The unfairness of place: A cultural history of the UK's ‘postcode lottery’

Abstract

The ‘postcode lottery’ has become a dominant political framing for place-based health inequalities in Britain, used by patient groups, politicians and in media coverage of regional health and healthcare inequalities. Using newspapers, parliamentary material and health policy documents, this paper traces how this term has changed and expanded from its origins as a protest about access to new pharmaceutical treatments, to a broader commentary about geographical variations in the quality of NHS and other public services, health outcomes, and deprivation. It traces this emergence and evolution from its origins in the 1989–91 introduction of the ‘internal market’ and the 1994 reintroduction of the National Lottery, through to New Labour health reforms, the introduction of austerity, and the Levelling Up programme in the present day. This paper finds that the term's concern with unfairness has enabled its incorporation into a range of political positions, both as a defence of universalism against market-based reforms in the NHS, and to rationalise distinctions between ‘unequal’ and ‘unfair’ disparities in health outcomes. We conclude that understanding and addressing place based differences and inequalities in health, healthcare, and health outcomes may be aided through investigation of cultural ideas and values as well as the deep histories of place and local services.