NHS rationing under the radar

After years of increasing deficits, that last year culminated in the NHS posting the largest overspend in its history, local health systems have been told to balance their books.

This intensifies the difficult decisions that commissioners and providers have been facing for some time, about how to prioritise limited funding and balance their budgets in the face of rising demand. While the NHS has always had to set priorities, with these unprecedented financial pressures it is inevitable that some organisations will be forced to restrict access to certain services or dilute quality of care as they seek to curtail spending. In some areas this is happening already.

On an individual level, this is like the bank cutting off the overdraft that you rely on when you have just started a family and your rent has gone up. You are forced to cut spending on non-essentials, but deciding what ‘the essentials’ are is tough.

NHS commissioners are starting to have honest conversations with their local populations about these tough choices. A recent example was the public consultation launched by St Helen’s clinical commissioning group about how to fill its £12.5 million funding gap this year. The money saving options presented to the public included ending prescriptions for over-the-counter medicines or gluten-free products, restricting access to IVF, or pausing non-urgent hospital referrals for a four-month period over the winter. The final option was withdrawn from the consultation after a public outcry that made headlines, but the fact it was being considered in the first place underlines the seriousness of the current financial challenge.

Of course, financial pressures affect some parts of the health system more than others. While NHS England has overspent on its specialised commissioning budget for the past three years (this budget pays for specialised treatment for the sickest patients), local authorities had to find £200 million pounds of savings in their public health budget last year, and have been asked to make a further 3.9 per cent annual real-terms savings for the next five years. While protecting care for the sickest patients has to be the right thing to do, cuts to public health budgets are stacking up problems for the future.

Less obvious, but equally important, are cases where patients still receive treatment but the quality of their care is diluted. For example in a service where staff numbers have been cut, they may be forced to spend less time with each patient or see them less often. Work by The King’s Fund on mental health and district nursing services shows that these are two areas particularly under pressure. It is in community settings that the impact of financial pressures goes largely unseen due to a lack of data being available to monitor quality. And these pressures have knock-on effects elsewhere in the system, as illustrated by our work on the current crisis in general practice and the crisis in social care.

Decisions to withhold or substitute treatment are not necessarily bad for patients if they are based on evidence about clinical effectiveness. For example, there are cases where the risks associated with having surgery outweigh the benefits for certain patients. There is also evidence from across the NHS of the overuse of ineffective treatments – an area where the NHS should be looking for opportunities to improve quality of care, as well as to save money.

Considering the wider impact of financial pressures on the health care system, it’s important to remember too that it’s not only patients who are affected. NHS staff often act as a buffer, working longer hours or more intensely to ensure the people they treat still receive a high-quality service. This can increase staff stress levels and lead to low morale, something that is particularly worrying given evidence that staff wellbeing can have a direct impact on patients’ experience of care.

The King’s Fund is currently researching how the slowdown in NHS funding since 2010 has affected patients’ access to high-quality care. The findings from this study, which will be published early next year, will provide valuable insight into the impact that financial pressures have had on NHS patients and staff. In the meantime the government should be honest with the public about what the NHS is realistically able to offer with its available funding.

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Comments

#548041 kevin riley
Solicitor - specialising in supporting front line staff in the NHS.
N/a

THE CONCLUSIONS IN THIS ARTICLE ARE FUNDAMENTALLY FLAWED AS, IN ARRIVING AT THESE CONCLUSIONS, THE AUTHOR HAS ACCEPTED THE PERCEIVED (“POLITICAL”) NEED TO MAKE SAVINGS WITHOUT CONSIDERING THE FOLLOWING REALITIES:-

A) THE REALITY THAT THE GOVERNMENT CAN SPEND AS MUCH AS IT LIKES ON THE NHS EACH FINANCIAL YEAR - THEREFORE THE CONCEPT OF “SAVINGS” DOES NOT ARISE AS IT IS A POLITICAL DECISION OF THE GOVERNMENT AS TO HOW MUCH OF TAX PAYERS MONEY IT IS PREPARED TO SPEND ON THE NHS.IN EACH FINANCIAL YEAR.

B) THE REALITY THAT OUT OF THE 15 ORIGINAL MEMBERS OF THE EU THE UK RANKS TWO FROM THE BOTTOM ON THE AMOUNT IT SPENDS ON THE NHS EACH YEAR AS A PERCENTAGE OF GDP

C) THE REALITIES ARISING FROM THE REMOVAL OF THE RUNNING OF THE NHS FROM DEMOCRATIC CONTROL AS A RESULT OF THE PROVISIONS OF THE HEALTH AND SOCIAL CARE ACT 2012

D) THE REALITY THAT SINCE 2013 NEITHER NHS ENGLAND, THE DEPARTMENT OF HEALTH JEREMY HUNT NOR THE GOVERNMENT ITSELF CAN FORCE ANY OF THE NOW “LEGALLY INDEPENDENT” NHS FOUNDATION TRUSTS THAT NOW RUN ALL NHS HOSPITALS AND CLINICS TO BEHAVE IN A PARTICULAR WAY NOR ACCEPT ALL OR ANY PART OF THE SO CALLED “FIVE YEAR PLAN”..

E) THE ONLY WAY THE ABOVE COULD BE ACHIEVED WOULD BE BY THE GOVERNMENT ASKING PARLIAMENT TO PASS PRIMARY LEGISLATION TO THAT EFFECT.

F) SHORT OF DOING THE ABOVE THE ONLY REMEDY OF JEREMY HUNT AND NHS ENGLAND WOULD BE TO PUT THE RECALCITRANT TRUST INTO SPECIAL MEASURES WHICH WOULD COST EVEN MORE MONEY AND WOULD BE ONLY A TEMPORARY REMEDY IN ANY EVENT.

KEVIN S. RILEY SOLICITOR.

#548056 Caroline Smith
District nurse
Community Foundation trust

I agree with solicitor. Rationing services only leads to more expensive crisis management in the long run. Reducing the budget to the NHS and increasing privatisation at the same time as doing nothing to increases staffing at the same time as trying to impose a 7 day service. These are all political decisions by a government that doesn't believe in public services. Most people will agree to increasing the proportion of our taxes to help maintain an excellent service. We pay less of our GDP than most countries on health because we have a government that don't value it. It should be them that are cut and not valuable services

#548061 John
Retired
Teacher

May be as the above comments state the NHS is not in itself in crisis it is the Conservative Government who want it destroyed . The New Right having gained power under Thatcher have never wanted it have always been against it. They are descendants of the Die Hards against Peel, opposing the Catholic Emanicipation Act.

All the Kings Fund positioning and detailed analysis has no relevance the Governmnet do not want the NHS to succeed it is socialistic [Thatcher] Politics is all, economics whatever that is now is irrelevant

Is the Royal Navyl, Army, RAF, Windsors [ Saxe Coburgs ] the House of Commons - are they supposed to balance a budget ?

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