These ‘unpalatable decisions’ are clearly laid out in a recent blog by the chair of Vale Royal Clinical Commissioning Group, which is a compelling but depressing read. He is a natural optimist, but outlines the glass-half-empty feeling of trying to find savings in his primary, community and mental health budgets while knowing the extra pressure this will put on already overstretched GPs and on patients.
Our work on the impact of financial pressures in the NHS maps out six ways in which health systems can restrict access to care when budgets are not large enough to cover patient demand. These are: delaying treatment by increasing waiting times, denying treatment or selecting patients based on characteristics such as BMI or smoking status (which is often in patients’ best interests), deflecting patients to other services (another hospital, for example) or other payers (such as a local authority-provided service), deterring patients from accessing care (for example, by not providing information about an existing service) and diluting the quality of care provided (for example, by providing the same service but with fewer staff). Of course the NHS could also improve productivity and avoid some or all of these measures, but the scale of the financial pressures it is facing and the immediate need to make savings means there is often not enough time to realise the benefits from efficiency programmes and still meet financial targets.
How do the public think the NHS should approach these difficult decisions? To find out, my colleague John Appleby and I have looked at data from NatCen’s British Social Attitudes survey – an annual survey which asks randomly selected members of the public (rather than patients) for their opinions on a wide range of issues including the NHS. Our analysis has just been published in the 33rd report.
The good news is that just 23 per cent of the respondents were dissatisfied with the NHS in 2015 – a comparatively low figure. However the less-than-positive finding is that beneath this low level of dissatisfaction, public views on NHS funding point to an increasing sense of crisis. Almost everyone agrees that the NHS is facing a funding problem (93 per cent of respondents) and one in three think that the funding problem is ‘severe’. But when we asked people what should be done about this, opinions were more fragmented. To raise more money for the NHS, just over 40 per cent of people support increasing taxes, 15 per cent support introducing charges for each visit to the GP and A&E department, and a similar proportion support charging for non-medical services in the NHS such as food and laundry. There is very little support for ending exemptions from current charges (for example, for children, pregnant women and older people), and 26 per cent of people are not willing to accept any of these revenue-raising options and feel the NHS should simply ‘live within its means’.
This brings us back to those tough prioritisation decisions. When survey participants were presented with four strategies the NHS could use to stay within its budget, almost half of respondents said the NHS should not provide treatments that are poor value for money; one in five supported restricting access to non-emergency treatment; and one in ten supported raising the threshold for treatment so that people have to be sicker to receive care. There was virtually no support for making patients wait longer. And a sizeable proportion (17 per cent) were not willing to accept any of these options.
Does this information help those faced with the dilemma of prioritising scarce NHS resources? It shows that the majority of the public would address budget pressures by implementing some restrictions on access to care. However, the NHS already has a system for evaluating whether treatments offer value for money, and examples such as cancer drugs show how difficult and contentious it can be to restrict access to treatment on this basis. Also, the survey measures attitudes of the general public and not of patients specifically, meaning some of the respondents won’t have used the health service in the past year – and their opinions may differ from those who are also patients and who could be affected themselves by restricted access to care. And so the difficulty for clinical commissioning groups, NHS providers and individual managers and clinicians is to work out which services potential restrictions should be applied to and for whom. Keeping the public on board as they make these tough decisions will be a key challenge for NHS organisations over the next year.