Introduction

• Dream of successive governments to make medicine calculable

  • Initial hope of administering healthcare in a ‘rational and effective manner’ as envisaged in the 1944 White Paper

• The NHS had been established as a ‘medical enclosure’ rendering it resistant to all attempts to represent and calculate it in financial terms (Rose and Miller, 1992)

• The Plowden Report of 1961 called for public expenditure controls as a way to achieve stable long-term planning with greater emphasis placed on the ‘wider application of mathematical techniques, statistics and accountancy’

• Not until the 1970s that the medical enclosure of healthcare began to be breached

• Attempted ‘marketization’ of healthcare under the Conservative governments of Margaret Thatcher and John Major

• Reference costs (introduced in 1998) represented an explicit attempt to use costing for identifying and revealing ‘unacceptable’ variation between service providers (Llewellyn and Northcott, 2005)

• In 2003, Reference Costing came to be harnessed for new uses, and gained greater significance, as the primary mechanism underlying the new NHS funding system called ‘Payment by Results’ (Department of Health, 2002)

  • To pay providers of healthcare ‘fairly and transparently’ for services delivered

  • Performance and accountability at its core

  • Pays providers according to a ‘standard’ national tariff’ based on the national average (‘reference cost’ of a given procedure

• Spate of predictions quickly followed concerning the likelihood of hospitals failing financial

  • The potential risks of regulating by accounting numbers became apparent

• Monitor was founded in 2004, to act as the independent regulator of NHS foundation trusts

  • Was given the responsibility for overseeing and supporting the aim of improving financial management

  • To enhance ‘performance’, ‘productivity’ and ‘profitability’

• The National Institute of Health and Clinical Excellence (NICE) emerged at the end of 1990s

The risks of regulating by numbers: ‘Costing’, ‘curing’, and ‘quantifying’

• Regulating by accounting numbers as represented by PbR

  • Produces risks which go beyond those supposedly temporary adjustments

• Regulating by accounting numbers produces distinctive and possibly competing calculable spaces (Miller, 1992)

• Hybridizing of the calculating and the medical self (Kurunmaki and Miller, 2006)

• Tripartite nature of regulatory arena in healthcare

• Accounting = costing

• Medicine = Curing

• Health economics = quantifying

• Costing can produce incentives to hospitals to alter the volume and mix of activities and at the limit to eliminate certain treatments or even entire departments because of their financial implications

  • This is in contrast to the aspirations of curing

• Quantifying seeks to make calculable the societal costs and benefits of particular drug regimes or treatments

  • Cost of treating one patient always represent benefits forgone by other patients, and the challenges for those designing healthcare systems and allocating resources is choosing among alternatives given scare resources

• Kurunmaki and Miller study the tripartite system in reference to renal failure and the choice between hospital and home-based dialysis care

Curing

• “In case of no medical contraindication, the choice of initial dialysis modality should be based on patient choice” (UK Renal Association, 2007)

  • The welfare and the views of the patient should be paramount, and the cost is not an issue

• Medics have been criticized for delivering clinical care which, too often, departs from best practice

  • Too ready adoption of health technologies with no...

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