‘Please Sir, I want some more’

When Oliver Twist approached Mr Bumble and, with great trepidation, said ‘Please Sir, I want some more,’ he elicited the sympathy of readers who could see the manifest injustice of a system run by well-fed individuals who had the power, but not the will, to improve the lot of those for whom they cared. Today, barely a week goes by without someone asking (or often demanding) ‘more’ from healthcare – more GP appointments in evenings and weekends, more care for the disabled, more funding for psychiatric services, the list goes on and on. Much as was the case with little Oliver, many such cases earn our sympathy.

George Cruikshank Oliver Twist

Many of these demands for ‘more’ are driven by clear need. Few would argue for example that psychiatric services have been greatly underfunded in recent years, or that social care provision is patchy and frequently inadequate. Failures to provide funding in one area often result in increased costs elsewhere in the system; a disabled patient with multiple long-term conditions may require admission to hospital, which might have been avoided with better provision of social care. This adds ammunition to the argument that although these demands for ‘more’ might cost money, they will generate savings that will ultimately mean that the entire system is better off, both in health and financial terms. But these arguments hide some assumptions that need to be addressed.

There can be little doubt that additional social care for the elderly person admitted with a chest infection, who was on the correct treatment but was unable to cope at home with the limited provision of care available, would have avoided the admission. One avoided admission would pay for a considerable amount of additional social care, the argument goes, so it is self-evidently a good idea to invest more money to prevent this sort of admission. The problem with this argument is that until the admission occurs, we don’t know that in this particular case, money could have been saved by better social care. Doctors are familiar with the concept of ‘number needed to treat’, or NNT for short – how many patients do you have to treat with drug X, for example, to reduce blood pressure sufficiently to prevent one stroke? A similar argument can be applied to almost every request for increased social care funding. How many disabled individuals with multiple conditions would qualify for additional funding, and how many of these might acquire a chest infection that threatens them with hospital admission? Once considerations like this are taken into account, the projected savings from preventive measures often diminish, if not disappearing entirely.

Leaving aside the demands for ‘more’ that are driven more by convenience than need – evening and weekend GP appointments is an example of something that might be very convenient, but there is no evidence that failure to provide such services is resulting in any major hardship or illness – most demands for more investment in one particular area of care fail to identify where these additional resources might be found. There should be better provision of services for condition A, GPs should be trained better to identify condition B, the list is endless. But where will the extra resources come from? And if GPs are to do more for patients with this particular condition, what can they do less of, in order to make room for it?

It is always easy to suggest new areas of spending. In the current financial climate though, it is clear that more for X means less for Y; this is not the situation faced by poor Oliver Twist, where money was clearly available but was not being spent. Anyone who demands more for X, without identifying a credible Y that they would reduce to pay for it, is naïve at best, and irresponsible and dishonest at worst.