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Affordability as a discursive accomplishment in a changing National Health Service


  • Russell, Jill
  • Greenhalgh, Trisha


Health systems worldwide face the challenges of rationing. The English National Health Service (NHS) was founded on three core principles: universality, comprehensiveness, and free at the point of delivery. Yet patients are increasingly hearing that some treatments are unaffordable on the NHS. We considered affordability as a social accomplishment and sought to explore how those charged with allocating NHS resources achieved this in practice. We undertook a linguistic ethnography to examine the work practices of resource allocation committees in three Primary Care Trusts (PCTs) in England between 2005 and 2012, specifically deliberations over ‘individual funding requests’ (IFRs) – requests by patients and their doctors for the PCT to support a treatment not routinely funded. We collected and analysed a diverse dataset comprising policy documents, legal judgements, audio recordings, ethnographic field notes and emails from PCT committee meetings, interviews and a focus group with committee members. We found that the fundamental values of universality and comprehensiveness strongly influenced the culture of these NHS organisations, and that in this context, accomplishing affordability was not easy. Four discursive practices served to confer legitimacy on affordability as a guiding value of NHS health care: (1) categorising certain treatments as only eligible for NHS funding if patients could prove ‘exceptional’ circumstances; (2) representing resource allocation decisions as being not (primarily) about money; (3) indexical labelling of affordability as an ethical principle, and (4) recontextualising legal judgements supporting refusal of NHS treatment on affordability grounds as ‘rational’. The overall effect of these discursive practices was that denying treatment to patients became reasonable and rational for an organisation even while it continued to espouse traditional NHS values. We conclude that deliberations about the funding of treatments at the margins of NHS care have powerful consequences both for patients and for redrawing the ideological landscape of NHS care.

Suggested Citation

  • Russell, Jill & Greenhalgh, Trisha, 2012. "Affordability as a discursive accomplishment in a changing National Health Service," Social Science & Medicine, Elsevier, vol. 75(12), pages 2463-2471.
  • Handle: RePEc:eee:socmed:v:75:y:2012:i:12:p:2463-2471 DOI: 10.1016/j.socscimed.2012.09.026

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    References listed on IDEAS

    1. Hughes, David & Doheny, Shane, 2011. "Deliberating Tarceva: A case study of how British NHS managers decide whether to purchase a high-cost drug in the shadow of NICE guidance," Social Science & Medicine, Elsevier, vol. 73(10), pages 1460-1468.
    2. Jones, Ian Rees & Berney, Lee & Kelly, Moira & Doyal, Len & Griffiths, Chris & Feder, Gene & Hillier, Sheila & Rowlands, Gillian & Curtis, Sarah, 2004. "Is patient involvement possible when decisions involve scarce resources? A qualitative study of decision-making in primary care," Social Science & Medicine, Elsevier, vol. 59(1), pages 93-102, July.
    3. Klein, Rudolf, 2010. "Rationing in the fiscal ice age," Health Economics, Policy and Law, Cambridge University Press, vol. 5(04), pages 389-396, October.
    4. Giacomini, Mita & Hurley, Jeremiah & Gold, Irving & Smith, Patricia & Abelson, Julia, 2004. "The policy analysis of `values talk': lessons from Canadian health reform," Health Policy, Elsevier, vol. 67(1), pages 15-24, January.
    5. Coast, Joanna & Donovan, Jenny & Litva, Andrea & Eyles, John & Morgan, Kieran & Shepherd, Michael & Tacchi, Jo, 2002. ""If there were a war tomorrow, we'd find the money": contrasting perspectives on the rationing of health care," Social Science & Medicine, Elsevier, vol. 54(12), pages 1839-1851, June.
    6. Jenkings, K Neil & Barber, Nick, 2004. "What constitutes evidence in hospital new drug decision making?," Social Science & Medicine, Elsevier, vol. 58(9), pages 1757-1766, May.
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