Dealing with NHS financial pressures – what do the public think?

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Growing financial pressures in the NHS mean that commissioners and providers are faced with increasingly tough choices about how to prioritise their spending.

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.



at home,
Comment date
03 July 2016
a charge for a GP at £10 per visit is calculated to be @ 2.5 visits per patient~2500 patients an extra £62,500 per annum each. This is an appalling extra tax on low income families where surgeries are allowed to keep their profits.

We know that CEOs are being paid 230+ x the amount of the lowest paid as opposed to 30x the amount around 3 decades ago. It isn't that there is less money, it is that it is not distributed as evenly which has reduced tax receipts.

It is probably too late in the day for me to do anything about it, however, it does look that we may be travelling backwards to a time of privilege and the poor house. From a local point of view, following the paying logic for low income people and with A&E possibly moving to a hospital an hour away, there is every possibility that a high number of elder medical emergencies would not survive to be "a problem" or "burden" anyway

It is unfortunate regarding the direction the UK is looking

Please don't respond, it is just a comment

David Greenwood

I am a patient, a taxpayer & a member of the public.,
Comment date
09 July 2016

Oh dear! Here we go again!

The projected forward finances look bad, so we must tighten our belts. Once again patients have a choice: reduced services or longer waiting times.

The enormous and overpaid bureaucracy cannot possibly raise its collective head and look outside its box.

The NHS in England is a nationalised industry. Our other nationalised industries were in similar ruinous financial states 30 years ago. Then they were PRIVATISED. Do you remember when British Telecom (BT) charged more for calls in the morning in order to reduce the demand? When BT was privatised it made 20,000 redundancies PER YEAR for 10 years, roughly halving its payroll while improving its service. Do you remember when nationalised electricity charged 9p per kwh (30 years ago), when we had ‘planned’ power cuts?

That’s what our NHS is like now.
Billions wasted on all-singing all-dancing IT systems that did not work. NHS university: shut after 3 years and £60 million down the drain. Ghastly PFI contracts that will cost the taxpayers millions for the next 30 years. (Incidentally these contracts are “secret” and no wonder). And don’t forget the CQC that has undergone three structural changes since it was formed. Organisational name changes that make one giddy. A Health and Social Care Information Centre (HSCIC) (now called NHS Digital!!) that has bungled its “” programme and is now under threat.
All these are the signs of a top management that is totally incompetent and has been for years.

Now is the time to call a halt and privatise it.

This does not mean patients will have to pay. After all, GP’s are private, but run on NHS contracts. Thousands of patients have been treated in private treatment centre at no personal cost. The same could apply to all the other hospitals and clinics.

Now is the time to act.

Kate Malcomess

Organisational Consultant,
Care Aims Well-being Outcomes Collabortive
Comment date
18 July 2016
I find this one of the most depressing blogs I have read in weeks. Not because of the public responses which, frankly, are reassuringly sane, but because if the options offered! I find it hugely worrying that the "solutions" being put forward are so uncreative, unevidence-based and financially focussed. The astonishingly reductionist approach shocks me coming from a "think-tank". For goodness sake, can we please start treating the public with respect and start a truly adult-adult conversation with them that involves collabortive ideas of how to spend the limited money and resources available to us better. Doing less of the same simply cannot be an option and offering people 5 ways offering less, less effectively is self-defeating and hugely self-fulfilling.

The questions we need to be asking are around prevention, self-management, personal responsibility and collaboration. We could save millions, if not billions, if we changed the "sickness" model of passive recipients of a health commodity or input. This study simply exacerbates a culture of psychological dependency and reinforces a negative view that prevails about the NHS that you have to accept a "second-class service" and with an inevitable delay.

The NHS is only failing because its policy makers, governors and inspectors are living in the dark ages and are feeding the press with these views, resulting in a negative downward spiral of helplessness.

Dirk Van der W…

Dubai Autodrome / METRO EMRS Port Elizabeth - South Africa
Comment date
21 July 2016
This is a good question, from my years working with the South African government working for the Emergency Services in Pre hospital care going through the installation of the current government and the dismantling of control measures that was put in place by the previous government, I was witness to how our national health system was falling apart, one of the challenges was the education of patients for various reasons such as to prevent those that do not need hospital care to be treated at the nearby clinic, preventing hospitals from filling up unnecessary for the simple reason that if we had to take patients to hospital, that do need care at a hospital, that there would be beds available for such patients, to reduce the burden on the hospital staff. It is here that I learned that such questions as yours should not only be asked to the patients, but should be addressed to the staff in the health care system, from the ambulance crew right through to the hospital porters as well, after analyzing the responses, should you be able to have an idea of what the options is.

Mike O'Driscoll

Comment date
31 August 2016
Healthcare is not telecommunications. Some products or services may work better in the private sector, some of them (healthcare, education, railways, housing to name a few fairly important ones) most certainly do not work well for most people when left to the market. You seem to assume that the private sector would run healthcare more efficiently but this flies in the face of all the evidence. Where do you think the money would come from to pay for advertising, marketing, sales people, inflated CEO salaries, shareholders' profits? All these are 'inefficiencies' which the NHS to a very large extent does not suffer from. Many of the 'inefficiencies' which it does have to deal with come from the forced marketisation: crippling debt from PFI, armies of lawyers and bureaucrats to run and support the 'clinical commissioning' process.

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