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How are NHS financial pressures affecting patient care?


The NHS is experiencing increasing financial pressure, but what does this mean for patients? This is a difficult question to answer because, while evidence on the extent of the NHS’s financial problems is piling up, information on the impact on patients remains scarce for a number of reasons.

First, across the country patient care varies for many reasons beyond the size of the local NHS budget: decisions about the care available to individuals are influenced by national bodies, local commissioners and providers, and clinicians at the bedside. Unlike health services in some other countries, the NHS does not specify a list of treatments that it will provide. Instead, patients have a series of broad legal rights (laid out in the NHS Constitution) and their care is influenced by a wide range of factors such as national policy initiatives, clinical guidelines, what’s been available locally in the past and current local priorities and needs. While decisions made by national bodies, commissioners and providers play an important role, clinicians’ decisions ‘at the bedside’ and the discussions they have with patients ultimately determine the care that each individual receives. So if an individual’s care differs from recommended practice or from the care someone else received, it may not necessarily be the result of financial factors.

Second, when budgets are cut or (more likely) do not grow in line with patient demand, some providers go into deficit. By overspending, providers may be protecting patients from the worst effects of funding pressures, meaning data on financial performance does not tell us anything about the impact on patients.

Third, sometimes restricting access to care may not be motivated by budgetary concerns even if it leads to a reduction in spending. It may mean better outcomes for patients, for example, if a treatment is ineffective or the risks of receiving it outweigh the benefits. There is extensive evidence of overtreatment in health services, so when referral rates go down or access to services changes, we should not always view this negatively.

Finally, tightening budgets can motivate providers to improve productivity. There are many examples of innovations that both improve the quality of patient care and cut costs, delivering better value.

Although the impact of financial pressures can be difficult to identify, it can and does affect patient care. In their paper, Thinking about rationing, Rudolf Klein and Jo Maybin described six ways in which this can happen:

  • deflection – individuals are bounced from one funder to another (eg, from the NHS to the local authority) or between organisations (eg, from the GP practice to A&E)

  • delay – people have to wait longer for treatment

  • deterrence – people do not access services because the NHS (either intentionally or unintentionally) makes it difficult for them to find out about services or book an appointment

  • denial – people are not routinely provided with certain treatments

  • selection – individuals with particular characteristics (like being obese or smokers) are not eligible for certain treatments

  • dilution – patients receive a lower-quality service as resources are spread more thinly.

Now, we have examined in more detail what each of these ways of restricting care means for the NHS and how individuals can see the impact in their own local health system.

Of the six ways mentioned above, the media often focuses on stories about patients who do not receive care because of delay (including stories about people waiting longer in A&E departments) or selection (including recent calls for the NHS to provide the meningitis B vaccine for children up to age 11 (currently the vaccine is only offered as part of the NHS routine childhood vaccination programme for babies)).

However, equally important and much more difficult to identify are examples of dilution, where patients still receive care, but that care is of lower quality. Mental health patients in some areas appear to have seen a dilution in the quality of care provided by the NHS as a result of increased demand for services and changes to the skill mix of mental health teams. While the number of people 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 individual has with the service is falling (by 4.3 per cent over the same period). This means that more people are receiving treatment, but their treatment involves fewer appointments or contacts with the service.

Another example is district nursing, where reductions in staff numbers have contributed to workload pressures. Three-quarters of the community and district nurses surveyed by the Royal College of Nursing in 2013 said that necessary activities were left undone because of a lack of time.

In both of these examples, the line between an effective productivity improvement and a service change that reduces quality is blurred. This adds to the challenge in identifying instances of dilution.

To explore this further, over the next nine months we are researching the impact of the slowdown in NHS funding since 2010 on patient care by looking in detail at four services. We hope to get closer to answering the difficult (but crucial) question of what the financial pressures in the NHS mean for patients.