Addressing the postcode lottery

24 Feb 06
TONY TRAVERS | The postcode lottery has become one of the most important concerns of British public policy.

The postcode lottery has become one of the most important concerns of British public policy.

Health, education, policing, even access to post offices and supermarkets are subject to an expectation that, wherever you live, there should be no differences in service provision as compared with anywhere else.

The most recent ‘hard cases’ of this kind have involved desperate decisions about whether or not to prescribe new and expensive drugs to patients with life-threatening conditions.

It is difficult to be sure why the British are so wedded to absolute fairness in the distribution of public services. The Fabians might have had something to do with it, as might the Attlee government after 1945. But wherever the expectation came from, it is a feature that the public sector has to live with.

The implications of an attempt to ensure common service standards and outcomes for all public service clients are even more awkward in a country where a relatively high degree of inequality in personal income is tolerated. Hospitals and schools are burdened with an expectation that, however rich or poor their patients or pupils, there should be no difference in outcomes.

Resource distribution systems underpin the services that are expected to achieve these equal impacts. It is easy to see why instruments such as the Revenue Support Grant and health service allocation formulas have assumed such prominence in Britain.

In short, there must be no postcode lottery. Plus, of course, all services are free at the point of delivery. So the state has to ensure an effective redistribution of tax resources at the same time as fine-tuning services to achieve precise levels of fairness. It is a tall order.

But this is not the end of the increasingly complex picture. The growth of consumerism and ‘human rights’ have now joined the ‘fairness’ demands affecting welfare services.

The public now believes it has the right to use hospitals, doctors, ambulances, schools and other services in ways that are analogous to consumption in the private sector.

We should all choose the very best because this will create pressures to improve service standards. Indeed, the whole ‘choice’ policy is intended to work in precisely this way.

The fact that public services are, for the user, a free good, means there is no price constraint on demand. People can press for the highest possible level of service, knowing there will be no cost to themselves.

The postcode lottery argument, allied to consumerism, means that everyone will inevitably want the very best provision in the best hospitals, schools and police services.

The fact that Britain is a small country with national media means there is plenty of evidence about where the best — and the not-so-good — are to be found. A gaggle of auditors and inspectors is also on hand to make clear just how much better most services could be. Finally, there are hundreds of performance indicators to help inform the public service consumer.

The passage of human rights legislation has further turned the ratchet. There are now respectable claims for services based on expectations that everyone has a right to the very best health care, school provision, social housing or whatever. Such arguments have been made to support patients’ rights to access expensive and (in some cases) unapproved drugs.

As a result of this cumulative set of expectations, our public welfare provision faces ever-increasing pressures as consumers choose the very best of world-class services.

It is hopeless for NHS trust managers to go on television to make the case for rational allocation policies in relation to, say, the Tamiflu drug. Worried parents, children of elderly people and hypochondriacs simply expect public services to lay out pre-emptive pharmaceutical supplies all round — even if the drugs are untried or inappropriate. If they don’t get them, then a lawyer can pursue their claim.

Much the same can be said for schools or levels of policing. Indeed, David Miliband’s speech this week, suggesting a move towards allowing neighbourhoods to demand new, public service providers might open up a new route for the aggressive pursuit of the best possible provision, regardless of price.

We have arrived at the point where it has become increasingly difficult for public institutions to resist particular pressures for services.

As more and more people learn how to demand their rights and exercise their choice, this pressure will intensify. Either taxes will be forced to rise or the public will be increasingly disappointed.

Or, at last, a brave politician will speak the unspeakable: not everyone can have everything, everywhere, free, all the time. And postcode lotteries are a fact of life.

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