It’s not only about money

NHS Funding

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.