Politics

NHS funding: Which services are being “rationed”?

“Sexual health and district nursing services are under particularly severe strain”

March 23, 2017
©Lynne Cameron/PA Wire/PA Images
©Lynne Cameron/PA Wire/PA Images
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There is not a health system in the world where decisions about resource allocation do not have to be made. Where resources are finite—which is the case in all health systems but particularly publicly funded systems such as the NHS—decisions on how to prioritise, allocate or, to use more emotive language, “ration” resources are inevitable. The unprecedented financial and operational pressures facing the NHS mean these decisions are becoming more frequent and more difficult. At The King’s Fund, we have looked at how different services have responded to financial pressures, and found that sexual health and district nursing services are under particularly severe strain.

Sometimes, decisions about the care patients are entitled to are taken explicitly by central government and NHS national bodies. These are often published in policy documents and are usually easy to recognise, for example, decisions taken on the funding of drugs and new technologies by the National Institute for Health and Care Excellence (NICE). But there are also many decisions taken at a local level by NHS organisations and doctors that can be much less explicit and harder to identify.

There are a number of ways NHS organisations can respond when their budgets are not sufficient to cover the cost of the care they are providing. Recently, many NHS trusts have gone into deficit; hospitals and other NHS providers accrued a deficit of £900m at the end of the third quarter of 2016/17. Another way they can respond is to cut spending, and there are several ways they can do this. One is to delay treatment, which we have seen in the recent rise in waiting times for routine operations such as hip and knee replacements. They can also stop offering treatment to certain groups of people—for example, in some areas access to hip and knee replacements has been restricted for people who smoke or are obese—or apply blanket bans (although, in reality, there are very few treatments denied to all patients in all circumstances). Organisations can also respond by cutting spending per patient, which may dilute the quality of the service delivered.

Given the size and complexity of the NHS, it would be very difficult (if not impossible) to detail how financial pressures impact on the availability and quality of care across the whole system, so we took an in-depth look at the impact across four very different areas: sexual health services, district nursing, routine hip replacement operations, and neonatal services.

We found that—to varying degrees—each service area is affected by a complex combination of financial pressures and other factors, such as growing demand and workforce shortages. For sexual health and district nursing services, we found clear evidence that access to and quality of patient care have suffered in some parts of the country. In both cases, staff are being forced to focus on the basics of diagnosis and treatment and do not have time to address important issues such as patient education and preventive work.

By comparison, financial pressures appear to have had less of an impact on routine hip replacements and neonatal services. Neonatal services, in particular, appear to have largely maintained quality and access, although there are several longstanding pressures on the service. There have been an increasing number of routine hip replacements in recent years and patient satisfaction remains high. But there are now some signs that care is being affected and the latest performance statistics show that waiting times have started to rise.

Comparisons across these four services provide an insight into why the impact of financial pressures has been greater on some services than others. Services may be particularly vulnerable if their funding does not increase even if there is more work to be done. For example, district nursing and other community health services are often paid a fixed sum regardless of the number of patients seen. Another factor that can make services vulnerable is a lack of good data to properly monitor what is happening, which again is an issue in district nursing services. Our research also suggests that services are more vulnerable to cuts if, as with a lot of public health and preventive work, the impact is unlikely to be felt for several years.

On the opposite end of the spectrum, routine hip replacements and neonatal care have—so far—been relatively protected from the impact of financial pressures, and this is likely to be the case for hospital services more generally. Acute hospital services are the subject of close monitoring and high-profile national performance targets, so problems are likely to become visible quickly and would have a high political and media profile. Hospital services also have the advantage of being funded under contracts that mean they get more money if they treat more patients.

This creates a fundamental challenge to the NHS’s ambition, set out in the “NHS five year forward view,” to make “out of hospital care a much larger part of what the NHS does” and “[get] serious about prevention.” When so many of the hopes for the future of the health service rest on strengthening community and preventive services, it is extremely concerning that we seem to be travelling in the opposite direction.