Postcode lotteries

In its just-published report Taking Exception on the allocation of cancer drugs by UK Primary Care Trusts, the Rarer Cancers Forum (  provides further evidence of a ‘postcode lottery’ operating within the UK National Health Service. For example (p. 26), the Mid-Essex PCT has granted 96% of requests to its ‘exceptional cases panel’, while neighbouring South-West Essex PCT has granted none.

If I’m much sicker than you, and there isn’t enough of the drug we both need to go around, the fact that I’m sicker will seem to most people a good enough reason for me to get the drug. What seems objectionably unfair in a postcode lottery is that whether a patient gets the drug she needs or not depends on where she happens to live.

There are several ways in which postcode lotteries might be avoided. One would be to ‘level down’, so that in every case where one patient might be offered a drug not available to some other, neither of them would get the drug. At least that wouldn’t be unfair. But this again doesn’t sound like a good reason for depriving someone of treatment they urgently need: to avoid unfairness to some other patient.

Another solution would be for the government to institute a real lottery, so that each patient would get an equal chance of receiving the drug in question. There is still a kind of unfairness here in the outcome, in that one patient will lose out merely because their number didn’t come up in the lottery. But the procedure itself might seem fairer than the current system, in which some people don’t get any chance of drugs at all.

Fairness is a complex concept, and it’s not unlikely that our views about it are piecemeal and internally inconsistent. In fact, it may well not be unfairness that really lies at the heart of the concern many of us feel about postcode lotteries. It may rather be a matter of rationality on the one hand, and of equal respect on the other. Patients who lose out in postcode lotteries will probably believe that there are good reasons for treating those who’ve won, and that those same reasons apply in their own case. That’s why they wouldn’t be happy with mere levelling down or a real lottery. And, as citizens of a democracy resting on the principle that each person deserves equal respect, they will feel slighted by a system of allocation which treats them worse than others in the same position.

There is here, then, an argument for the centralization of basic bureaucratic functions such as the distribution of health care. Even if the different views of the PCTs are each reasonable, even if we have to accept that there is room here for discretion, and even if we are in the middle of a grey area of unclarity and vagueness, there is a case for ensuring that each citizen is treated by the state in the same way, no matter where they happen to live. Perhaps NICE, which has come in for so much criticism in recent weeks, should in fact be given even greater powers to decide which treatments should be available, either to all or to none.

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