An inevitable consequence of underfunding of the NHS is that some element of rationing creeps into the services that are offered. As NHS organisations struggle to fund services they are increasingly seeking to reduce their spend by rationing services.
Rationing 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 have become more severe and widespread in the last few years.
Rationing of physical treatments
Rationing of physical treatments has been ongoing for many years as the NHS has struggled under the Conservative government, with inadequate funding settlements.
A report at the end of 2017 highlighted that 51% of CCGs were 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.
In 2018, NHS England scrapped 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.
Despite opposition from the Royal College of Surgeons, NHS England pushed ahead with this rationing of treatments with plans in 2019/20 to stop 100,000 procedures a year to avoid spending £200m. GPs argued that such measures do not save money in the long-run and simply prevent patients from accessing necessary treatment.
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. The rationing of IVF services also significantly affects cancer patients. A report published in The Breast Journal in 2020, found that only 30% of CCGs surveyed offered cancer patients unrestricted access to fertility preservation treatments. This goes against recommendations from NICE.
In 2020, a Pulse investigation revealed that even before the pandemic, an increasing number of procedures were considered of low clinical value, and were being rationed by CCGs.
The investigation found that a year on since the 2018 changes were added to the 2019/20 NHS standard contract, the repercussions were being felt by both GPs and patients.
The guidance obliges GPs to argue why their patient should be considered for any of the 17 treatments – which include breast reduction, tonsillectomy, and haemorrhoid surgery. GPs have found that the ‘prior approval’ processes effectively see patients blocked from both treatments and consultant opinions.
Figures collated by Pulse’s investigation indicate increasing numbers of patients are being put through this process. Using data Pulse obtained through freedom of information (FOI) requests, it estimated that almost 17,000 referrals were rejected across 57 CCGs last year, compared with just under 9,000 in 2015.
By August 2022 the waiting list for an appointment with the NHS in England topped 7 million. As a result, referral rejections are likely to increase.
Rationing of mental health services
One major result of years and years of underfunding and increasing demand is that accessing mental health services is becoming harder and harder. The services are associated with long waiting times for appointments, particularly in the area of children and adolescent services. Waits of as long as 18 months have been reported. It has also been reported that the threshold for receiving treatment has increased, with people having to be suicidal before they are referred for treatment.
In April 2022, the official waiting list for mental health services stood at around 1.6 million people, but the NHS Confederation reports that there are also an estimated eight million people in England that are being denied access to mental health services because they do not have severe enough symptoms to get put onto a waiting list. This means there are now almost 10 million people in England struggling without adequate help and support from mental health services.
The 8 million figure is based on the known prevalence of mental health conditions and the thresholds dictating who gets access to treatment; NHS England considers it an accurate figure for the number of people who are missing out on care because services are not adequate.
As a result, the number of A&E attendances by young people with a recorded diagnosis of a psychiatric condition has almost tripled since 2010 and an increasing number of GPs are now advising parents to seek private mental health care for their children.
Rationing also takes the form of a short duration of treatment available on the NHS. Patients then feel that they need to go private to complete any therapy.
In 2017, NSPCC children’s charity warned that 150 children a day were 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.
In September 2022, research by Dr Agnes Ayton and 22 other psychiatrists found that in 2019/20, just 31% of eating disorder services accepted all patients, regardless of the level of illness. Adult eating disorder services are so severely underfunded and understaffed that they are having to employ rationing measures and turn away patients. The researchers warned that the situation had become more serious following the pandemic, which had driven a “worsening of the demand and capacity” crisis across the services.
Experts have called for emergency funding to meet the needs of adult patients with eating disorders, and say that these services should be receiving at least £7m per million population each year to meet standards.
The imposition of conditions on patients who smoke or who are obese has been a common theme of the changes that have implemented to reduce costs. Although, CCGs have reported that many of the restrictions have been on procedures that are of limited clinical value, this has been questioned by other organisations.
In 2017, charity chiefs across the country 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, raised the alarm about NHS England “restricting and rationing treatment” because of underfunding, especially for patients with rare and complex conditions.
Doctors 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. In 2019, the BMJ found that rationing of access to cataract surgery by CCGs across England was directly ignoring clinical guidelines. In fact, rationing of this surgery has increased in parts of the country against NICE guidelines published in 2017.
Doctors have also revealed that they are being prevented from prescribing the best and most appropriate drugs for treatments due to rationing. Breast Cancer Now charity revealed in 2016 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.
In 2017, Diabetes UK claimed 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.
In 2018, British Hernia Society claimed that rationing is leaving patients waiting in pain for treatment. This has led to increased risks of emergency surgery and even death.
In 2020, NHS protocol in response to the coronavirus pandemic stated cancer services should be rationed to patients with the highest chance of survival should hospitals become overwhelmed. They warned that immunotherapy treatments could be halved in frequency and long-term follow-ups postponed indefinitely.