‘The synergy illusion’ – do all good things go together?

In 1991, the German political economist Albert Hirschman published a short book called The rhetoric of reaction. In it, Hirschman categorised what he saw as the foundational argumentative styles of different political traditions. Most of the book is devoted to styles of argument that people make to oppose policy agendas. However, Hirschman also identifies three key narratives that people call on when they are proposing new ideas – narratives that he argues are fundamentally flawed.  

The first of these is what Hirschman dubs ‘the synergy illusion’. When people put forward an idea that they think would be positive, they are always quick to illustrate how it works alongside, and reinforces, other things that are also generally considered to be good. Investing in transport will be good for economic growth. Cutting taxes will spur investment. We all know the script.  

However, Hirschman argues that this idea of synergy is almost always an oversimplification. Rarely do we consider the ways in which multiple things that are all individually good might actually work against each other in ways that are complex – and sometimes even destructive.  

I’ve been thinking a lot recently about this question of whether all good things go together in health policy – in particular, during conversations about the government’s proposed ‘shift from hospital to community’. What I’ve found striking is that when you bring up this idea of moving care closer to home people agree with its premise and then immediately start talking about something else, most likely prevention or integration.  

Perhaps this is because people simply see these as more important conversations and are trying to tactfully guide me towards their point of view. However, my take is that, increasingly, people see all these terms as essentially synonymous. We saw a similar dynamic around the creation of integrated care systems a few years ago – when it never seemed enough just to say that integration was a good idea, it was always necessary to say that it was a good idea that would unlock everything from prevention to personalised care to democratic accountability.  

Everything, it seems, is now part of a big bucket of ‘good things’ that right-minded health policy folks want to see happen. In the incredibly fuzzily defined term ‘left shift’ (a loose term used to talk about things such as prevention and care in the community), perhaps this bucket has already actually been formally named.  

This is not just a semantic debate. There are real consequences for this kind of definitional blurriness. First, it prevents us from being able to dig into the substance of the kind of ‘how’ conversations that are needed to fix the myriad problems facing the health system. In order to devise finely turned programmes of reform – to identify which levers need to be pulled when and in which order – we need to know specifically which outcomes we are trying to achieve. And if we’re unsure whether that outcome is, for example, preventing cardiovascular disease versus changing the setting in which people with cardiovascular disease are treated, then we have a bit of a problem. These two outcomes would require investment in different service areas, for example public health management data projects versus something like virtual wards, and as such involve different staff – so leaders need to be clear about what they are asking and from whom in order to prevent confusion on the front line and ensure things actually get implemented.   

The second and perhaps most important issue that comes from seeing all good things as inherently synonymous and synergistic is that it prevents you from getting into a conversation about choices. There’s a lot that this government has set out that it wants to do, and much of it is seen by most observers as ‘good’. However, just because it is good, doesn’t mean that that the good stuff can’t be contradictory.  

You can’t have a laser focus on fixing the crises in acute care – and therefore by necessity investing in that part of the system – while also seeking to address the balance of investment between acute care on the one hand and primary and community care on the other. Or rather, you can, but it would require massive investment on both sides of the equation, and we’ve repeatedly been told that simply isn’t possible. In that context, we have to break the synergy illusion and get into the messy business of prioritisation. To its credit, this is something that the government has started to talk about in the macro, but there is still a lot of detail to work out.  

Politics is about choices, and policy debates reflect that reality. The synergy illusion offers us a comforting escape from that. However, as the name suggests, it is an illusory one. In the end government and policy-makers have to be absolutely clear about what they want to do, and equally clear about what they are regrettably going to have to come back to later. 

Without this clarity of vision, we will end up with the worst of all worlds – achieving nothing because we were never able to decide on what we wanted in the first place.