Six ways in which NHS financial pressures can affect patient care

NHS finances are almost at breaking point. Since 2010, the unprecedented slowdown in funding growth and rising demand have made it increasingly difficult for the health service to live within its means. In the past, some hospitals have received extra financial support from the Department of Health when they have overspent, but the latest NHS planning guidance signals a shift from this approach by asking providers to balance their budgets by the end of 2016/17.

But what does this mean for people who access health services, and how can they examine the effect of financial pressures on their local health system?

Health care systems around the world have to take decisions about which services and treatments to provide and for whom. These decisions – sometimes referred to as 'rationing' – are taken at many levels: by national bodies; by local commissioners and providers; and by clinicians. While some decisions are explicit (agreed in law or policy) others are less easily identified as they are based on individual judgements.

Commissioners, providers and clinicians base their decisions on a range of factors. These include national policy initiatives, clinical guidelines, historical local provision, local priorities and needs, individual clinical judgements and conversations with patients. Because of this it can be difficult to disentangle the impact of financial pressures from the range of other factors that shape local services.

The task is further complicated by the fact that when the NHS restricts access to treatments, this can sometimes be a good thing. There is extensive evidence that ineffective treatments are overused in the NHS and that reducing their use can benefit patients and save money. The implementation of new service models can also improve productivity by providing higher-quality care for the same or lower cost.

Consequently, there is a range of ways that the NHS can respond to financial pressures, some of which can have a positive impact on patient care.

When budgets are not large enough to cover patient demand, providers have four options:

  • go into deficit (which is not sustainable)
  • improve productivity (delivering better value care has helped the NHS meet its efficiency targets for the past five years)
  • restrict access to services
  • dilute the quality of services.


In The King’s Fund report Thinking about rationing, Rudolf Klein and Jo Maybin describe a useful framework for understanding the different ways in which access to high-quality care can be limited by commissioners and providers, building on earlier work by Roy Parker. Their typology outlines six ways in which patients can be affected by financial pressures and provides a useful means of examining what is happening in local health systems.

  1. Deflection
  2. Delay
  3. Denial
  4. Selection
  5. Deterrence
  6. Dilution

The first five categories relate to restrictions on access to care, the final category (dilution) relates to reductions in the quality of care. In the following sections we describe what each approach means in the NHS, and provide links to data sources to help individuals find out more.

Our ongoing project work

To understand more about how the current financial challenge is affecting patients’ access to high-quality care, The King’s Fund is conducting some in-depth research over the next six months.

We are looking at the impact of financial pressures in four service areas, to explore whether financial pressures are being felt differently in different parts of the health system. These are: genito-urinary medicine (GUM) clinics, district nursing, elective hip replacement and neonatal services.

If you work in one of these service areas or have used the service as a patient, we would like to hear your views on whether financial pressures have had an impact on the quality of patient care. Please get in touch with Ruth Robertson, Fellow in Health Policy: r.robertson@kingsfund.org.uk. All discussions are confidential and we will not identify research participants in our publication.

1: Deflection

Six ways in which NHS financial pressures can affect patient care: (1) Deflection
What is it?

The NHS or one of its providers refuses to treat an individual or pay for their care, and instead ‘deflects’ them elsewhere in the system. There are two ways in which the responsibility for funding or providing care can be deflected in the NHS:

  • to another payer – for example, to the local authority or the individual (the latter may result in denial)
  • to another NHS organisation – for example, from a GP practice to a hospital.


For patients, this can create uncertainty and anxiety as they are passed between organisations. This might result in a delay in getting care or in frustration as they have to repeat the same information multiple times. They may get the wrong care in the wrong place from the wrong professional and in some cases they may be deterred from seeking care or denied treatment.

Is this happening in the NHS now?

An example of deflection (from the NHS to local authorities) is when applications for Continuing Health Care (CHC) funding are inappropriately turned down by the NHS. The NHS must pay for an individual’s ongoing care if they are assessed as having a ‘primary health need’. For those living in a care home, CHC funding includes the cost of their board and lodging, in addition to their medical expenses. If they are not assessed as having a ‘primary health need’ then care is paid for from the local authority’s social care budget – if the individual meets the means test criteria – or by the individual themselves. Decisions about whether to award CHC funding can have a huge financial impact on individuals and their families.

Within the NHS, responsibility for assessing CHC applications lies with local clinical commissioning groups (CCGs). They face the inherent difficulty of establishing the point at which someone’s health needs become severe enough to warrant NHS funding. Over the past 20 years, eligibility decisions made by the CHC programme have been the cause of some controversy. This includes investigations by the Ombudsman that found the NHS sometimes applies overly strict criteria when assessing claims, a Health Select Committee inquiry that highlighted variations in funding across the country, and legal challenges (from individuals) to eligibility decisions.

Despite financial pressures in the NHS, a growing number of people receive CHC funding: the number of recipients increased by 38 per cent between the first quarter of 2009/10 and the first quarter of 2015/16. Without data on changes in care need over that time, we are unable to say whether the current financial pressures are affecting individual eligibility decisions.

Cuts to local authority social care budgets mean deflection is increasingly running in the other direction: from the local authority to the NHS. For example, difficulties establishing social care support for people when they leave hospital contribute to delayed discharges, leaving patients under NHS care for longer.

A recent example of deflection from one NHS organisation to another is the decision by a number of major NHS teaching hospitals to refuse to accept patient referrals from outside their local area, even though hospitals are contractually obliged to accept patients referred from anywhere in England. High patient demand means some hospitals do not have the capacity to treat all the patients referred to them within target waiting times, so patients are deflected to a different NHS hospital for treatment.

Another example of deflection is when patients who are unable to get a GP appointment seek treatment elsewhere – for example, an accident and emergency (A&E) department. The national GP patient survey asked patients who were unable to get a convenient appointment last time they called their GP what they did instead. It found that in 2015 9.9 per cent went to an A&E department or a walk-in centre, up from 8.5 per cent in 2012.

Where can I go for more information?

  • Continuing Healthcare data showing the number of patients in each CCG area eligible for Continuing Healthcare funding is published quarterly by the Health and Social Care Information Centre (HSCIC). This data should be interpreted with caution as it does not provide any information about changes in care need.
  • National GP patient survey provides data on where patients go when they are unable to get an appointment with their GP. Results are available at national, CCG and GP practice level. When looking at information for individual GP practices the data should be interpreted with caution as the sample sizes are sometimes very small.
  • Patient opinion websites If people are being refused care and sent to alternative providers this may show up in comments posted on websites such as NHS Choices, Patient Opinion or Iwantgreatcare.
  • Local Healthwatch Each local authority area has a local Healthwatch organisation that acts as a consumer champion for people using health and social care services locally. They collect views from service users, giving them an overview of local issues.

2: Delay

Six ways in which NHS financial pressures can affect patient care: (2) Delay

What is it?

People wait longer for diagnosis and treatment as services struggle to employ the staff or fund the premises and equipment needed to treat everyone who needs care in a timely way. National minimum waiting time targets attempt to limit the extent to which the NHS can delay access to some services.

Is this happening in the NHS now?

The long waiting times that troubled the NHS for the first 50 years of its history are now a thing of the past. In 1980, nearly a third of inpatients waited more than a year for treatment. However, following a decade of NHS funding growth during the 2000s and the introduction of waiting time targets, waits of this length have been successfully eliminated.

Although the NHS is unlikely to return to the very long waits experienced in the 1980s and 1990s, financial pressures and rising patient demand mean that waiting times are currently at their highest level for several years.

One example is the length of time that people spend waiting in accident and emergency (A&E) departments, which has worsened over the past couple of years. This measure is often seen as an indicator of the general health of the NHS: if hospitals are stretched, beds are full, or services are not available outside hospital so patients can be discharged, the flow of patients through the hospital is disrupted and people wait longer in A&E. Despite a national target that 95 per cent of people spend less than four hours in the emergency department, 8.5 per cent of people attending an A&E department in England waited longer than four hours in December 2015. Performance has deteriorated since December 2013 when the target was met with less than 5 per cent of attendees spending more than four hours in A&E.

Another example is the time spent waiting from GP referral to treatment, which the NHS Constitution states should be no more than 18 weeks. Data from December 2015 shows that 8.2 per cent of people waiting for treatment in England were still waiting after 18 weeks; this breaches the target of 8 per cent for the first time since it was introduced in April 2012.

As well as waiting to be admitted to hospital, patients can be delayed when leaving hospital while arrangements are put in place to support them at home or to transfer them to another NHS service. Between April and August 2015, the total number of days that patients were delayed in hospital was 11 per cent higher than in the same months the previous year.

Delays also occur outside hospital. Difficulties getting a GP appointment have been widely reported in the press, but there is no central data collection to monitor this. The national GP patient survey asks adults registered with GP surgeries in England how easy it is to get an appointment at their GP surgery. In July 2015, 11 per cent of adults were not able to get an appointment or speak to someone the last time they called their GP surgery, up from 9 per cent in June 2012.

Many other areas of NHS care such as physiotherapy and most mental health services are not currently subject to waiting time targets, and data on waits for these services is not routinely collected (although waiting time targets have recently been introduced for some mental health services). It is in these areas that waiting times are most difficult to monitor and it is likely to be in these areas that people are left waiting longest as the health service comes under greater pressure.

Where can I go for more information?

  • The NHS Constitution handbook outlines patients’ rights and government pledges for waiting times.
  • NHS waiting times data (national) You can track national data on NHS waiting time performance by following our Quarterly Monitoring Report and Quality Watch from the Nuffield Trust and the Health Foundation.
  • NHS waiting time data (local) NHS England publishes data on NHS waiting time performance for individual NHS providers including:
  • The national GP patient survey includes questions about waiting. Results are available at national, clinical commissioning group and GP practice level. When looking at information for individual GP practices the data should be interpreted with caution as the sample sizes are sometimes very small.
  • Patient opinion websites If people are waiting an unreasonable time for treatment this may show up in comments posted on websites such as NHS Choices, Patient Opinion or Iwantgreatcare.
  • Local Healthwatch Each local authority area has a local Healthwatch organisation that acts as a consumer champion for people using health and social care services locally. They collect views from service users, giving them an overview of local issues.

3: Denial

Six ways in which NHS financial pressures can affect patient care: (3) Denial
What is it?

Patients do not receive treatment because their local health commissioner does not fund it, or their health care provider feels it is not appropriate. These decisions are usually based on evidence about clinical and cost effectiveness. This means denial can sometimes be a good thing for patients, if they forego ineffective treatment, but it can also be a bad thing if they miss out on effective care.

Denial is closely linked to selection, but while selection is based on the characteristics of the person being treated, denial is based on the nature of the treatment. In practice, examples of denial often include an element of selection as there are very few treatments that are denied to all patients in all circumstances.

Is this happening in the NHS now?

The NHS, like any government-funded health care system, has a limited budget so cannot pay for every potential treatment. While some countries clearly set out the package of benefits that people are entitled to, there is no specific list of services to which individuals using the NHS are guaranteed access. Instead individuals have a number of legal rights that are set out in the NHS Constitution. These include the right to: receive most NHS services free of charge; receive certain treatments within a maximum waiting time; be treated in a safe and clean environment; have access to drugs and treatments recommended by the National Institutute for Health and Care Excellence (NICE), if a doctor says it is appropriate.

NICE’s clinical guidelines influence both national and local decisions about which services to provide for patients, but the NHS is not required to adhere to them (aside from a legal requirement to fund the relatively small set of treatments covered by NICE’s technology appraisals). This means that while patient entitlements are broadly defined by legislation and national frameworks, many of the choices about which treatments are available on the NHS are made by local health service commissioners or by clinicians ‘at the bedside’.

Although the NHS does not publish a list of what it does fund, most clinical commissioning groups (CCGs) publish lists of the treatments that they do not routinely fund. Patients can still access treatments that are not routinely funded in some circumstances. For example, clinicians can submit individual requests to their CCG (or NHS England, for services within their commissioning remit) on behalf of their patients. Individuals with cancer can apply to the Cancer Drugs Fund, which was set up by the government in 2011 to provide access to drugs that are not routinely provided on the NHS.

Our analysis found that 95 per cent of CCGs publish exclusion lists or policy statements on their websites. These lists differ by area (although more than half of CCGs agree joint policies with neighbouring CCGs), and the excluded treatments broadly fall into two categories:

  • treatments that are not funded because they have low or no clinical value
  • treatments that are only funded for certain individuals (ie, patients are selected for treatment based on factors that may affect the success of the treatment, eg, whether they smoke or are overweight – see selection section).


Decisions to deny treatment can represent the best outcome for patients if the risks associated with a procedure outweigh the benefits. Overtreatment is prevalent throughout the NHS and many commissioners and providers are working to reduce it.

However, there is no national list of low-value treatments to guide decisions and most local areas draw up their own exclusion lists based on their analysis of the evidence. Some areas use the list of 34 procedures developed by Croydon Primary Care Trust (‘the Croydon list’) as a starting point. This includes procedures that are considered to be relatively ineffective (eg, grommets), largely cosmetic (eg, varicose vein removal), to have a small benefit-to-risk ratio in mild cases (eg, wisdom tooth extraction) and for which cost-effective alternatives should be tried first (eg, carpal tunnel release surgery). There is also some nationally produced guidance and support that includes the Commissioning for Value programme and NICE’s ‘Do not do’ guidance. Clinicians are also encouraged to discuss the value of treatments with patients in the Choosing Wisely campaign.

One study explored whether the NHS has reduced its use of low-value treatments since the slowdown in funding growth in 2010 by examining trends in the rates of six procedures. The study found that the rates of three (myringtomies, hysterectomies and cataract removal) of the six procedures declined during the first year of the government’s efficiency savings programme (2011/12), while rates for the other three procedures (hip replacements, spinal surgery and inguinal hernia repair) increased or remained unchanged. There were also significant variations between areas. Even where rates of low-value procedures reduced, the authors concluded that the resulting savings were likely to have been modest due to the low cost of these procedures and the relatively small-scale reduction in their use. Furthermore, some have raised concerns that procedures considered of low clinical value are beneficial in some circumstances, so savings from discontinuing their use might be overestimated if the (all be it modest) clinical benefits are not fully considered.

While denial can result in individuals accessing appropriate care, it can also be detrimental if individuals are denied effective treatments. An example of this is the cut in inpatient mental health bed numbers made as part of NHS cost-saving programmes. This has resulted in some people with mental health problems being unable to access the inpatient treatment they need during a crisis.

Where can I go for more information?

  • NICE guidance outlines recommended best practice for a wide range of conditions. The guidance is not mandatory, but clinicians are expected to consider it, along with their own professional judgement, when taking decisions. NICE guidance is a useful source of information to help you assess whether your local CCG is providing care in line with recommended practice.
  • NHS atlases of variation provide an overview of variations in clinical practice across England.
  • National and local newspapers often cover local decisions to deny individuals treatment. Trade press publications, such as the Health Service Journal, Pulse or GP online, also often cover these stories.
  • CCG websites usually publish a list of treatments that CCGs will not fund or will fund only in certain circumstances, although the information is presented in different ways by different CCGs. Some publish a ‘schedule of policy statements’ or a list of ‘procedures of low clinical value/effectiveness’. Others publish individual policies on the rules applied to specific treatments.
  • CCG board meeting papers If proposed restrictions are discussed at CCG board meetings, you will be able to find out more about these in the board meeting papers and minutes, which are published on every CCG’s website.
  • Patient opinion websites If people are being refused care this may show up in comments posted on websites such as NHS Choices, Patient Opinion or Iwantgreatcare.
  • Local Healthwatch Each local authority area has a Local Healthwatch organisation that acts as a consumer champion for people using health and social care services locally. They collect views from service users, giving them an overview of local issues.

4: Selection

Six ways in which NHS financial pressures can affect patient care: (4) Selection
What is it?

Patients might be denied treatment because they do not meet certain eligibility criteria. These decisions are usually based on evidence about clinical effectiveness of treatments for people with particular characteristics. For example, a GP might not refer an individual for surgery if they are less likely to benefit from it because they are a smoker or are overweight.

Selection is closely linked to denial, but while denial is based on the nature of the treatment, selection is based on the characteristics of the person being treated.

Is this happening in the NHS now?

Although there are some treatments that local commissioners refuse to fund for any individual (one example is tattoo removal, which many clinical commissioning groups (CCGs) don’t routinely fund as they consider it to be a cosmetic procedure) more often access is restricted for a selected group of people based on the severity of their condition, their age or lifestyle factors such as smoking or body mass index (BMI).

Selection comes in two forms. It can be explicit, where local commissioners agree clear criteria for who should and shouldn’t receive treatment; or it can be implicit, where decisions are made by individual clinicians during a consultation. The latter is sometimes referred to as ‘bedside rationing’.

Examples of explicit approaches to selecting individuals for treatment include guidelines and decision tools that help GPs assess when a referral is appropriate and more directive approaches such as strict referral criteria or referral management centres that filter GP referrals.

As with treatments that fall into the denial category, most CCGs publish lists of treatments that they will not fund in certain circumstances. These differ by CCG, although most develop joint policies with their neighbours (in our analysis of CCG websites 62 per cent of CCGs had joint policies). These policies often restrict access to treatments of low or no clinical value based on evidence about clinical effectiveness for particular groups of patients (see also denial).

In our analysis of CCG websites, reproductive health, fertility treatment and other gynaecological procedures was the area most often subject to restrictions: 175 out of 209 (84 per cent) CCGs published policies about access to these treatments. People wishing to access in vitro fertilisation (IVF) are sometimes selected based on age, and CCGs vary in the age limits they put on eligibility for access to IVF .

Lifestyle factors are also commonly used by CCGs to decide who is eligible for treatment. In 2015, an investigation by GP magazine based on Freedom of Information Act responses from 145 CCGs found that 62 per cent of CCGs restricted access to some treatments based on smoking status and 83 per cent restricted access based on BMI. These restrictions were often likely to be in best interests of the individual as, for example, interventions may be less effective if individuals are overweight.

This approach to selecting who is eligble for NHS treatment receives a lot of media attention, raising fears that cuts to NHS budgets are leaving people without the care they need. One example is access to hearing aids, where individuals are sometimes selected for treatment based on their level of hearing loss. Policies that mean that people with mild or moderate hearing loss cannot access hearing aids from the NHS have been controversial and have been criticised by hearing loss charities.

Selection (and denial) can also happen implicitly during the GP consultation, when clinicians decide whether to refer patients on for care. Even the most common and clinically effective procedures have admissions rates that vary significantly across the country. One example is hip replacement operations which vary from 55 to 208 per 100,000 population between CCGs with the highest and lowest rates. This is an almost four-fold variation, even after adjusting the data for the age and sex of the population. These are unwarranted variations that go beyond what can be explained by differences in need. They reflect overtreatment in some areas as well as undertreatment in others and are likely to be the result of longstanding differences in policies and service structures in different areas, as well as differences in individual clinicians' decisions and responses to current financial pressures.

While restrictions on access to treatment for specific groups as a result of their lifestyle choices or age often makes media headlines, these decisions are usually based on evidence about the clinical effectiveness of treatments and the amount of money saved in this way is relatively small. Far greater savings could be achieved by addressing variations in clinical practice across the NHS.

Where can I go for more information?

  • NICE guidance outlines recommended best practice for a wide range of conditions. The guidance is not mandatory, but clinicians are expected to consider it, along with their own professional judgement, when taking decisions. NICE guidance is a useful source of information to help you assess whether your local CCG is providing care in line with recommended practice.
  • NHS atlases of variation provide an overview of variations in clinical practice across England.
  • National and local newspapers often cover local decisions to deny individuals or specific groups treatment. Trade press publications, such as the Health Service Journal, Pulse or GP online, also often cover these stories.
  • CCG websites usually publish a list of treatments that CCGs will not fund or will only fund in certain circumstances, although the information is presented in different ways by different CCGs. Some publish a ‘schedule of policy statements’ or a list of ‘procedures of low clinical value/effectiveness’. Others publish individual policies on the rules applied to specific treatments.
  • CCG board meeting papers If proposed restrictions are discussed at CCG board meetings, you will be able to find out more about these in the board meeting papers and minutes, which are published on every CCG’s website.
  • Patient opinion websites If people are being refused care this may show up in comments posted on websites such as NHS Choices, Patient Opinion or Iwantgreatcare.
  • Local Healthwatch Each local authority area has a Local Healthwatch organisation that acts as a consumer champion for people using health and social care services locally. They collect views from service users, giving them an overview of local issues.

5: Deterrence

Six ways in which NHS financial pressures can affect patient care: (5) Deterrence
What is it?

The NHS – either consciously or unconsciously – can put up barriers that make it difficult for patients to find out about and book appointments with local services. If individuals are not given information about a service, they may not realise that their access to care has been restricted.

Is this happening in the NHS now?

In most cases, if individuals are deterred from using NHS services it is the unintended result of other service pressures. Whatever the cause, there are examples throughout the NHS of individuals not seeking treatment because they either do not know about or are unable to access the services available.

One example of people being unable to access appropriate services is in general practice, where people are finding it increasingly difficult to contact their GP surgery. While some will persist, others may give up and either self-care, go to another NHS provider (see deflection), or wait for their condition to worsen before seeking help. In January 2016, the national GP patient survey found that 26 per cent of people reported having difficulties getting through to their GP practice on the phone, up from 18 per cent in June 2012. 11 per cent of people said they were not able to get an appointment to see or speak to someone at their GP surgery the last time they tried – a figure that is slowly increasing (up from 9 per cent in 2012).

A lack of information can also deter people from accessing services. Often, they will not know a service exists unless it is offered to them. One example of this is diabetes care. The National Diabetes audit found that in 2014/15 only around a third (32 per cent) of people newly diagnosed with type 1 diabetes were offered a structured education programme – an important tool, recommended by NICE, to support people manage their diabetes effectively. While the number of newly diagnosed individuals offered the programme is far higher than in the past (just 1.5 per cent were offered the programme in 2009/10) the vast majority of people newly diagnosed with type 1 diabetes are still not given the chance to access nationally recommended care because of a lack of information. It is also worth noting that providing information does not guarantee people will access care – in 2014/15 just 1.8 per cent of those offered this training course actually attended.

Deterrence is particularly difficult to monitor as it is usually results from the NHS not doing things, rather than from doing things badly. It is also important to remember that deterrence is not always a bad thing – in some cases it is in the best interests of individuals to deter them from using services that are not best placed to meet their needs. For example, some local CCGs run campaigns encouraging people to go to A&E only in an emergency and instead, where appropriate, to access care from local pharmacists or GP out-of-hours services.

Where can I go for more information?

  • The national GP patient survey provides information on difficulties people experience getting a GP appointment. Results are available at national, CCG and GP practice level. When looking at information for individual GP practices the data should be treated with caution as the sample sizes are sometimes very small.
  • NHS complaints data, published by the Health and Social Care Information Centre, shows the number of complaints received by each NHS provider and some information on the type of complaints (the latter is available for regions only).
  • Patient opinion websites If the quality of care is suffering locally this may show up in comments posted on websites such as NHS Choices, Patient Opinion or Iwantgreatcare.
  • Local Healthwatch Each local authority area has a Local Healthwatch organisation that acts as a consumer champion for people using health and social care services locally. They collect views from service users, giving them an overview of local issues.

6: Dilution

Six ways in which NHS financial pressures can affect patient care: (6) Dilution

What is it?

Patients receive the same basic treatment, but as budgets are cut and resources are spread more thinly, the quality of their care may suffer. This might mean appointments are shorter or less frequent as a service can no longer employ as many staff as in the past. It might also mean the care pathway changes so certain diagnostics, follow ups or other services are no longer included in the patients’ package of treatment. Not all changes to patients’ care packages dilute quality though; new service models may improve or maintain quality and lower cost.

Is this happening in the NHS now?

The NHS employs an estimated 1.4 million people and staff costs account for around 70 per cent of NHS providers’ recurring expenditure each year. This means that when finances are tight, reductions in staff numbers (or not employing extra staff as demand increases) are one of the main ways in which the NHS can save money.

Of course not all reductions in staff numbers result in patients receiving lower-quality care. There are many innovative approaches to changing staff roles that can mean, for example, that fewer GPs might be needed in a practice if practice nurses and health care assistants are given extra training and new roles.

Not all staff shortages are caused by budget pressures: some are due to workforce planning issues. It takes three years to train a nurse and at least a decade to train a hospital consultant. Decisions taken today about the number of training places available for medical and nursing students will affect the number of doctors and nurses working in the NHS in 10 years’ time.

There are some areas of the NHS where acute staff shortages and increased patient demand are compromising the quality of services patients receive.

One example is district nursing. Between September 2009 and September 2014 the number of senior district nurses in England fell by 30 per cent (while the downward trend is indisputable, there are some complications in interpreting this data due to changes in the employment model, which are explained more fully in our report, Workforce planning in the NHS). A survey of district and community nurses conducted by the Royal College of Nursing in 2013 revealed the impact this has had on patient care. The survey found that the vast majority (77 per cent) felt their workload was too heavy, and that 83 per cent felt that there were not enough nurses to get the work done. Unsurprisingly, this meant 75 per cent of nurses said that necessary activities were left undone because of a lack of time.

Another example is mental health services, where increased demand and changes to the skill mix of mental health teams appear to have led to a dilution in the quality of care provided in some areas. While the number of patients using mental health services in England is rising (by 5.1 per cent between 2011/12 and 2012/13) the number of contacts that each patient has with the service is falling (by 4.3 per cent over the same period). This means that more patients are receiving treatment, but their treatment involves fewer appointments or contacts with the service. There has also been a reduction in the proportion of people who are treated using the Care Programme Approach – a structured way of planning and co-ordinating care for people with complex mental health needs – suggesting fewer patients are receiving this higher level of support.

In both these examples, interpreting data about dilution in care quality is difficult. The line between an effective productivity improvement and a change that reduces quality is blurred. Consequently, instances of dilution can be difficult to identify, but are potentially very damaging to patients.

Where can I go for more information?

  • NHS workforce statistics are published monthly by the Health and Social Care Information Centre for every NHS organisation. Workforce data should be interpreted with care as changes in staffing mix may not indicate a deterioration in the quality of care provided. Also, these statistics do not include agency staff or many other staff working for the NHS who are employed by private sector organisations.
  • Key national indicators of care quality are tracked in the Nuffield Trust and Health Foundation’s QualityWatch.
  • The Care Quality Commission inspects health care providers, rates them and publishes reports on their performance.
  • MyNHS publishes a range of quality indicators for local health care providers including infection rates, mortality rates, staff satisfaction and many more. You can compare providers, but you cannot look at changes over time.
  • CCG outcomes tools allow you to compare health outcomes in your local CCG area with other CCGs across the country.
  • The national patient survey programme asks patients for their views on the overall quality of care they receive. Data is available at national and provider level.
  • NHS complaints data, published by the Health and Social Care Information Centre, shows the number of complaints received by each NHS provider and some information on the type of complaints (the latter is available for regions only).
  • Patient opinion websites If the quality of care is falling this may show up in comments posted by patients on websites such as NHS Choices, Patient Opinion or Iwantgreatcare.
  • Local Healthwatch Each local authority area has a Local Healthwatch organisation that acts as a consumer champion for people using health and social care services locally. They collect views from service users, giving them an overview of local issues.