Sustainable for whom?

Sustainable for whom? For the annual budget, for those working in services, for those waiting for treatment? Without a subject, sustainability is a word that closes the discussion just when it ought to begin.

Resources are limited. Opportunity cost takes that limit seriously: funding one intervention can divert resources from other health benefits. The NICE manual makes this relationship explicit. Ignoring it would leave unrepresented the people who lose something without appearing in the case under discussion.

The next step, however, requires a political choice. Which resources do we consider available? Over what period? Which costs fall on families and which remain within the public budget? Changing the boundaries of the account changes what appears cost-effective.

Imagine a service reducing its expenditure by transferring an activity to family members. Its budget may record a saving. The time of those providing care is still being used up. This is a hypothetical example, but it makes a concrete problem of perspective clear.

Scarcity deserves analysis. So does the way it is distributed. Calling an arrangement sustainable without saying who supports it leaves someone carrying the weight outside the frame.