The impact of NHS financial pressures – a mixed picture

Recent figures reveal a provider deficit of nearly £900 million for the first three quarters of 2016/17 – a clear sign that NHS organisations are struggling in the face of constrained budgets and growing demand. At the same time, key performance data shows that hospital performance, in some areas, is slipping.

As NHS organisations seek to manage current pressures, the number of media stories suggesting that tight health budgets are having a negative impact on patient care is increasing. But is this the whole picture?

For the NHS, the relationship between financial performance and quality of care is complex. Indeed, a recent Public Accounts Committee report recommended that the Department of Health and NHS England undertake work to better understand the association between the two. We know that the actions NHS organisations take when they are under financial pressure can affect patient care in a number of ways. We also know that patient care is affected by many factors besides funding, and that both national data and public attention tend to focus on care delivered within hospitals.

Our research, set out in Understanding NHS financial pressures, aimed to get beneath the top-level data and explore in more detail how patients are being affected by the financial pressures facing the NHS. We looked at four different service areas – genito-urinary medicine (GUM), district nursing, elective hip replacement and neonatal – to try to understand the impact in different parts of the system.

The clear message was that – to varying degrees – each of these service areas is being affected by a combination of financial pressures and other factors, such as growing demand and workforce shortages. We found that these pressures are having the greatest impact in GUM services and district nursing, where both access to and quality of care are being affected in some parts of the country. In both services, for example, we found that care is becoming more task-focused as staff have less time to support patients’ broader needs. Our research into hip replacement services found that although patient satisfaction remains high, there are early signs that care is being affected as average waiting times for treatment are beginning to rise. Neonatal services appear to have largely maintained quality and access, although significant variation between local services, and longstanding pressures, such as workforce shortages, remain.

Looking across the four service areas we identified some common themes; for example, we found evidence that pressures are having a significant impact on staff, with many health care professionals working more intensely and for longer hours in order to protect patient care. This is particularly worrying given the well-established link between staff experience and patient experience. We also found that although organisations are working hard to maintain services and improve productivity in response to financial pressures, these pressures can also act as a significant barrier to innovation when either the funding, staff or skills necessary for change aren’t there.

Comparing the experiences across the four services also gave us an important insight into how – and why – the impact of these pressures varies. We were struck that the impacts were greatest in GUM and district nursing services, where they were also least visible in routine data. Perhaps this isn’t a surprise – while the length of time patients wait for hip replacement surgery is subject to a national target, the length of a district nursing appointment is not. The ‘dilution’ in quality of care represented by shorter district nursing visits is also unlikely to grab the public’s attention in the way that a reduction in access to surgery does. Indeed, our research pointed to several factors which can combine to make services vulnerable to financial pressures. In addition to the absence of high-profile national targets, factors such as block contract arrangements that don’t change in line with rising demand, and limited data to support service monitoring, may also put services at risk when budgets are tight. This might help to explain the impact on GUM and district nursing services, and the relative protection – so far – of some acute services.

That some of the greatest impacts on patient care are happening under the radar is worrying, and underlines the importance of defining and monitoring quality appropriately in all parts of the system. That negative impacts are being felt particularly in community-based and public health services – services central to the vision set out in the NHS five year forward view and the implementation of new models of care and sustainability and transformation plans – is perhaps more worrying still.

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#549126 Tessa Jelen
Breathe Easy Westminster

I have an elderly colleague complained of back ache consistently. Finally after 6 years was referred to a physio team and a scan taken in January 2017. Severe damage was seen and the possible need for an operation. Her condition can cause paralysis. She is unable to walk more than 100 yards and virtually immobilized and dependent upon the charity of others. OK - understood, but finally a referral to neurology has been booked for June 2017, almost 6 months on, just to be seen by a specialist, let alone for advise on treatment

#549139 Ben Gray

Excellent blog.

A point I'd like to raise is that we seem to have normalised the inaccurate financial position. We all know that the deficit wasn't £2.5bn last year and we all know that the £900m is probably too low this year.

Even if we discount the financial 'fudge' that has taken place I'd love to see an estimate of the financial savings made by worsening performance. What I mean by this is that if we have an extra 100,000 on the WL that last year which we shouldn't. We have in effect saved the costs of 100,000 procedures etc.

Many people will see the £900m and think that £900m will solve the issue. However, we've created a backlog of work which needs to be paid for and we haven't even got a value for that. Imagine its far more than £900m

#549140 Mike Leaf
Former Director of Public Health/ Director of Health Improvement
Turning Over Ltd

Great blog.
I think you have nicely illuminated the iceberg from below! All too frequently we focus on what we can see easily, and ignore what is below the surface.
I have been an advocate for public health being part of local government, but I worry about the impact of the local government financial squeeze on NHS services, particularly in early years services...Health Visiting and school nursing. Have you considered the impact of the financial crisis on NHS services commissioned by local government?
As you rightly point out, the current situation flies in the face of FYFV.

#549141 Benny Goodman
lecturer (Nursing and Sociology)
Plymouth University

Clear, concise and informative. Pointing out: "We were struck that the impacts were greatest in GUM and district nursing services, where they were also least visible in routine data. Perhaps this isn’t a surprise – while the length of time patients wait for hip replacement surgery is subject to a national target, the length of a district nursing appointment is not" is crucial. In nursing much of what is done does not appear in routine data, I call it 'soft metrics' - when for example a patient gets or does not get a decent cup of tea (not trivial to the patient). May i also be a pedant? We talk about 'demand' increasing when perhaps we ought to talk about 'need'. 'Demand' is straight of economics 101 as in the 'laws of demand/supply' and thus suggests the people actually want to use the NHS. In the main we don't. Most of us would prefer to be healthy enough never to have to visit the GP, call a paramedic or require visits by District Nurses. When we do it is because of a health need not a demand. I wonder if the tone of the debate would alter a little if we substituted the words. So is there are difference between: "...a clear sign that NHS organisations are struggling in the face of constrained budgets and growing need" and "a clear sign that NHS organisations are struggling in the face of constrained budgets and growing demand?" Managing demand is ethically different from managing need? I 'demand' an iphone but I 'need' a hip replacement. If Apple fail to provide me with an iphone when I demand it, I can go elsewhere if I really want one. Meanwhile, I'm not in pain or suffer functional disability or in danger of being off sick from work.

#549142 Gill Adgie
Regional Head- North
Royal College of Midwives

Excellent blog.
Whilst the impact on patient care and safety is of the greatest concern it is clear that there is also clear evidence of the impact on the health, safety and wellbeing of the dedicated NHS staff as they strive to provide high quality care. The evidence is also telling us there is a direct link between staff wellbeing and patient experience and outcomes. what strikes me is not only are our patients at risk due to under funding so are the staff who are trying desperately to care for them.

#549438 Elvi
MH support worker

we were told that instead of money we sent to Brussels we could every week to build the hospital but hospitals are closing down everywhere.... as we see and patients are suffering and competent, caring, wonderful staff losing their jobs. Not happy at all.

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