IDEAS home Printed from
MyIDEAS: Login to save this article or follow this journal

Affordability as a discursive accomplishment in a changing National Health Service

  • Russell, Jill
  • Greenhalgh, Trisha
Registered author(s):

    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.

    If you experience problems downloading a file, check if you have the proper application to view it first. In case of further problems read the IDEAS help page. Note that these files are not on the IDEAS site. Please be patient as the files may be large.

    File URL:
    Download Restriction: Full text for ScienceDirect subscribers only

    As the access to this document is restricted, you may want to look for a different version under "Related research" (further below) or search for a different version of it.

    Article provided by Elsevier in its journal Social Science & Medicine.

    Volume (Year): 75 (2012)
    Issue (Month): 12 ()
    Pages: 2463-2471

    in new window

    Handle: RePEc:eee:socmed:v:75:y:2012:i:12:p:2463-2471
    Contact details of provider: Web page:

    Order Information: Postal:

    References listed on IDEAS
    Please report citation or reference errors to , or , if you are the registered author of the cited work, log in to your RePEc Author Service profile, click on "citations" and make appropriate adjustments.:

    as in new window
    1. 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.
    2. 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.
    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. 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.
    5. 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.
    6. Daniels, Norman & Sabin, James E., 2002. "Setting Limits Fairly: Can we learn to share medical resources?," OUP Catalogue, Oxford University Press, number 9780195149364.
    7. 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.
    Full references (including those not matched with items on IDEAS)

    This item is not listed on Wikipedia, on a reading list or among the top items on IDEAS.

    When requesting a correction, please mention this item's handle: RePEc:eee:socmed:v:75:y:2012:i:12:p:2463-2471. See general information about how to correct material in RePEc.

    For technical questions regarding this item, or to correct its authors, title, abstract, bibliographic or download information, contact: (Zhang, Lei)

    If you have authored this item and are not yet registered with RePEc, we encourage you to do it here. This allows to link your profile to this item. It also allows you to accept potential citations to this item that we are uncertain about.

    If references are entirely missing, you can add them using this form.

    If the full references list an item that is present in RePEc, but the system did not link to it, you can help with this form.

    If you know of missing items citing this one, you can help us creating those links by adding the relevant references in the same way as above, for each refering item. If you are a registered author of this item, you may also want to check the "citations" tab in your profile, as there may be some citations waiting for confirmation.

    Please note that corrections may take a couple of weeks to filter through the various RePEc services.

    This information is provided to you by IDEAS at the Research Division of the Federal Reserve Bank of St. Louis using RePEc data.