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NHS rationing under the radar


After years of increasing deficits, that last year culminated in the NHS posting the largest overspend in its history, local health systems have been told to balance their books.

This intensifies the difficult decisions that commissioners and providers have been facing for some time, about how to prioritise limited funding and balance their budgets in the face of rising demand. While the NHS has always had to set priorities, with these unprecedented financial pressures it is inevitable that some organisations will be forced to restrict access to certain services or dilute quality of care as they seek to curtail spending. In some areas this is happening already.

On an individual level, this is like the bank cutting off the overdraft that you rely on when you have just started a family and your rent has gone up. You are forced to cut spending on non-essentials, but deciding what ‘the essentials’ are is tough.

NHS commissioners are starting to have honest conversations with their local populations about these tough choices. A recent example was the public consultation launched by St Helen’s clinical commissioning group about how to fill its £12.5 million funding gap this year. The money saving options presented to the public included ending prescriptions for over-the-counter medicines or gluten-free products, restricting access to IVF, or pausing non-urgent hospital referrals for a four-month period over the winter. The final option was withdrawn from the consultation after a public outcry that made headlines, but the fact it was being considered in the first place underlines the seriousness of the current financial challenge.

Of course, financial pressures affect some parts of the health system more than others. While NHS England has overspent on its specialised commissioning budget for the past three years (this budget pays for specialised treatment for the sickest patients), local authorities had to find £200 million pounds of savings in their public health budget last year, and have been asked to make a further 3.9 per cent annual real-terms savings for the next five years. While protecting care for the sickest patients has to be the right thing to do, cuts to public health budgets are stacking up problems for the future.

Less obvious, but equally important, are cases where patients still receive treatment but the quality of their care is diluted. For example in a service where staff numbers have been cut, they may be forced to spend less time with each patient or see them less often. Work by The King’s Fund on mental health and district nursing services shows that these are two areas particularly under pressure. It is in community settings that the impact of financial pressures goes largely unseen due to a lack of data being available to monitor quality. And these pressures have knock-on effects elsewhere in the system, as illustrated by our work on the current crisis in general practice and the crisis in social care.

Decisions to withhold or substitute treatment are not necessarily bad for patients if they are based on evidence about clinical effectiveness. For example, there are cases where the risks associated with having surgery outweigh the benefits for certain patients. There is also evidence from across the NHS of the overuse of ineffective treatments – an area where the NHS should be looking for opportunities to improve quality of care, as well as to save money.

Considering the wider impact of financial pressures on the health care system, it’s important to remember too that it’s not only patients who are affected. NHS staff often act as a buffer, working longer hours or more intensely to ensure the people they treat still receive a high-quality service. This can increase staff stress levels and lead to low morale, something that is particularly worrying given evidence that staff wellbeing can have a direct impact on patients’ experience of care.

The King’s Fund is currently researching how the slowdown in NHS funding since 2010 has affected patients’ access to high-quality care. The findings from this study, which will be published early next year, will provide valuable insight into the impact that financial pressures have had on NHS patients and staff. In the meantime the government should be honest with the public about what the NHS is realistically able to offer with its available funding.