Funding, the NHS and the challenge of setting service limits

Reflecting on his tenure as Minister of Health, Enoch Powell wrote in 1966 of the ‘political odium of being seen to reduce expenditure’ and the ‘continual deafening chorus of complaint which rises day and night from every part’ of the NHS. Since that time the upward trend in health spending has proved to be something of a permanent phenomenon: rising from £20.6 billion per year (3.4% of GDP) at the time of Powell’s writing, to £140.6 billion (7.4%) in 2015-16.

No doubt subsequent Ministers have also lamented the constant pressure to increase spending on health, and have perhaps grown resentful of, if not resistant to, appeals for more resources. This certainly appears to be the tone of recent statements from government and NHS senior management and - beyond the much-disputed £8 billion of additional funds promised over a five-year period - there has been little to suggest that NHS current spending caps will be relaxed.

Government acknowledges that this creates a funding gap and sees the solution to this as coming from greater efficiency in the system. However, few commentators believe this will be enough. The uncomfortable reality is that much has been attempted in the NHS – from devolvement to shifting care, from commissioning to competition, from innovation to integration – and so far nothing has made a substantial impact on the efficiency of the system.

Meanwhile, local services are suffering not just from recent spending constraint (including in social care and public health) but also medium and long term trends in workforce numbers (going down) and patient demand (going up). As a result, capital spending plans are being shelved, posts left vacant, and targets missed. Unsurprisingly Powell’s ‘deafening chorus’ is currently ear-popping.

Recent research completed at the University of Birmingham suggests that one response to these pressures has been an unprecedented increase in ‘decommissioning’, i.e. the planned removal, replacement and reduction of health care services. Although health care rationing is nothing new, formal and explicit limit-setting on a significant scale has remained rare and/or peripheral. This is apparently no longer the case, with NHS commissioners following their Local Government counterparts in embarking on programmes of service closure and reductions in treatment options.

However there are good reasons why decommissioning has been avoided in the past, both here and internationally. Firstly, it is of course an almost inherently unpopular activity and the range of bodies lined up in opposition to plans – from both inside and outside of the system – is invariably daunting. Our research confirms that even well-resourced programmes of change often falter in the face of resistance from clinical, organisational, community and policy interests. Secondly, the evidence base drawn upon to support the ‘case for change’ of decommissioning is often skewed towards the priorities of the system. In our research, citizens, patient/service user representatives, carers, third-sector organisations and local community groups expressed both outrage and loss, with many feeling that decommissioning decisions are made mainly for financial or political reasons rather than to improve patient experience. These not entirely unfounded fears in turn make budget holders anxious about consulting on their plans and reticent about building the relationships required to make decisions that have a chance of implementation.

There is no formula for making unpopular changes to health and care services and at the very least it should be considered a long-term pursuit, based on an understanding of local and national politics, and supported by thorough planning and engagement. Unfortunately, the experience to date suggests that those tackling decommissioning in the NHS lack the resources and support required to do so in a way which is deemed acceptable to patients and communities.

This is of particular concern at the current time as the NHS and its partners prepare to implement regional ‘transformation’ programmes with unclear processes of public consultation and prohibitive timescales. Worryingly, some basic questions about the plausibility of achieving these unprecedented levels of change to the NHS and Social Care landscape do not yet appear to have been addressed. Until they are, it is difficult to see how the ‘chorus of complaint’ will subside.

Iestyn Williams

Reader in Health Policy and Management, Health Services Management Centre