Pinhead dancing angels

In their defence, mediaeval scholastic philosophers never postulated how many angels could dance on the head of a pin.  If they had it would have made about as much sense as the debate about whether the NHS is  ”affordable” now or in the future.   “Affordability”, that inelegant neologism, is conditional and not an absolute.  If you said “the NHS is purple”, that would be silly but it would be an absolute – either it is or it isn’t purple.  Whether or not the NHS is “affordable” is conditional on other factors.  The most important of of these are political. We avoid talking about them like the plague and get terribly vexed when they pop up.

Latest affordability punch up

It was no surprise to see the latest punch up around the “can we afford the NHS?” question last week.  The Kings Fund’s economics seer John Appleby’s data briefing in the BMJ this week was bold: “Can we afford the NHS in future?”  Yes, he said because of underlying economic growth.  It was a short but spirited riposte to the claim in Mr Lansley’s eeyorish health economics in 2030 vision in the Telegraph at the beginning of June about English NHS finances: “If things carry on unchanged, this would mean real terms health spending more than doubling to £230 billion.” … “This is something we simply cannot afford.” 

“Can we or can’t we afford the NHS in the future?” This is quite different from the question “DO WE WISH as taxpayers to afford a particular sum for health care in England?” We can’t answer the latter question because we are ignorant of what the ends of the NHS in England should be – what the NHS is actually for, its “ends”.  That’s different from what it does and how it does it, which are all just “means.”

Clarify ends first, then talk about means

Without clarity about ends, no organisation can hope to have efficient governance or be held accountable. We suggest David Nicholson puts that up on the wall of the National Commissioning Board HQ.   There has been governance muddle about the NHS since the beginning.  MAC’s proposition has always been that the end of the NHS in England is “The health of all people in England is maintained as fully as possible for a sustainable tax burden”.

Taking this view, the deciding factor about what the NHS does to achieve its end relates directly to what level of resources the people are willing for Parliament to spend in their name on the NHS coupled with how efficient the machine is in using this fuel.  Determining the answer to “how much is enough to spend on health?” in turn depends on people’s perception of what they are getting for “their” money balanced against their expectations and sense of value.

Immutable principles aren’t public services reality

The policy implication of this is that governments should not waste time identifying eternal and immutable principles for the NHS or public services generally. They should instead take a radical consensus building approach with the public to identify realistic expectations.  We have no doubt this would confirm that tax-supported healthcare is “worth it” to people. It is flexible enough to meet their changing expectations and maximises the risk pool. They perceive it represents value for “their” money because they are the real owners of the NHS.

Resource limits and demand management are political issues which elected representatives working with clinical experts and the public must decide on the basis of the end of the NHS.   How available resources are then applied to this end is another matter and should be an open process resting on evidence-based clinical decisions, public health imperatives to protect health and reduce health inequalities, and user and public views balanced with issues of local feasibility and achievement of value for money.  This does not preclude doing better with the same or less resource, otherwise we are simply being profligate with our own money.

“Rights” aren’t “ends”

Making the NHS Constitution central to how we move forward after the “listening pause” as Government has now done in its response to the Future Forum’s recommendations does not move towards this pragmatic objective.  We fear it may  lock the biggest public service into litigious confrontation.  That is because rationing decisions are inevitable and even desirable on clinical, safety and effectiveness grounds.  But they must always be explicit and contestable.  This will involve “constructive discomfort”, but that will happen covertly anyway. Making the discomfort overt will be a creative process in which people can be encouraged and supported to take a meaningful role. That would be a huge spur to involvement and shared decision making at every stage of the system not just across the consultation table.  This would bring “nothing about me without me” to life in a dramatic way.

Who is right about NHS affordability?

So who is right, Appleby or Lansley about “is the NHS affordable”?  Our money is on John Appleby.  He recognises that “affordability” is at bottom a political decision about what we want to spend our (the public’s) money on for what outcomes that we value.  As he sums it up, “Spending on health will be a matter of choice, not affordability. The real question to ask about health spending is what we think we might get in return as a result of forgoing the benefits of spending increasing amounts of our wealth on other things.”  

Put another way, you can have as many angels dancing on your pinhead as you wish, provided you know what they are there for and have decided you want to pay for them.

The Moore Adamson Craig Partnership supports user and public participation,  trains lay representatives and develops responsive  health, care and education organisations.  We are ready to work with and support all those who want to make sense and a success of the new structures of patient and public engagement within the new arrangements for health and social care commissioning and providing.  Feel free to contact us to discuss the opportunities.

 

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