Understanding how financial pressures can affect patients is key to minimising their negative impact, writes Ruth Robertson

The NHS is halfway through a decade of austerity that has seen the proportion of GDP spent on health fall from 8.8 per cent in 2009 to 7.3 per cent in 2014-15. We know budgets are not keeping pace with patient demand, but what do these financial pressures mean for local services and for the care patients receive?

Decision making

Decisions about what services to provide for patients are made at every level of the system: national bodies, local commissioners, individual provider organisations, clinical teams, individual clinicians and patients all make choices that influence what care is provided and for whom.

When budgets fall short of what’s needed, each of these actors has to decide how to respond. Within organisations, managers can shift money around between services, or draw on reserves to fund extra activity.

As budgets tighten the NHS is inevitably facing tough prioritisation decisions that may result in restrictions on patients’ access to care

But when extra money can’t be found, the NHS must improve productivity (and so deliver more for the same or less) or they are left with the much less palatable options of restricting the number of patients who use the service or spreading resources more thinly and diluting the quality of care patients receive.

During the first five years of this decade the NHS delivered substantial productivity savings, mainly through cuts in wage costs and a reduction in the tariff price paid for care. There are many ways in which the NHS reduces demand for services, some of which are in patients’ best interests and are just about providing good care (for example where the risks of treatment outweigh the benefits).

There are also opportunities across the NHS to get more value from the NHS budget through implementing changes in clinical practice based on evidence of what works.

However, as budgets tighten the NHS is inevitably facing tough prioritisation decisions that may result in restrictions on patients’ access to care. In a report written for the King’s Fund a few years ago, Rudolf Klein and Jo Maybin outlined six ways in which NHS organisations can restrict access to high quality care.

Now that the NHS financial challenge has deepened we have gone back to their framework to see if these six types of rationing are happening in the NHS today.

Six ways NHS financial pressures can affect patients:

1. Deflection

2. Delay

3. Denial

4. Selection

5. Deterrence

6. Dilution

The first is deflection – where the NHS or one of its providers “deflects” a patient elsewhere in the system because they cannot afford to treat them. One example of this in the NHS is the decision taken by a number of major teaching hospitals to refuse to accept patients referred from outside of their local area, due to high demand for their services.

Another example is when patients are unable to get an appointment with their GP and so head to the accident and emergency department instead.

The national GP patient survey asks patients who were unable to get an appointment last time they called their GP what they did instead. Almost one in 10 said they went to the A&E department or walk-in centre, up from 8.5 per cent in 2012.

Deflection can also happen between different parts of the public sector. Cuts to social care budgets means that the cost of patient care can be deflected from local authorities to the NHS.

Patients who are unable to get an appointment with their GP head to the accident and emergency department instead

Difficulties establishing social care support for people when they leave hospital are one of the causes of delayed discharges that leave patients in hospital for longer, taking up costly hospital beds.

The second approach is delay. This is how the NHS rationed care in the 1980s and 90s, when it was relatively common for patients to wait more than a year for treatment (in fact in 1980, nearly one in three inpatients waited this long).

Although the NHS is not heading back to those extremely long waits, waiting times are currently at their highest level for several years. For example, patients are waiting longer from referral to treatment – in December 2015, the 18 week target was breached for the first time since its introduction three and a half years earlier.

The third and fourth ways of restricting care are closely related – patients might be denied treatment based on the nature of that treatment, or they might be selected for treatment based on their own characteristics (for example their BMI or smoking status). In reality, very few treatments are denied to all patients.

A third of CCGs have policies in place to stop overweight patients or smokers receiving routine surgery

However, clinical commissioning groups often develop policies outlining who can receive particular treatments, or clinicians also take their own judgements about when to prescribe or refer that can result in selection or denial. A recent report from the Royal College of Surgeons reported that a third of CCGs have policies in place to stop overweight patients or smokers receiving routine surgery.

The question as to whether these sorts of policies are financially or clinically motivated are a cause of debate.

The fifth approach is deterrence. Either consciously or unconsciously the NHS can reduce the number of patients who use its services by making it difficult for them to find out about them or book appointments.

In these cases patients may never realise that their access to services has been affected, because they may never know that the service existed in the first place. One example of this is diabetes care.

Unprecedented challenge

The national diabetes audit found that in 2014-15 only around one in three newly diagnosed type 1 diabetics were offered a structured education programme, which is a National Institute for Health and Care Excellence recommended tool to help patients manage their condition more effectively.

The final approach is when the quality of care patients receive is diluted because resources are spread more thinly. Staff costs make up the majority of the NHS’ operational budget, so when budgets are tight, reductions in staff numbers are one of the main ways the NHS can save money.

When budgets are tight, reductions in staff numbers are one of the main ways the NHS can save money

There are some areas of the NHS where staff shortages and increased patient demand are diluting the quality of services patients receive. One example is district nursing, where staff numbers have fallen sharply in recent years – some estimates say by almost a third.

The impact of these pressures can be seen in the results from a survey of district and community nurses conducted by the Royal College of Nursing in 2013, which found that the vast majority felt their workload was too heavy and three in four said that necessary activities were left undone because of a lack of time.

The current financial challenge in the NHS is unprecedented in its scale. Understanding whether and how financial pressures can affect patients is key to minimising their negative impact.

To understand more about these issues, The King’s Fund is conducting a piece of indepth research looking at the impact of financial pressures in district nursing, genito-urinary medicine (GUM) clinics, elective hip operations and neonatal care. If you would like to know more about the project or if you work in or use one of these services and would like to tell us about your experience, you can find more information on the King’s Fund website.

Ruth Robertson is a fellow in health policy at The King’s Fund