Column

For real answers, face up to the real problems

Patiently waiting her turn at the hospital Maggie catches sight of the new notice on the wall:

YOUR HEALTH CHARTER

‘Utopia NHS Trust seeks to achieve maximum health output for all its patients, according to resources available. Patients can be assured that they will at all times receive efficient, ethical service. Where resources are less than ideal all patients will be treated fairly.’

‘That’s reassuring,’ thinks Maggie, ‘and so true. My doctors have always been nice to me, and even though I’ve had to wait nine months so far for my surgery it is good to know that my hospital has such fair principles. I know I’ll get my op. when the time is right.’

Sorry to disillusion you Maggie, but (like the rest of us) you are being seriously misled. Your new Health Charter is using empty words to shield you from a chaotic reality. Worse still, the shield is being held in place by the very people who ought to be ripping it down.

Can I prove it? Well, imagine you were to ask the board of Utopia NHS Trust to explain what it means by ‘health output’, efficient’, ‘ethical service’, and ‘fairly’. At the very least the board would have to define these terms. And I think they would be stumped. In fact I would stake my life savings that they would fail to give a substantial reply.

But assume that Utopia Trust is blazing a trail in the NHS and I lose my bet: astonishingly the board has worked out a comprehensive theory of distributive justice for health services. Now imagine you were to ask the board for its method, that you were to ask how — in this world — they can apply their theoretical framework. What then? Would they be able to tell you? I’d stake my life they would not.

Let’s be absolutely blunt about it. Health services are never rationed according to academic theory, How long a person stays on a waiting list is not decided by a universal philosophical formula but by countless practical factors and biases — different hospitals reach different decisions about similar patients.

The rationing process cannot be anything other than inconsistent and value-based unless all rationers share a general theory of rationing, and no such theory exists. Logic tells me that I must win this bet — my life is safe!

Perhaps Maggie needs the reassurance that someone somewhere has things under control, even if no-one really does. Perhaps we all need this when we sit frightened and vulnerable in hospital waiting rooms. But if general health service policy is ever to improve, the rhetorical shields must be set aside.

Lamentably this seems increasingly unlikely as health economists, ethicists and management scientists voraciously succumb to their own myths.

The route to a better health service, they say, is to get better value for money and to use ethical principles: we must obtain maximum cost-effectiveness; the way to deal with paternalism is to demand total patient autonomy; the answer to the problem of unjust resource allocation is to insist that everyone has equal rights, and so on. But unless these abstract ideals are examined in real contexts — where what counts as ‘value for money’ is hotly disputed, where only limited autonomy is possible, where rights are frequently overridden for defensible reasons, and where much of what happens is not governed by any notion of fairness at all — those who use academic tools will only ever come up with artificial solutions.

Real solutions can only come from trying to solve real problems, and the sooner this writing appears on NHS walls the better.