that people are placed in n invidious position to one or another extent , for many its amounts to a £10,000 one time tax based on the roll of a dice and that a mile away others avoid the axe only heightens the sense of injustice
OK Personally I am unconvinced by the minor sub theme of localism which has after all been tested to destruction by the likes of Enver Hodge and Hit Man Hatton but this is a very different context but is it not possible to have localism for some things , planning for example , and not others .....why yes I think that might actually be possible even for dim witted bureaucrats.

IVF , women’s lifestyles and the fairness or otherwise of the middleclass welfare state ( small thought it is ) are a large and serious problem you are not interested in because it chiefly effects women with careers . Your post trivialises the issues throws silly partisan pies and fails entirely to address what is a real and growing cause for dissatisfaction. A few focus groups and Polls and you may just get it , better be quick.

roym said...

i don't see where you're getting trivialisation of the issue from.

right at the top he says
"IVF is just too important an issue for different provision."

this post is merely pointing out the real possibility that post-code lotteries are set to increase under cameron. more fodder for the mail no doubt

Bearded Socialist said...

That's what most advocated of decentralisation and localism don't so often talk about, the different standards inherent in it, or 'postcode lottery' as the phrase goes.

Cameron is very adept at saying one thing an then another, so expect some more on this

Sunder Katwala said...


Sorry, that wasn't the intent of my post. The point was that there is a trade-off to be openly scrutinised and discussed, but that this rarely happens and so we get conflicting calls which are difficult to reconcile. Parris' column seems to me to capture this well.

You suggest you recognise that trade-off, being somewhat sceptical about the localism argument. So I wasn't being particularly critical of Shapps' argument or evidence about IVF services, but was pointing out that it depends on a willingness to reign in local variation.

It might be, if we had that more engaged discussion of the trade-off, that health would turn out to be the area where there is the strongest public sense that local variation should be rather limited, against national guaranteed minimum standards, and probably in areas like the approach taken to public health and preventive services.

There are those who would contest the idea of IVF as meeting need or being publicly supported at all. Personally, I am broadly sympathetic to the argument which you make for some public provision of that. In that case, there is a question of how resources are distributed, and whether this should or should not be subject to local variation.

But there might be less emphasis on that, and more support for local priorities and varied provision, in for example culture and sporting provision.

_______ said...

As long as you can choose to go to any public service in the country and the government pays for travel costs, post code lotteries are not really a bad thing.

Though you don't want variation in schools as it's not feasible to travel long distances to one.

Newmania said...

Ta for your response