The director of the Nuffield Trust explains why it is crucial that all aspects of frontline care are carefully scrutinised
Forget the bill. The biggest issue facing the NHS is the longest budget squeeze in its history, penned in to last until at least 2015. Unless the service can do more with less, the pips will squeak.
Cutting back on managers and red tape was first. Freezing pay of staff and cutting prices paid to hospitals for treatments was next. But these won't be enough. A hard look will have to be taken at all aspects of frontline care. Could costly admissions to hospital be prevented? If so, should some hospitals close? Could more services be delivered digitally? Could nurses substitute for doctors in some areas of care? Taken together, these and other such changes could deliver the savings needed.
The good news is that in a service as large as the NHS there are plenty of efficiencies to be made. And the £20bn budget challenge will prompt innovation. But the question is, can the service move fast enough to stave off more unpalatable responses to austerity?
Suggestions will come thick and fast: charge people to see their GP; give NHS patients details of how much their care has cost (debated last week in parliament); encourage people to take up private insurance; deny treatments such as IVF to women over a certain age, cosmetic surgery or bypass surgery for smokers. Letting waiting lists grow is no longer an option, as the 18-week waiting promise is enshrined in the NHS constitution.
Denying specific treatments is, in fact, a reality in every health system in the world. While the NHS offers a comprehensive service, not everyone can have everything, and priorities are already made locally up and down the land. Although relatively few services or treatments are "rationed" in this way, pressure on funds could force more, as we have seen with the new restrictions in some places on hernia operations, vasectomies and diagnostic scans.
If the bill is passed, groups of GP practices will be making these decisions. Dislike of a postcode lottery in care is strong among the public, who think what is available in Southampton should be available in Sunderland. Unsurprisingly then, professional and patient groups have started to get vocal. The prospect of setting out explicitly and nationally what is and isn't available on the NHS may become more attractive, as discussions on the ConservativeHome website have recently shown. It would be a wrong step.
Drawing up such a list on any rational basis would be impossible and unfeasible, due to a lack of information about the costs and benefits of services. Thus, applying it rigidly would be inappropriate. Those needing off-list treatments would have to pay out of their own pocket or insure themselves – hardly an equitable solution. Most countries who have flirted with this idea have backed off.
More fundamentally, should we be considering this when efficiencies can still be made? We could do better, but without such a list. The National Institute for Health and Clinical Excellence (NICE) has made a good fist of giving guidance on which drugs are cost-effective. This principle could be extended to a wider range of existing, as well as new services, building on NICE's list of "do not do" recommendations (examples include screenings of low-risk populations and the prescription of antibiotics for children with gastroenteritis). This should also be backed up by scrutiny of variations in treatment rates, which essentially go unchallenged.
This will take time. Some believe the pips will squeak loudly enough for George Osborne to write a big fat cheque for the NHS just before the next election. But even if he does, the relief is likely to be temporary. There is no option but radical change. The Guardian
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