The future outside the budget.

We grow used to discussing which treatments we can afford. We less often discuss the conditions that determine the answer. Debate takes today’s rules as a permanent frame, then calls any proposal that fits inside it realistic.

Meanwhile, we ask technology to invent the future. We ask politics to administer the present. This division of labour leaves untouched the very mechanisms that determine who will be able to use what gets invented.

A different price, another form of funding, a differently organised service: each possibility requires evidence, resources and debate. None is good simply because it is an alternative. But excluding them before the analysis makes the result predictable, and predictability comes to look like necessity.

Pharmacoeconomics can do something more interesting than certify compatibility with existing arrangements. It can compare scenarios, make trade-offs explicit and test new rules. To do so, it also needs to be able to choose the question.

This notebook begins at that point. Where a conclusion presented as inevitable becomes open to discussion again. And therefore, perhaps, to change.