Managed Difference, Local Solutions, Market Forces – Anything but Postcode Lotteries!

Chris Game

It was over six years ago that Sir Michael Lyons launched his campaign to abolish ‘postcode lotteries’ from the local government lexicon.  As he wrote in his 2007 report, “I would hope to see debate about postcode lotteries being replaced, over time, by discussion of ‘managed difference’ – recognising the right and ability of local communities to make their own choices, confident in their own competence, and in the knowledge of their own preferences.”

Others, doubting perhaps the rallying appeal of ‘managed difference’, proposed alternatives – local difference, local solutions, postcode preferences – but to nil avail. The campaign made no more headway than most of the Lyons Report’s substantive recommendations, as was painfully apparent last week – during which the populist media brought us what seemed like a new PL each day, each of course with its accompanying outrage and public alarm. 

First was the Diabetes Treatment Postcode Lottery. A National Audit Office (NAO) report showed “significant variation in quality of care received by people with diabetes across the NHS”. Quality of care was defined here solely in terms of the 9-process care regime advised – yes, only advised – by the Department of Health (DH) and National Institute for Health and Clinical Excellence (NICE), and the most recent data were from 2009-10.

Still, I mean, the results were, like, just incredible. The 151 English PCTS and 34,000 GPs clearly weren’t all following fully and identically the DH’s recommended care package.

Next came the seasonal Holiday Cash Postcode Lottery. Which? magazine sent mystery shoppers to a range of different currency exchange providers across the UK on the same day and – surprise! – found they weren’t all offered exactly the same number of euros for their £500s. In fact, there were regional variations, with London and Glasgow shoppers getting more euros than those in Birmingham, Sheffield and, yes, Haverfordwest – except that there weren’t really, since over a two-month period the Post Office and Thomas Cook offered the best deals, irrespective of region. 

Then lgcplus ended the week with the Child Care Postcode Lottery, choosing to lead its news round-up on 25th May with a Times story: “‘Postcode lottery’ in child care proceedings”.  A Cafcass (Children and Family Court Support and Advisory Service) report found that, in the three years since the Baby Peter Connelly case, there has been an increase of over 60% in local authority care applications – but, again amazingly, not spread absolutely equally across all 152 relevant local authorities.

Let’s start with the child care case. First, I’m fairly certain the Cafcass report itself contains no mention whatever of a ‘postcode lottery’. The cheap and misleading headline was chosen by The Times – presumably to rubbish local government in general and certain councils in particular – and then, regrettably, recycled by LGC.

Second, the report’s main findings constituted a generally highly positive local government news story – though you’d never know it from The Times’ version, since the very term ‘lottery’ has deliberately negative connotations.  

To quote directly from the report: “as a result of intensive work on behalf of children, court applications to protect vulnerable children are being made in a more timely way than in 2008 and at an earlier stage of local authority involvement with a family. In particular, neglect cases are being acted on more quickly … and local authorities are more fully prepared coming into court”.

Third, the whole point of a lottery is that there are unmistakeable winners and losers, good and bad outcomes. For the media, the good guys here are, no question, those councils heading the league table of public law applications per 10,000 children. That’s not, however, the Cafcass view.

Cafcass CE, Anthony Douglas, stressed that it’s impossible from the statistics alone to know whether high appliers are being diligently active or defensively over-reactive, and whether low appliers are being slow or perhaps have much better family support services.

The authors warn that their study “does not provide evidence about what the ‘proper’ level of care applications should be”, and admit they were hesitant about publishing statistics in this form, given the likelihood of their prompting comparison of authorities’ levels of intervention. Perhaps they should have hesitated longer.

The diabetes treatment case is not dissimilar. Again ‘postcode lottery’ comes not from the NAO report, but is a media tag to justify the pillorying of, in this instance, Primary Care Trusts. Again too the lottery headline obscured an at least partly positive story: that the proportion of diabetes patients receiving the full recommended care package had increased significantly since the previous audit.

This time, however, the report’s authors were quite certain who the lottery losers were: diabetes patients in PCTs in which only relatively small numbers – say, under 40% – received all nine DH-recommended care processes in 2009-10, regardless of any other treatment they may have received.

Almost as striking, though, is that in not one of the 151 PCTs were more than 69% of diagnosed diabetics receiving all nine processes. Which, to an outsider, suggests either that there are no even moderately high performing PCTs in this field – which seems unlikely – or that many, including the best, are employing other tests and other forms of care, in which the NAO were not apparently interested.

They, it seemed, were more into the blame game – the problem being to decide whether it was the recalcitrant PCTs themselves at fault or the DH’s sloppy monitoring.

By contrast, my problem – indeed, my profound irritation – is that none of these three cases is at all accurately or usefully labelled a ‘postcode lottery’. The cheap point here, of course, is that postcodes were designed for the purposes of delivering mail – the clue’s in the name – and therefore have little to do with council, PCT, or any other political or administrative boundaries.

I’ll tell you what a postcode lottery is. It’s if you happen to live in the Galashiels postcode area in TD9, 12 or 15, and may be either in Scotland or England; or in the Newport postcode area in NP7, 16 or 25, and not know which side of Offa’s Dyke you are.

No, the postcode bit is just silly. It’s the lottery bit that’s serious. Variations in policy and practice across local authorities or PCTs aren’t products of chance. They result from people exercising their right to make decisions in what they judge to be the best interests of those to whom they are answerable – for example, to follow official guidance or try an alternative that is or might be better or more locally appropriate, or from which they and others might learn.

In both the diabetes and child care cases, the ‘postcode lottery’ presentation of the story was not only misleading, and possibly unnecessarily alarming, but militated against our understanding of what the reported variations actually do represent. As for the exchange rate differences, they result from straightforward high street competition, that Which? magazine must surely have come across before.

Chris Game is a Visiting Lecturer at INLOGOV interested in the politics of local government; local elections, electoral reform and other electoral behaviour; party politics; political  leadership and management; member-officer relations; central-local relations; use of consumer and opinion research in local government; the modernisation agenda and the implementation of executive local government.

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