An inevitable consequence of underfunding of the NHS is that some element of rationing creeps into the services offered by the organisation. As NHS organisations struggle to fund services they are increasingly seeking to reduce their spend by rationing services. This presents itself in two forms: either NHS organisations refuse to pay for treatments or they change the eligibility criteria so less people are eligible to receive the service. Both these forms are have become more severe and widespread in the last few years.
Rationing by CCGs widespread
A report at the end of 2017 highlighted that 51% of CCGs are planning to extend eligibility criteria for treatments as part of their efforts to balance the books. In addition, 44% of CCGs said they were planning to place more limits on access to treatments such as IVF.
At the end of June 2018, NHS England announced plans to scrap four surgical procedures and a further 13 only to be commissioned when certain criteria was met. These surgeries include grommets for Glue Ear, trigger finger release, breast reduction and many more that are deemed to be ‘ineffective’ by NHS England.
IVF services are another service that have faced cuts due to rationing with only 1 in 10 areas offering the recommended three cycles of treatment. Pulse reports that NHS Croydon CCG, NHS Mid-Essex CCG, NHS North East Essex CCG, NHS South Norfolk CCG and NHS Basildon and Brentwood CCG are all no longer offering NHS-funded IVF treatment.
Hastings and Rother CCG and Eastbourne, Hailsham and Seaford CCG both have large deficits for 2018/19 and are struggling to agree on a budget. However, it is reported by HSJ that the two CCGs could make cuts of up to 5% to non-acute services (excluding primary care and mental health) that will impact community services.
NHS Herts Valleys and NHS East and North Hertfordshire CCGs are proposing to either reduce or scrap IVF treatment. They're also introducing requirements for smokers or obese patients to quit or lose weight before being referred for non-urgent surgery. The two CCGs are also proposing to stop funding for female sterilisation and vasectomies, except in exceptional circumstances, in a bid to save £265,600.
Mental health services rationed
NSPCC children’s charity warned that 150 children a day are being turned away from NHS mental health services, with more than 100,000 children referred to NHS child and adolescent mental health services (CAMHS) having their referrals rejected in the past 2 years. There are fears that this number may be even higher as 1 in 5 trusts refused to disclose the number of rejected referrals.
A Guardian article in January 2018 reported that mass closures of NHS walk-in clinics across the country. The closure of these services that treat minor injuries and ailments has increased the number of patients attending A&E and increasing pressures on the service.
Moreover, in Scotland there have been emergency closures to out-of-hours primary care emergency services. Primary Care Emergency Services at hospitals in Dunfermline, St Andrews and Glenrothes are now closed between midnight and 8am and this is expected to be extended to January 2019.
Weston-super-Mare hospital’s A&E service was reduced from a 24-hour service to closing between 10pm and 8am in June 2017 and there are no foreseeable plans to reopen it to a 24-hour service. Also, at the beginning of 2018, a children’s ward in a Lincolnshire hospital faced closure and all non-urgent children’s operations were cancelled due to staff shortages.
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.
Charity chiefs across the country have called for the NHS to stop rationing treatment for seriously ill patients. 30 health charities, including the Teenage Cancer Trust, National AIDS Trust and Motor Neurone Disease Association, have raised the alarm about NHS England “restricting and rationing treatment” because of underfunding, especially for patients with rare and complex conditions.
Doctors have also warned that rationing of treatments such as hip surgeries, cataract removals, and drugs such as those to treat arthritis are leaving patients in pain.
Doctors are also revealing that they are being prevented from prescribing the best and most appropriate drugs for treatments due to rationing from their CCGs. Breast Cancer Now charity revealed last year that some women were missing out on a potentially life-saving drug that costs 43p a day. Bisphosphonates cut the risk of cancer spreading to the bone, but many CCGs have blocked their use.
Diabetes UK claim that the NHS are putting lives at risk by rationing test strips that monitor blood glucose levels in an attempt to save money. If diabetes is not monitored and controlled properly, through the regular use of test strips such as these, then health complications such as heart disease, strokes, blindness and amputations could occur.
British Hernia Society claim that rationing is leaving patients waiting in pain for treatment. This has led increased risks of emergency surgery and even death.
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.
Referral management centres have also been employed by several CCGs. These deal with GP referrals and conduct clinical triage. They may redirect or reject referrals, or just deal with one speciality. They can also give clinical guidelines to influence GP referral behaviour. It is hard to determine how much rationing these cause, but it is a growing concern.