Last Word


Hard to be optimistic

Rachel Power, chief executive of the Patients Association, warns that we must be realistic about the very real effects of continued underfunding across the health service.

It’s now beyond doubt or dispute, other than in government, that the NHS is inadequately funded. Even the secretary of state has argued that it will need more money in “the years ahead” – a phrase that allows him to stop just short of acknowledging the shortfall today. Whether the current underfunding will continue for years to come or a sensible settlement will be reached will be an important future political battleground. But in the meantime, we have a growing body of evidence to show us what an underfunded NHS – and also, importantly, social care system – means for patients.

Obviously the NHS isn’t going to vanish if the necessary funding is not made available. Instead, it will continue to provide a reduced service: it will cease offering some things it currently provides, and directly or indirectly oblige people to fall back on their own private resources when they can do so (or simply suffer if they cannot) in a growing range of circumstances. Waiting times will be longer, and experiences generally – and in hospitals in particular – poorer.

This deterioration in the NHS’s offer is emerging through a combination of local decisions made to balance books, and central policy drives. Locally, CCGs are finding savings by a variety of restrictions on provision. Bars on joint replacement surgery are being imposed, obliging patients to stop smoking or lose weight – neither clinically necessary for a good outcome. Access to IVF and cataract operations are also being targeted. Another common initiative is to cap the value of Continuing Healthcare packages, so that people with the highest needs must either leave their homes to enter residential care, or accept an inadequate package to avoid moving.

Centrally, NHS England is attempting to introduce savings in a more consistent and equitable way. The net effect of this is to draw a new boundary between what patients can expect from the NHS and what they need to fund themselves. So, its guidance on ‘low-value’ medicines is aimed at reducing the variation in spend between CCGs on some questionable drugs – at the non-negligible risk of trampling over patient preferences, and accidentally catching effective drugs up in the clear-out. Its next step is a bar on prescribing over-the-counter medicines in some circumstances, which we expect will leave GPs having to make eligibility decisions for which they are ill-equipped, making access to treatments more haphazard for some patients. Additionally, NICE-approved drugs that carry the greatest cost to the NHS may now be introduced more slowly, delaying their benefit to patients. NHS England has been frank about the inadequacy of the current funding envelope for maintaining services, including its blunt response to last November’s Budget – its openness about this is quite correct, but it doesn’t make the message any more welcome to patients.

The current winter pressures are widely understood: it was clear for a long time that anything other than a very mild winter would stretch hospitals intolerably, and so it has proved. With elective surgery now cancelled throughout January, rather than just its first half as originally planned, and with an extended moratorium into February not yet ruled out, it’s hard not to conclude that we have an NHS that struggles to function 10 months of the year and undergoes a partial collapse for the other two.

We know that vanguards have enjoyed some success in reducing demand for acute services, at least in relative terms – one vision of the future for the NHS entails the effective transformation of services to keep people as well as possible in their homes, thus avoiding traditional acute services becoming overloaded. But with so little money available to keep current services running, never mind ensure the transformation – and here the crisis in social care is absolutely vital – it’s hard to be optimistic about this scenario coming to pass. A future of widely variable services, with high hurdles to access them – and a real risk of people going without care entirely if they can’t clear those hurdles – seems at least as plausible.

Talk is swirling of initiatives to secure a longer-term settlement for health and social care – this needs to happen soon, as without a political commitment to appropriate spending levels, patients will inevitably get an increasingly raw deal. The Patients Association welcomes the calls for a cross-party initiative to secure the necessary long-term funding solution for the NHS and social care services.




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