An inevitable consequence of underfunding of the NHS is that some element of rationing creeps into the services offered by the organisation.
In general, it has been recognised that overall decisions for the NHS to fund a treatment or procedure should be based on clinical and cost-effectiveness, with additional patient-specific factors then taken into account. Underfunding is changing this situation; as NHS organisations struggle to fund services they are increasingly seeking to reduce their spend by rationing services.
Rationing can be on two levels: an NHS organisation can simply refuse to pay for a treatment or procedure or it could introduce or change the eligibility criteria for a procedure thereby reducing the number of patients eligible to receive the service. There is considerable evidence that both types of rationing are taking place in the NHS and over the last two years it has been getting more severe and more widespread.
Rationing by CCGs widespread
In April 2015, a survey by the Health Services Journal (HSJ) found that almost two in five of England’s 211 clinical commissioning groups (CCGs) were considering imposing new limits in 2015/2016 on eligibility for services such as IVF, footcare and hip and knee replacements. In particular, people who smoke and those who are obese will be among those denied surgery and other treatment.
A survey by Pulse in July 2015 found that more than a third (36%) of GPs say they are facing new constraints on services to which they were previously able to refer. The constraints have been put in place by CCGs that are in deficit or that are heading for deficit. The Pulse investigation found that 19 CCGs were already in deficit and that NHS England requires them to eliminate this deficit. By September 2015, the HSJ found that nearly a third of clinical commissioning groups had actually implemented or were considering restrictions to services in 2015/2016.
The restrictions that CCGs either plan to or have already put in place are a mixture of restrictions and eligibility criteria changes. For example, NHS North East Essex is to restrict several services, including vasectomy, female sterilisation, spinal physiotherapy and impose threshold conditions on the basis of smoking and weight for patients before some elective procedures can be carried out. North Staffordshire CCG is no longer routinely providing hearing aids to patients with mild hearing loss.
In September 2015, HSJ reported that all CCGs across Nottinghamshire, except Bassetlaw, had agreed to a joint commissioning policy that included a list of treatments, including surgery for sleep apnoea and hysterectomy for heavy menstrual bleeding, which “can only be paid for by the local NHS in certain restricted circumstances”.
In March 2016 a group of CCGs in the Midlands outlined proposals for restrictions to services: the CCGs are facing a deficit of £25 million, which they need to reduce. The proposals include restricting access to knee and hip operations, no longer providing hearing aids for people with mild hearing loss, and restricting access to some treatments “for patients who have unhealthy lifestyles”. Other targets for restrictions include IVF treatment, a number of cosmetic procedures, and post-surgery physiotherapy.
Mental health services rationed
A form of rationing is also prevalent in mental health services. A report from the CentreForum released in April 2016 showed that mental healthcare providers refuse to treat an average of 23% of the under-18s referred to them by concerned parents, GPs, teachers and others. Among the reasons reported for turning under-18s away included the child or young person not being unwell for a long enough period of time or their condition not yet being serious enough – in other words eligibility criteria are in place.
Rationing is also seen in hospitals – in March 2016 Cambridge University Hospitals Foundation Trust temporarily restricted access to its outpatient cardiology service for out of area referrals, due to its waiting list for routine cardiology outpatients rising by 50 patients a week and staff shortages. The Trust did not consider the waiting list levels as safe.
Concerns over rationing
The imposition of conditions on patients who smoke or who are obese has been a common theme of the changes CCGs have implemented to reduce costs. CCGs have also reported that many of the restrictions have been on procedures that are of limited clinical value, however this has been questioned by other organisations.
The restrictions on hearing aids, a move reported to have been considered by around 22 CCGs, has been condemned by charities, such as Action on Hearing Loss, as they note that access to hearing aids helps combat dementia, depression and social isolation among the hard of hearing. In June 2015 GP Online reported that GP leaders were concerned about NHS England’s restrictions on referrals of obese patients for bariatric surgery.
In April 2016 the Royal College of Surgeons revealed that it had written to six CCGs to criticise proposals to restrict referrals for several surgical procedures. The CCGs in Birmingham plan to place thresholds on referrals for several procedures, including hip and knee replacement and hernia operations as well as back pain treatment. In the letter the RCS urged the CCGs to reconsider their policies, warning that such a restriction on surgical referrals would “act as a barrier to patients receiving necessary clinical treatment”. Furthermore, the letter noted that: “some policies are presented as if they are supported by clinically-evidenced guidance but in fact contravene this guidance.”.
In April 2016 after an inquest into the death of baby, a senior coroner warned that there will be more deaths if the NHS continues to make decisions for delivery based on cost: funding pressures are forcing maternity wards to favour natural births over more costly caesareans, risking the lives of some mothers and babies.
Rationing in other ways
Rationing of services is often not as overt as the situation outlined at the CCGs with lists of restricted services and eligibility criteria. Rationing could be due to simply not having the staff to carry out a procedure or treatment or the service not existing any more due to cuts.
Then there is the least transparent rationing of all, the employment of referral management centres by CCGs. Referral management centres are involved at a number of levels: they can deal with all GP referrals and conduct clinical triage that may redirect or reject referrals or deal with just one speciality or condition; or they could just give clinical guidelines that are intended to influence GP referral behaviour. They are employed by several CCGs, including Kernow, Brighton & Hove and Milton Keynes. It is hard to determine just how much rationing is being exerted by these centres, however.