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Tories: you can’t have localism without postcode lotteries

4:41 pm - August 6th 2009

by Sunder Katwala    

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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.

Cross-posted from Next Left

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About the author
Sunder Katwala is a regular contributor to Liberal Conspiracy. He is the director of British Future, a think-tank addressing identity and integration, migration and opportunity. He was formerly secretary-general of the Fabian Society.
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Story Filed Under: Blog ,Conservative Party ,Health ,Local Government ,Westminster

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Reader comments

I could be wrong, but I get the impression that a lot of the public reaction against perceived ‘postcode lotteries’ is not a dismissal of localism per se but rather a reaction against the perceived unfairness of there being disparate treatment within the same, purportedly ‘universal’, organisation. At the moment, it’s like people get the downside of localism – the disparities of services received – with none of the upsides – like competition between different local governments. If the different local policies on IVF were a) made public and transparent, b) arrived at as a result of local decision-making rather than handed down from the centre, and c) allowed those people who live in regions with fewer services to feel the upside in other ways (lower taxes, perhaps) then I’m sure there would be much less ill-feeling on the issue.

Having experienced a big country – and I mean the second largest in the world – the UK is not a big country at all. So travelling isn’t that much of a problem.

Why does it have to come down to having the local hospital providing everything?

Would it not be better to have (as an example only) 4/5 hospitals in the country at various locations, one south, one west, east, up norf etc, where these services can be expertly run?

The NHS cannot provide everything to everyone at a local level – but it can at specialist hospitals if those hospitals are funded correctly and, of course, with the right administration.


I think you are wrong – people get angry about “postcode lotteries” in other contexts too, even those that are “local” services.

Social care, education, bin collection, roads etc. All local services. All services where people perceive local variation as unfair.

On the point of IVF, I really don’t understand why the NHS is funding it. Surely an extravagance in a time when public spending needs to be retracted significantly.

4. Alisdair Cameron

It’s certainly not the Tories’ issue alone. New Labour have spent over a decade shying away from this plain fact, and indeed, I’d ascribe much of their fervour for the disastrous and ruinously expensive privatisation of public services (“expansion of choice” being the bullshit cover) as a means of trying to have it both ways.

5. dreamingspire

I’m suspicious of politicians who advocate local choice, because it will too easily be a way to cover up central govt inadequacy: not us, blame the locals. It really has to be about local variations to avoid being confined within a straightjacket that may not be appropriate in particular areas. It has to be about local discretion – but with a national standard applied in order to avoid local unfairness or even bad provision through incompetence, or, worse, the problem of local corruption. So it still needs that competent centre that we are so unwilling to create. And it needs to be about local accountability so that problems can be addressed fairly and competently locally. No mainstream party is prepared to address the problem of lack of competence in so many public service Whitehall depts.

I agree that slamming postcode lotteries and calling for greater markets within healthcare is incompatible.

I do however find the call within the Building Britain’s Future strategy for legally enforceable minimum standards in public services an interesting one. It’s a rights-based approach – which normally I’d be sceptical of because of the dangers of stagnating political culture – but in the context of a potential tory government which would introduce massive and damaging cuts to political services, it’s an attractive idea.

Within that context it could be possible to give providers greater control and also guarantee a certain level of service, guarding against accusations of a postcode lottery.

In principle Shapps is wrong. However, variation in IVF provision is a bit of different kettle of fish to policing, education etc for which there is a much greater justification for regional variation.

Dan @1 is spot on.

Dan @1 is absolutely right.

I also agree with Dan @1

The point about postcode lotteries is that is a local variation that comes down from central government. With localism, you still get the same sort of variation, but that variation comes up from the people and, providing there is sufficient support, can easily be changed.

E.g. with localism, if people are unhappy about local NHS IVF provision then they can get that changed through voting. With the current setup, central government dictates NHS IVF provision and there is absolutely nothing local people can do about it.

11. dreamingspire

And so do I – agree with Dan @1. Should have written that earlier. Good,too, that a female voice (cjcjc) agrees.

Under central government, you have post code lotteries. Under localism you get post code Differences. The service isn’t the same but it reflects the priorities.of the local community rather than some bureaucratic funding formula, which means in terms of outcomes, you might see greater equality.

Of course, it shouldn’t be seen as an excuse for not delegating power even further down to the individual whenever possible. School vouchers could allow for greater variation of schools even within the same district, and Dutch-style healthcare insurance (with government top-ups for the less well off) could allow for health providers to compete for individual customers more effectively.

It’s not just the Tories of course: Polly has been railing about postcode lotteries for years.

To extend Dan’s point: markets/localism, call it what you will, can be seen as a process, not a static outcome. Different places try different things and we find out through such experimentation what works best (the aim being to find out what works best for consumers of course, not producers).

Over time (and there are very definitely lags in the system) our knowledge of what works best increases and we would expect to see provision get gradually better as that knowledge spreads.

My basic problem with centralism is that this experimentation leading to innovation does not happen.

I’m thus (and do understand that others might disagree) willing to put up with the postcode lottery now so as to get increasing stadards over time.

@11 – I hope you won’t think any less of my voice, but it is deeper than you suggest!

15. dreamingspire

Nick’s statement (@12) is the first positive pointer that I have seen about making localism work in the future context (rather than trying to revert back to pre-1970 organisation and methods). Is there more anywhere? From a mainstream political party, even? From a think tank that tries to tell us how our public sector ought to work?

Dan’s argument @1 is a useful contributions to how to discuss and decide on this equity/local choice trade-off. However, the premise of Dan’s argument has to be that there would be a broad acceptance of the fairness of variations if they are chosen in that way.

Personally, I expect that would differ according to what we are talking about, being seen as a good approach to some services and not others. On the whole, I think that may prove relatively difficult in the area of health provision, where the strength of belief fairness as equitable provision may well trump that (but perhaps less so in areas like preventive services) but probably would be rather more in other areas (eg culture, sport, leisure to take an example which might be towards the other end of the spectrum).

A (Rawls-like) test might be what we could agree can be legitimately varied before we know what variations will be chosen, and whether we agree with those specific choices or not. And a key political test of its sustainability is whether somebody who then misses out on provision because of the variation can see the process fairness/legitimacy in why that has happened. (This isn’t, I think, likely in the case of acute health treatment). The visibility of the devolution of local decision-making, funding, etc is probably crucial here, as Dan suggests.

Something like Tim’s argument @13 is I think part of the motivation for the approach which suggests that variation is a good idea – because of the potential to drive innovation or experimentation – as long as there are some floor standards and guarantees to protect service users from a major failure, so reflecting the trade-off being made. But that could then have limited effect if there is pressure to make the minimum standard the norm, so that there is little or no real scope for variation beyond it.

17. Alisdair Cameron

One (huge) unmentioned issue with all this is the definition of and boundaries to a ‘locality’ (using that as the term for the sovereign unit for localism). Local Govt boundaries don’t map on to historical boundaries, community sentiment or affinity, let alone outlook. The problem also then arises of the contested zones: those areas which dislike the locality in which they are assigned, and also the problems of grey areas and ‘border’ areas. For example some streets where I live are technically half in North tyneside and half in Newcastle. Were localism to be along local govt boundaries, then there is the prospect of very differing services according to which end of the street you live (which already happens to much disgruntlement), something which the media would pick up very quickly and so condemn well-intentioned ‘localism’.
In truth, I think the real outcome of localism might be as Sunder says, a kind of lowest common denominator standard being adhered to by local authorities, who fear complaints were they to deviate.
I shopuld make it clear, I’m very much a fan of localism, but it carries a whole host of problems of its own.
I don’t know if you recall Terry Collier in the Likely lads :

Terry – “I haven’t got much time for the Irish or the Welsh, and the Scots are worse…”

Bob – “And you never could stand southerners.”

Terry – “To tell you the truth, I don’t much like anyone outside this town. And they’re aren’t many families down our street I can stand.”

BTW – hello? – has anyone noticed the rather large differences which have arisen between England and (especially) Scotland, but also Wales, since devolution across all kinds of areas of provision?!

So the idea of British “national standards” has already gone, hasn’t it?

19. Matt Munro

“IVF is just too important an issue for different provision.”

Why ? No one ever died from not having kids. I would dispute that IVF should be funded by the taxpayer at all.

@19 in the cause of playing Devil’s Advocate, I wonder if perhaps people have actually committed suicide because they weren’t able to have children. It’s possible and I think there’s a tendency to forget that mental health impacts can be fatal.
[PS This new editor tool is rather wonderful…]

Forgive me for saying so, but potential suicides are possibly not likely to make the best parents anyway…

19 – That sentence was intended as a summary of the motivation/argument of Shapps’ report.

But I have been struck by several people – esp on Con sites – seemed to respond yesterday and today by saying IVF is something the NHS should not be doing anyway, or should cut now given spending constraints.

That’s arguable, of course. But, politically, I am not sure I see Mr Cameron trying to put ‘no IVF on the NHS’ past the Daily Mail (who were showing a touching attachment to tax credits for the middle-classes recently too) or indeed past voters more generally. Perhaps you think he should. I am simply predicting that he will not.

It is another example of how “cuts” are easier in the abstract than the proposal of a specific cut…

“It is another example of how “cuts” are easier in the abstract than the proposal of a specific cut…”

It’s one of our mantras at the Adam Smith Inst. that cutting bits and pieces is indeed difficult. The answer is to cut entire functions of government rather than simply tinker.

For example, we probably need about 30-50 billion’s worth of cuts to get rid of the structural deficit (remember, bing Keynesian doesn’t just mean fiscal stimulus in the bad times, it means fiscal contraction in the good as well), 6-8% or so of total spending. Trying to salami slice that off everything will create so much screaming and wailing that it’s going to be impossible.

So rather go for a few big ticket items. ID cards, the NHS computer system: one we don’t want anyway the second has simply become the most gargantuan monster.

Save 14 billion or so by leaving the EU. Simply get rid of corporate subisdies, abolish the Business department, all the little tinkering with grants for this and that. 10 billion more: abolish regional assemblies, regional development corporations, that entire structure, regional development funds….

We’ve pretty much made the savings we need to and not pissed off all that many people….

the NHS computer system … the most gargantuan monster.

Another example of top-down idiocy. Top-down does not work; all that is needed is a minimum standard (e.g. what goes into an electronic medical record, or what constitutes a medical broadband connection) and let the ‘market’ take care of the rest.

The minimum standard should be the norm – what drives standards up is people voting with their feet/money/vouchers.

Or we can carry on pissing away billions of pounds.

“all that is needed is a minimum standard (e.g. what goes into an electronic medical record, or what constitutes a medical broadband connection)”

I edited that suggestion out of my comment: couldn’t think what the name of such a standard should be. .pdf? XML? Something like that but I don’t speak computer….

26. Alisdair Cameron

@ Tim (25) that’s to confuse the style/format of a document/record with its contents…

Tim @25, take RFC821, Simple Mail Transfer Protocol – wot email was based on. The author, Jonathan Postel, wrote a clear objective (“to transfer mail reliably and efficiently”), and “this is the communication model, this is how the machines will communicate” etc. Today we have the choice between lots of email clients and servers (from £free+) but not because Postel had billions of pounds to throw at people, and said you must use this software or that hardware from this company or that government department, and it’s got to have these colours and these size buttons, and work on this specific operating system, but rather a principle along the following lines: “you have to do this as a minimum, how you do it is up to you, and what you add is up to you.”

We wouldn’t have email, we wouldn’t have the intertubes (based on RFCs 791 and 793), if a government had approached those problems (e.g. how to transfer mail reliably and efficiently) in the same way as NHS Connecting for Health, or indeed any other government IT project.

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