Short Abstract:

This paper reflects on conceptions of aspiration, capability to aspire and capability to realise aspirations, drawing on the capability approach and sociological theory. These concepts deepen understanding of the potential of person-centred healthcare approaches using the example of the NHS in England. The conclusions are relevant to health and welfare policies and practices in diverse contexts.

Long Abstract:

Introduction

This paper reflects on conceptions of aspiration, capability to aspire and capability to realise aspirations, drawing on the capability approach and sociological theory. These concepts are applied to deepen understanding of the potential of person-centred healthcare approaches using the example of the personalised care agenda in the NHS in England. The conclusions are relevant to health and welfare policies and practices in diverse contexts.

Key words: capability to aspire, capability approach, health capability, personalised care, NHS England.

Context

Over the last two decades there has been growing interest in the concept of the capability to aspire and its relevance for human flourishing. Although the literature has grown, so too have misconceptions of terminology related to the capability to aspire (aspiration, capacity to aspire, capabilities to realise aspirations) and the positioning of aspirations and capability to aspire in a capability approach paradigm. The opening task of this paper is to offer clarification on key concepts with a particular focus on the capability to aspire. Then, in the second part of the paper, the paper draws on work by Venkatapuram (2011) and Ruger (2010) to relate health capability with the capability to aspire and the NHS in England is used as an example to explore the transformative potential of institutions. The focus is the person-centred approach to health care that has evolved significantly in the NHS over the last decade.

The budget for the National Health Service in England is estimated at £155 billion for 2022-23 (Kings' Fund, 2023). It is the biggest employer in the UK and one of the largest in the world with just under 2 million employees. However, it is facing increasingly challenging times with thousands of vacant posts, chronic under-funding and a rising demand for services. An exponential rise in long term conditions and co-morbidity is predicted in England and by 2035 two-thirds of adults are expected to be living with multiple health conditions and 17% will have four or more conditions. There is a health gradient with significantly poorer health and earlier onset of co-morbidity in disadvantaged areas (NHS, 2023). Already 84% of General Practitioners (GPs) have said that their workload is unmanageable or excessive and can prevent quality and safe care (NHS, 2019). In response to this evolving crisis, the NHS has adopted a ‘personalised care’ approach aimed particularly at increasing individuals’ abilities to self-manage their long-term conditions, becoming more active agents in their own care. The drivers are social, political and economic with rising costs of care and rising demand, fuelled by co-morbidity and an ageing population.

Central Arguments

The paper argues that it is vital to focus on the twin areas of individuals’ capabilities to aspire alongside their capabilities to realise their aspirations and not only on the former although capability to aspire has an intrinsic value. In light of neoliberal tendencies to position individuals as individually responsible and accountable, an argument is also made to increase transparency and awareness of the wider determinants of health and variation in the real opportunities individuals have to live in ways they have reason to value. The discussion also addresses tensions and opportunities in the relationship between individual flourishing and collective well-being, foregrounding institutional challenges in sharing limited resources and acting in ways that support equity as perceived within a capability paradigm.

Conclusion

Person-centred approaches in healthcare and elsewhere have the potential to support and nurture individuals’ capabilities to aspire. However, there are numerous caveats to this. Some individuals will enjoy greater capability to aspire than others and some will be more or less capable of realising combinations of aspirations they have the greatest cumulative reason to value. Moreover, not all individual aspirations will be in keeping with equity and justice in relation to wider societal, collective and individual needs. Realising aspirations that contribute to the climate crisis is an example of this. Future institutional policy and practice in the NHS in England, and elsewhere, may more effectively pursue social justice and the fullest human flourishing possible by balancing nurturing individuals’ capabilities to aspire and their capabilities to realise aspirations being mindful of resource limitations, wider social determinants and moral consequences, in the short and longer term. It is incumbent on individuals as well as institutions, governments and policy makers to reflect on the degree to which individuals are able to equitably realise their aspirations in the present, with consideration to future generations, other species and the environment and, ultimately, at a global level.

References

Department of Health and Social Care (2023) Major Conditions Strategy: Case for Change and our strategic framework (UK government, UK).

Jennifer Prah Ruger (2010) Health and Social Justice. New York, Oxford University Press.

Kings’ Fund (2023) The NHS Budget and How it has Changed accessible at The NHS budget and how it has changed | The King's Fund (kingsfund.org.uk)

NHS (2019) Universal Personalised Care: Implementing the Comprehensive Model, NHS, London.

Venkatapuram, S. (2011) Health justice: An argument from the capabilities approach. (n/a ed.) Polity.