Australia does not have an NHS but it does have a national pharmaceutical subsidy scheme, which is easily big enough to simulate the effect of a single puchaser so as to appropriate drug company rents. The (pre-subsidy) prices of drugs on the Australian PBS are about the cheapest in the developed world. We still get those drug-company sponsored “life saving drug denied to war veteran by heartless bureaucrats” stories in our tabloids, but they don’t have much political effect.

I’m talking here about a specific case, we’re you’re limited to a set number of treatments smaller than the number of needy patients (perhaps due to supply or organs or drugs, that cannot be increased in the short-term); not allocation of money.

Even so, I would agree that other criteria may come in to play – e.g. QALYs, ‘fair innings’, whether need is self-inflicted, etc. All I’m saying is that at the end of the day, when you can’t treat all of the equally needy/deserving cases, you need some method of allocation. In that case, I think a lottery would be fair but, despite a long tradition accepting the fairness of lotteries for such distributions, the media fuss around ‘postcode lotteries’ teaches people to think that lotteries are a bad thing.

You might want to check the last issue of the JRSM (J Roy Soc Med) for an editorial on NICE that conveys some identical opinions regarding the negativity bias carried by the media towards NICE.

Another part of the ‘postcode lottery’ not addressed very often is that there is no apparent reason why the lottery exists, and to the best extent one is able to assess these things, healthcare received is not necessarily closely related to the level of need in the area. So it may actually really be a ‘lottery’, and this is generally not good. It’s a sign either of inequality in an unobserved variable (and British researchers still haven’t clearly established what that variable is, though it’s almost certainly got an element of wealth to it…) or local inefficiencies, also so far relatively unexplained. Neither situation is commendable, though as a research exercise once we have pinned down the causes the local variation will be very useful in enabling us to improve efficiency, as I think Daniel was observing in his article on rape clearance rates.

This seems to me obviously wrong, at least if there is to be no rationing and standardising process that occurs first. Let’s say we have a fixed budget, and we run a lottery the winner of which gets to pick a medical treatment until we run out of money. Inevitably, we are going to end up treating trivial complaints before serious ones. That strikes me as clearly unfair: it is not fair that part of a limited medical budget goes to fund, say, laser eye surgery to correct slight short-sightedness when someone could be cured of some life-threatening disease instead. So, for the claim to be true, it has to be the case that some process of rationing and standardisation goes on. It has to be lotteries amongst like cases, but that requires decisions about what like cases are, and there have to be decisions about which sets of like cases to fund and how much to fund them. Otherwise, we will get objectionable cases of people being funded for trivial interventions when the money could provide others with vital and cost-effective care. Under that set of circumstances, lotteries could be fair, but that’s the set of circumstances we have, effectively, where an arbitrary factor, under certain constraints, sets what care is available. So I don’t see why ‘the postcode lottery’ maligns lotteries either.

Maybe you should take the gloves off and up to it “unelected, unaccountable pen-pushers”?