Has the budget squeeze in the NHS had an effect on NHS performance, beyond waiting times? In particular, has it reduced the quality of care? The King’s Fund has tried to answer this question with its report ‘Understanding NHS financial pressures’, published on March 14th. The study focused on hip replacement, neonatal care, district nursing and genito-urinary medicine. It concluded that acute services – hip replacement and neonatal care –have been relatively protected so far, whilst community-based services have experienced static or falling budgets, with probably knock-on negative effects on patient care.

The number of hip replacements is rising (although this trend may be plateauing or reversing) but waiting times have lengthened slightly. A small number of elective operations have been cancelled because of pressures on beds.

The quality of neonatal services is improving, even though these services have a long-standing difficulty with workforce recruitment and retention. There is no evidence of financial pressures having increased recently, but there are some capacity limits that cause patients to be moved to distant units.

There is little data on demand for district nursing services, and on their quality, but the Kings Fund notes growth in activity despite static or falling budgets, lengthening rotas, and long-standing difficulties in recruiting and retaining staff. Block contracts make district nursing vulnerable to budget squeezes.

Genitourinary medicine services are provided by local authorities and expenditure on them has fallen by 3.5% between 2014/15 and 2015/16 despite a one third increase in GUM clinic attendances. There are fears that the quality of care is being compromised.

What can we learn from this? The King’s Fund points out that a transition to a health service based in the community – as desired by Sustainability and Transformation Plans  and the 5 year Forward View – does not fit with the relative sparing of hospital services (if hip replacement and neonatal care are typical). This we can agree with. The report also points out how little we know about what the NHS does, and how little it collects data on the quality of care. Neither of these are new ideas, but we need reminding of them.

The Government may find comfort in these findings, which show that the NHS is resilient, that it can become more efficient (but only if squeezed firmly) and that the clamour around A&E waits and delayed hospital discharge is not typical of the whole health service. One reading of ‘Understanding NHS financial pressures’ is that things are not as bad as the Government’s opponents suggest; a conclusion that Teresa May needs to strengthen her reputation as a safe pair of hands for the NHS.

The right wing think tanks will be disappointed because they want the dominant narrative to be about how the NHS is failing, and how it should be replaced with an insurance based service. Critics of the Kings Fund will dismiss the report as Tory whitewash – a lazy judgement, the Kings Fund explores NHS policy whatever party is in office – and ignore its’ inconvenient evidence. Few will demonstrate outside GUM clinics threatened with shorter hours, and district nursing will remain invisible.

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  1. Mervyn Hyde says:

    So the solution to underfunding is to squeeze the NHS tighter and more bureaucracy?

    1. Steve Iliffe says:

      No, I don’t think that is what the Kings Fund report argues, but I may have misread it ; check it out at http://www.kingsfund.org.uk/publications/understanding-nhs-financial-pressures
      Jeremy Hunt may be pleased to have ammunition against catastrophists of left and right, because report does demonstrate the NHS’s ability (at least in some parts and up to now) to absorb shocks and increase productivity despite slower growth in overall budget. The KF report does point out the longstanding problems of staff recruitment and replacement, which predate the austerity policy. It is more concerned that expectations of great things developing in the community is unrealistic given the protection being given to core acute services – the NHS’s default operating procedure. On cue, most of the acute sector deficit is being paid off using the £800 million reserves held by CCGs. That is money that is not going to community services. The SHA might debate what steps a future Labour government would need to take to disrupt the default operating procedure.

  2. rotzeichen says:

    Steve thank you for your comment:

    I am some what depressed that we are so far down the road at present and all the so called studies are able to figure out is that the NHS is having difficulties and contort facts and figures around to the nth degree.

    These reports are meaningless, I simply carried out a freedom of information request asking about the costs of the outsourcing units and the total cost of the CCG. This was only for our locality here in Gloucestershire.

    The Commissioning support unit in it’s first year cost £6 million, that was to set up and all the consultancy fees etc., the actual cost of the unit was in the region of £4.5 million

    This overall cost was 9% of the total overheads of CCG, therefore the annual running costs will be in the region of £50 million plus inflation and normal increase factors.

    These are costs that the NHS had never previously incurred, it doesn’t take a rocket scientist to multiply theses costs up nationally to see what the marketization process has inflicted on the NHS, secondly that of course doesn’t take into account all the regulatory bodies and other administrative cost to service this madness.

    I could offer some real savings to the NHS by scrapping this madness and return all GPs pretending to run the NHS back into their surgeries doing the job they were trained to do and at a stroke increase the number of GPs available to their practices.

    The other small point is in addition to these imposed costs this government has taken £42 billion out the NHS budget, So called efficiency savings whilst at the same time transferring the burden of inefficient private sector providers back onto the NHS. We have had a nightmare with Arriva, 111 service, and now the out of hours debacle.

    Need I mention all those private clinics that dump their patients unexpected problems onto the NHS to sort out. Do we remember the breast implant fiasco?

    In a four year period there were 800 actual, (not statistical like in Mid Staffs), but actual unexpected deaths, from the private sector, due to under-manning and lack of specialist crash personnel. In other words the private sector operates on a shoe string in order to make profits.

    When are we going to look into that little bit of nonsense?

    It’s the market dear Watson, it’s the market that is destroying the NHS.

    1. Steve Iliffe says:

      It is sobering to think about how little progress has been made despite all the attempts to move towards a primary care based health service. But that makes it a good subject for debate within the Labour movement, should Labour want a grounded policy towards the NHS. The current push against the purchaser-provider split from within the NHS may free up clinician time as commissioning winds down, as you propose. Do GPs currently involved in NHS politics at this level really want to go back to the front line? Some seem to prefer the corridors of power, even though we have evidence that forward deployment of the most skilled leads to good clinical outcomes and lower costs. For me the test of GP commitment would be attempts to reclaim the out of hours services and run them as co-operatives.

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