HEALTH CARE ANALYSIS VOL.I: 165-169 (1993)

Critique The Strange Quest for the Health Gain Michael Loughlin

Of the many bizarre discussions taking place in the increasingly surreal world of health-service management, perhaps the strangest of all concerns the expression "health gain', which has for several years been a topic of debate amongst managers in the British National Health Service (NHS). This expression has become so popular that it is now an officially recognised qauzz-word of the nineties', 1 and as such it can circulate freely through conference halls and is deemed fit to be the subject of numerous articles, reports and questionnaires. In scores of publications and other circulated documents administrators and so-called 'health academics' explore the nuances of this 'technical term', demonstrating their enthusiasm for 'health gain" by describing it as 'a radical and challenging concept', 2 'the way forward', 3 'a philosophical basis for the activities for purchasing authorities', 4 and even 'the ultimate purpose of the NHS'. 1

'There is agreement that "'health gain" is a massive conceptual advance but there is little discussion of the nature of this advance'

Yet in the same articles in which they make these claims, and sometimes even in the same paragraph, authors admit that they cannot say what 'health gains" are, that they do not know how to define or measure them and that, in all probability, neither does anyone else. While there is general agreement that the introduction of "health gain' into the vocabulary of the NHS represents a massive conceptual advance, there is little description of the precise nature of this advance. 1065-3058/93/020165-05507.50 9 1993 by John Wiley & Sons, Ltd.

Authors fail to explain exactly what has been discovered about the nature of health to generate such confidence that health care is now not simply a matter of making people healthy, but rather is all about producing something called "health gain' (or gains). If there existed clear criteria for identifying specific 'health gains' then we could, in principle, know how many of them resulted from a particular course of action. Or if the expression 'health gain" referred to quantifiable empirical products---and it were obvious that the best policy for health was the one which maximised the production of these products--then, as one health economist points out, this would simplify decision-making in the health service no end. In that case: The intervention that achieves the greatest health gain at the lowest cost would be judged to be the most efficient. In theory it should be possible to evaluate a whole range of different health interventions and compare the net costs of health gains from primary health promotion, secondary and tertiary prevention, and treatments, s A single 'health gain' (or one unit of 'health gain') would be the basic unit of value against which all other values in health care could be measured: a sort of health care equivalent of the European ECU. Decision-making in the health service would then be a branch of economic science with qualified managers, trained in identifying "health gains', making demonstrably rational decisions on behalf of us all. Sadly, reality is not like this, as all those who write on the subject of 'health gain" know and freely admit. Not only is there no clear account of the meaning of the expression, there is not even any consistent view to be found in the literature as to what type of entity a 'health gain"

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might be: it is variously described as an 'approach', 3 a 'perspective', 4 a 'means of improving the health of the population" (indeed, 'the most efficient means ... ,)3 as well as the 'product', 'output' or 'result '1 of health-service activity. 'Health gain' 'theorists' sometimes speak of 'health gains' being 'enabled '3 by health care, which would suggest that they are not in fact products of the health service but are instead activities or processes that the existence of the health service makes possible. At other times 'health gains' are described as being 'secured', 'assured', 'achieved' and 'purchased '5 for patients by health care providers, although it is generally admitted that because there is no known w a y of quantifying 'health gains' it is impossible to say how many of them were achieved or purchased by a specific intervention or policy. Given these difficulties, it is not easy to see how the concept of 'health gain' can be of any help at all in the making of practical decisions about the provision of health care, let alone how it can represent a 'challenging concept' for the health

"... since no-one knows what it means how can "health gain" be any help at all in practical decision-making?"

service and the ultimate purpose of the NHS. Indeed, since no-one seems to know what it means, it is not easy to see how it can be a 'concept" at all: unless, of course, talk of generating 'health gains' is just a needlessly contrived w a y of saying that the goal of the health service is to make people healthier, in which case the terminology of 'health gain" hardly constitutes a massive conceptual advance. Undaunted by such apparent problems, the health service continues to discuss 'health gain', and devotes substantial sums of money to doing so. Despite, and perhaps even because of the confusion over what 'health gain' is and how one brings it about, the NHS funded two 'Standing Conferences' in its honour in 1991 and 1992, where the participants (representatives of Regional Health Authorities) described their experiences of 'health gain', monitored the progress of this 'concept' in their geographical area and

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boasted of people and organisations being 'developed for health gain', or 'empowered for' it. 6 Far from being concerned by the apparently vacuous nature of their debate, attendants at such gatherings, like the writers for journals which discuss 'health gain', regard the hollow quality of their own terminology as thought-provoking--as a useful stimulus to conceptual and empirical research to determine what it is that is really being said. As if the absence of semantic content makes a term all the more worthy of serious attention, some contributors boldly declare themselves ready to take on the 'challenge' of finding a meaning for the cherished expression. The bravest of this group proffer their own definitions of 'health gain', while those less intellectually intrepid argue that 'the concept is probably best left broad', attempting instead to identify various things which people might count as 'health gains" in the hope of providing a 'more systematic view of how the term is used'. 7 Those who adopt this latter approach tend to call for a 'dialogue' to 'agree' on a meaning for the term. 8 Others, perhaps speaking for the majority of health care administrators, are content to label 'health gain' a 'catchphrase' and then go on to say how much they and others are doing to bring about 'health gains', apparently in the hope that through frequent use the words will somehow acquire meaning along the way. 4 One health service manager to take the courageous line and offer his own definition of 'health gain' is Alasdair Liddell. Writing in an issue of HFA 2000 News dedicated entirely to the idea of 'health gain', Liddell acknowledges the largely empty nature of discussions of 'health gain' but says: personally I feel it is a pity to condemn such a potentially useful term without a serious attempt to give it some consistent meaning. 9 It is hard to see how Liddell can know that a term is potentially useful if he does not already know what it means: and if a term already has meaning then it is surely not necessary to 'give' it meaning. This sort of comment is, however, something of a trade mark of writings on 'health gain'. Typically, accounts of plans to 'make health gain a reality', 3 and reports of policies already in practice to 'action health gain initiatives '1~ and 'convert the health gain rhetoric into purchasing strategies', 8

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are followed by speculations on what the rhetoric might or might not signify. If Liddell is at all unusual it is because he actually notices that this is paradoxical before offering this definition: health gain is the sum of benefits arising from the applications of NHS resources to improving the health of the population and delivering quality health care to individuals. 1 The problems with this definition are shared by all the other attempted definitions of 'health gain' that managers have come up with, for instance: ... a measured improvement in health, resulting from a planned intervention 11 and health gain aims to improve the quality of life by enhancing the (sic) physical, social and emotional well-being, by measuring the associated costs of effective, appropriate, efficient and equitable services, to identify with our communities the most effective use of resources to improve health and social care. 1~ Although this last one is put forward as a definition it is surely obvious that you do not define something by saying what it 'aims" to do. This, however, is not the 'definition's" major flaw. What is odd about all these proposed definitions is that they attempt to define 'health gain' in terms of other, equally abstract terms. What, for instance, is 'quality health care' and 'physical social and emotional well-being'? If to understand what 'health gain' means we must first understand what counts as a measured improvement in health, then what does the concept of 'health gain' tell us that we did not already know? All these definitions tell us is that 'health gains' are beneficial and quantifiable: the latter is expressed by Liddell in the word 'sum', and in the other two definitions by introducing the idea of measurement. But without any serious reflection on the nature of benefit, and with no actual method of measurement available, this information is not terribly helpful. Other attempts to render 'health gain" significant are worse. A paper extravagantly entitled 'Towards a General Theory of Health Gain' begins: The concept of health gain offers a philosophi-

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cal basis for the activities of purchasing authorities in the post-1991 NHS 4 and goes on to propose an 'inductive approach' to understanding "health gain'. This approach apparently consists in 'examining current health problems from a health gain perspective' which amounts to no more than briefly discussing some practical questions about health care, in the process occasionally mentioning the words 'health gain', but never stopping to explain what they mean or how these words throw any new light on existing problems: to do that would be to take a 'deductive approach', which the paper of course avoids. 4 Astonishingly the writers of this paper seem to accept that 'a health gain perspective' does not help in the making of difficult decisions: Health authorities will need to make choices between investment in different health gain programmes, but in the absence of a common health gain 'currency' it is difficult to make comparisons between different health gain areas...4 and they condude: a comprehensive theory of health gain will require further work on practical health problems and the incorporation of the lessons learned from this work into a general theory of health gain. 4 This seems to be saying that, far from guiding practice, the 'Theory of Health Gain' can only be articulated when we have already solved the real problems in some other way. A further attempt to make sense of 'health gain' involved circulating to Public Health Departments in the UK a questionnaire beginning: 'Everybody is talking about health gain, but what is it ...? How would you define health gain?'. 7 This exercise, reported at the 1992 Standing Conference, was an attempt to systemise people's uses of the term 'health gain' by collating responses to this opening question, and to a series of other questions about ways in which the respondents felt that they were working for 'health gain'. From this the authors of the questionnaire hoped to work out what "health gain' 'probably means'. Such an exercise could only possibly provide any useful information given that people are already using the term in a systematic way, and provided

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there is some definite meaning that underlies its various uses. But the authors say nothing to justify this assumption, and they seem to concede that the term was introduced into the service in a haphazard way and has been given no consistent meaning since its introduction. 7 They nonetheless feel that their exercise was useful, although they are a little troubled by the fact that: None of the respondents.., could offer a comprehensive method of measurement. This is not surprising given the potential breadth of the concept... which, the authors feel, is 'probably best left broad because there is endless room for argument at the detailed level'. 7 At which point, one wonders, did the authors lose track of whatever it was they were supposed to be doing in the first place? H o w did they become embroiled in an exercise where the replacement of ordinary language terms with more obscure, badly defined 'technical' terms is viewed as the appropriate result of an effort to understand what one is doing? H o w can they view detailed argument about the meanings of key terms as something that it is best to avoid? What emerges from all this is that NHS managers, and others involved in the discussion and formation of policy in the NHS, are deeply confused about the nature of meaning. They seem to think that by simply inventing a new term one can solve conceptual problems and thus, without having done any philosophy, one has a 'philosophical basis" for one's future activity. It is as if there is a natural law to the effect that the ideasterminology ratio must remain a constant, so when they invent new words or 'catchphrases' they can rest assured that meaning will eventually rush in to fill the semantic vacuums they create. Should this law fail, one can always 'agree' a meaning later on, once the term is in such widespread use that everyone agrees it certainly ought to have some meaning. And there is always the hope that this will prove unnecessary, since if you use the term often enough and encourage others to do the same, it may simply pick up meaning like a benign virus caught from the lips of those who speak it, growing naturally from a sound into a concept and perhaps eventually turning into a theory. Thus the practice of modern management (not

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just in the health service, but particularly there) is characterised by a massive proliferation of terminology. While people with valuable practical and intellectual skills are being made redundant, and while those in need are being told that the resources to meet their needs are simply not available, vast sums of money are spent employing bogus intellectuals to engage in research designed quite literally to investigate the meaning of their own jargon.

'The appearance of extreme irrationality in a publicly funded organisation calls for an explanation"

H o w could this situation have come about? The appearance of extreme irrationality, sometimes bordering on collective insanity in a massive, publicly funded organisation certainly seems to call for a radical explanation. One possible explanation is that a real solution to the problems of the health service is not possible, or it is feared that it might not be possible, within the constraints of the dominant political ethos. When the consequences of searching for real solutions are unacceptable, and one cannot afford to be seen to be doing nothing, there is no option but to search instead for bogus solutions, and those who are skilled in this department are those who demonstrate a natural capacity for talking nonsense so fluently that even they appear to believe that their verbal innovations constitute profound insights. After all, w h y do administrators find the term 'health gain' so very attractive? Why does it come across as 'potentially useful '9 and worthy of being given meaning? It cannot be being valued for what it means: in the first instance, if it doesn't already have a meaning all there is to go on is the word itself. The answer, I think, is firstly because it is a noun, and one which suggests reference to a particular, rather than a universal and abstract concept. As such it sounds as if it might be a product. It can be provided to and purchased for people, while the adjectives 'healthy' and 'healthier' can merely be predicated of them and the term 'health' is far too abstract to be a product. Free market ideology suggests that every worthwhile

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activity should be analysed on a model of producer and consumer, and it is much easier to understand an activity in this w a y if it has a known product: 'providing health gains' sounds a lot more like the activity of a business than 'making people healthier'. Secondly, the term suggests quantification and hence the possibility of evaluating the performance of health care workers in terms of productivity. (That there is in fact no method of quantification is besides the point: it only shows that 'the development of a coherent theory of health gain is in its early stages'. 4 What is important is the appearance of work in progress). Enthusiasts for "health gain' stress that the term is in use as a result of changes in the NHS in response to free market reforms. The editorial of the 'health gain" issue of HFA 2000 News speaks of the "new managerial relationships ... being forged within the NHS (and between the NHS and other sectors)" and of the fact that 'the performance of professional staff and managers is under much closer scrutiny '12 describing both these 'key shifts' in the health service 'culture' as "themes' that are 'captured ... within the unique concept of health gain'. If this means anything at all it suggests a fairly close link between these changes and the reasons for talking about 'health gain'. The editorial begins by stating: Historians may puzzle on how a package of NHS reforms originally sparked off by the need to control public expenditure, led the UK to the brink of a national health strategy. 12 I doubt that historians will puzzle on this statement, though they and others might puzzle over it, or be puzzled by it. You can have a strategy that leads you to the brink, but what is it to be led to the brink of a strategy? From the articles which follow this comment it seems that being on the brink of a strategy means being near enough to having a strategy to be allowed to say that one exists, but not so near that one can give a coherent account of

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what that strategy is or explain w h y one thinks it makes any sense. What is not really so puzzling is the fact that this state of affairs is the result of arbitrary political decisions that had nothing to do with rational thought about health. It is not only unlikely that moves to cut public spending would create, as a fortuitous by-product, penetrating insights into the nature of health care: the idea, like that of the 'health gain agenda" and other associated contemporary innovations, is evident nonsense.

References 1. Liddle, L. (1992). Health gain. Proceedings from Health Gain 92: The Standing Conference. Norwich, 23-24 July 1992. 2. Chambers, J. (1992). Health gain--is there a need for the centre? HFA 2000 News 19. 3. Eskin, F. (1992). Developing public health practitioners for health gain: what needs to be different? HFA 2000 News 19. 4. Towards a General Theory of Health Gain. Seminar Summary. Proceedings from Health Gain 92: The Standing Conference. Norwich, 23-24 July 1992. 5. Godfrey, C. (1992). Investing in health gains: an economic approach. HFA 2000 News 19. 6. Gibbs, R. et al. (1992). Public empowerment for health gain. Proceedings from Health Gain 92: The Standing Conference. Norwich, 23-24 July I992. 7. Anon. (1992). Health gain. Proceedings from Health Gain 92: The Standing Conference, Norwich, 23-24July 1992. 8. Health gain learning set: Parkside. Proceedingsfrom Health Gain 92: The Standing Conference. Norwich, 23-24 July 1992. 9. Liddell, A. (1992). Why should general managers be involved with health gain? HFA 2000 News 19. 10. Hounslow/Spellthorne and Hillingdon Health Gain Learning Set. (1992). Proceedings from Health Gain 92: The Standing Conference, Norwich, 23-24July 1992. 11. Yorkshire Regional Health Authority (1991). Implementing Health of the Nation, an example: ischaemic heart disease, Harrogate. 12. Adams, S. and Chambers, J. (1992). HFA 2000 News 19.