Policy Pulse 24: Can you still get that on the NHS?
The story of how the NHS has reduced its offer to patients
Hello, and welcome to your weekly pulse of public policy. This week, I’m back on my old stomping ground of health policy.
There are several things about the NHS I’ve always been curious to see researched. One is the amount of voluntary sector money sloshing around the system. The NHS in England doesn’t allow charities to subsidise its services, but that’s only ever narrowly defined: charities may not add to the NHS’s commissioning budgets (under the purchaser-provider split that is currently being dismantled). In practice, lots of condition-focused charities have agreements with hospitals and other service providers to fund posts relating to the aspect of health they work in, and these staff members operate as an integral part of the NHS team. If they were suddenly to vanish, an awful lot of patients would lose vital and often specialist support. The new legal framework for the NHS might potentially disrupt some of these arrangements, although as it’s putting providers more in the driving seat it will probably be less disruptive to locally-evolved ways of working than the Lansley reforms were. Add in charities’ funding of equipment, from walking sticks to scanners, plus their heavy investment in biomedical research which the NHS participates heavily in, and the extent of charitable subsidy to the NHS must in fact be very substantial. And that’s leaving aside the indirect subsidy provided by many local charity-funded workers who ease the burden on the NHS by providing support to people, and helping to maintain their wellbeing, over and above formal NHS service provision. A research project into the role of charities in the NHS is currently underway, although its scope appears to be limited to charities that are in some form “NHS charities” and not to cover the contribution of independent, condition-specific charities. So the true extent of charitable subsidy to the NHS appears likely to remain obscure for some time to come.
But today I want to cover something else that I would like to see investigated, which is the extent to which the range of treatments available on the NHS has been cut since 2010. This could be considered in relative terms: there is a live debate about whether the NHS can afford to keep up with new medicines as they come on the market, with some muttering that the treatments available to patients in England are less modern and comprehensive than in other developed nations (though I say “muttering” as it often comes from pharmaceutical companies with an obvious interest at stake, and I can’t readily identify an authoritative exploration of it – links gratefully received in the comments). But it can also be considered in absolute terms: how many treatments were available on the NHS ten or more years ago that patients can no longer access?
Even within this, there is much complexity. Under current plans to scrap free prescriptions for people aged 60 to 64, some people will not access treatments that they otherwise would have done, although they will still in principle be available on the NHS. And of course there is rationing, with the NHS restricting access more and more tightly as it has found itself more and more tight for cash during the longest funding squeeze in its history. A major driver of rationing is the need for individual NHS organisations to balance their books, meaning decisions get made locally, and there is a postcode lottery in access: the tighter the NHS’s finances get, the more pronounced this variation is likely to become.
These decisions play out in a variety of ways, as can be seen from a few examples:
- For IVF, the number of cycles available per person can be tightened, or policies can be introduced to bar people with children from previous relationships from access
- Cataract operations are perhaps the classic example of treatment that quickly gets rationed when money is tight, for instance by introducing tighter and tighter criteria, regardless of recommended good practice, or only making treatment for one eye available (yes, really)
- Fertility preservation treatment for breast cancer patients can be subject to restricted access, or policies on whether eggs or embryos may be frozen
- Rationing can be done by stealth, for instance by applying weight bars to joint replacement surgery, requiring people to lose weight even though this is clinically spurious
- Rationing can also be done by simply not meeting legal requirements, and relying on patients not being able to enforce them, including not having the wherewithal to take the NHS to judicial review (and individually sorting out the small number of cases where that is threatened) – its increasingly poor implementation of NHS Continuing Healthcare, to provide care for seriously ill people in their own homes as well as funding nursing home placements, illustrates this approach
Pre-pandemic, rationing was already being raised as a concern by health charities.
However, that is at least well documented. And it doesn’t quite amount to the NHS not providing a service: it’s more a matter of poor access, although the cumulative effect has been to make much-needed treatment unavailable to many patients. But there are some treatments where the restriction is much more clear-cut than this: the NHS has decided to stop providing it, and has done so overtly on cost grounds (albeit often with some efforts to claim a clinical fig-leaf, which have fairly nakedly been afterthoughts). Again, complexity rules: this hasn’t amounted to making it impossible for doctors to prescribe these treatments and for them to be available on the NHS’s dime: but it does amount to a clear direction that this should not happen, either often or at all.
The thing that prompted me to write on this subject was this tweet, with the accompanying chart exported from the FT’s Our World In Data, showing the UK now spending nearly as much as the USA in out-of-pocket expenses on healthcare.
In fact, this was from an interesting but politically loaded thread, arguing that, “the situation for the Conservative Party is worse than you think.” My view is that the thread succeeds in showing why all sorts of situations are very bad for the United Kingdom and the people who live in it, but that it’s a leap from there to arguing that it is bad (presumably electorally) for the Conservative Party. No doubt Twitter would have been awash with similar threads in the mid-to-late 1980s if it had existed back then, but the Conservative Party’s position remained healthy for some time after that. Perhaps tellingly, I couldn’t easily recreate the same chart on Our World In Data, as I could only find the data in US dollars, not as a proportion of GDP; the USA’s much stronger GDP growth over the period accounts for much of the striking convergence of the lines. (The same data measured relative to real incomes might have been more illuminating.)
Even so, aggregate out-of-pocket spending has been going up in the UK, and the trend has been more pronounced since 2010. Almost certainly the rationing noted above, which has collided with growth in levels of patient need as the ‘baby boom’ demographic bulge has entered older age, accounts for the bulk of the acceleration. The data includes, as far as I can tell, both payment for things like over-the-counter medicines, and private healthcare treatment not funded by an insurer.
But I suspect the NHS’s drive to remove some treatments from the scope of its provision (in England, I must emphasise) has probably got a bit lost in all this. NHS England has run three strands of work, at least one of them still ongoing. These have been on “low value” medicines, over-the-counter medicines, and “evidence based interventions”. All three have followed a broadly similar rationale: they have used prescribing data to identify medicines or treatments where there is considerable variation, with some providers or practices prescribing them more than mainstream practice suggests is warranted. They have then issued guidance advising that these treatments should not be used routinely, or in the first instance. In a few cases they have been banned by adding them to an official medicines blacklist; in others, contractual changes have been made within the NHS.
The policy processes for introducing these changes, the first of which started in 2017, have tended to have certain characteristics. The measures have been promoted both as saving the NHS money, and as improving care for patients by placing less reliance on old-fashioned and sometimes less safe treatments, encouraging self-care, and in some cases encouraging shared decision making between patients and clinicians, to reduce the rush to more invasive treatment. The latter group of objectives are all very fair. However, metrics for success, although always vague, have always focused on the cash saving to the NHS and not on patient benefit. No assessment has been made of benefit to patients, or harm for that matter, of any of these initiatives (one has been commissioned for the first wave of restrictions for “evidence based interventions” but still not published despite two more waves of restrictions having been brought forward). Let’s briefly look at each initiative in turn.
First came the “low value” medicines guidance in 2017, which emerged in its final form as guidance on items which should not be routinely prescribed in primary care, listing 18 in total. Each was identified as having one or more of the following drawbacks: lack of robust evidence of clinical effectiveness, or even significant safety concerns; being less cost-effective than other products to treat the same condition, or a product that has seen considerable price inflation; being a low priority for NHS funding, even if effective. Homeopathy and herbal medicines were on the lists (readers will have their own views on those), as was co-proxamol, a painkiller with well documented safety concerns. But some inclusions were more contentious, such as liothyronine, a drug for some thyroid patients (for whom alternatives are unsuitable), that was on the list principally because of a market failure: it is a generic medicine, but with no competition among manufacturers the price paid by the NHS had skyrocketed. But barring patients from accessing it clearly shouldn’t be the answer, and campaign groups have been trying to reverse the decision ever since.
Interestingly, NHS England was alert to the contentious nature of the proposals, despite the relative success of their efforts to spin them as freeing up large amounts of cash for other things (and whether savings on any such scale have ever been achieved is very much open to question). When a second wave of restrictions was proposed on “low value” medicines, the terminology was changed and the initiative was framed as being about “low priority prescribing”. From this consultation, a further seven items were added to the list of items not to be routinely prescribed in 2019.
The second initiative related to over-the-counter (OTC) medicines. NHS England wasn’t without a point when it argued that issuing prescriptions, which other things being equal carry a charge of £9.35, for items like basic painkillers that can be bought over the counter for pence makes little sense. But what it ended up doing was restricting the prescribing of 37 items, not all of which cost mere pence: headlice treatment was on the list, the cost of which can soon mount up, at a fiver per bottle or more, potentially across multiple children in a family and on multiple occasions. Also on the list were treatments for many minor conditions, such as earwax removal (which has been contractually moved out of the group of core services that all GP practices must provide): while self-care may be effective a lot of the time, if it’s not the result can be deafness and balance issues; yet if you need earwax removal now, you will most likely either have to push hard to get a referral to an audiologist, or shell out £60 to £80, for something that makes a huge difference to your quality of life and was previously free on the NHS. Treatment for all sorts of other conditions, including hayfever, infrequent migraine and athlete’s foot are on the list: for some people, self-treatment and advice from a pharmacist will be fine, but for others it won’t be adequate, and the challenge of finding even the small amount of money needed will be hard to meet.
The third strand of work (“evidence based interventions”) has been similar to the “low value” medicines approach, but for operations and other treatments, rather than medicines. There were 17 interventions in the first wave, 31 in the second and a further 17 in the third (which has recently been consulted on, and the results not yet published). These “minor” interventions include haemorrhoid surgery, hysterectomy for heavy bleeding, removal of the adenoids for the treatment of glue ear, prostate-specific antigen (PSA) test, low back pain imaging, and tonsillectomy. The last of those is the only item on the EBIs list that I’ve ever needed: regular bouts of tonsillitis proved hugely disruptive to my schooling when I was little, and I shudder to think what another ten years of regular absences would have done to my education. In England today, some children are finding out the hard way.
In fairness, the third wave of EBIs has been a bit different. As well as identifying treatments that are performed unusually commonly by some providers, it has followed the same logic in the other direction and identified treatments that some places are not performing enough. Its recommendations are therefore to increase the use of, for example, bariatric surgery. It is at least possible to take this push as being advanced somewhat more in good faith, as it clearly delivers on its professed rationale about patient benefit, instead of just being aimed at cash savings like all the others were in practice.
That said, whether the NHS has actually realised any meaningful cash savings from all this is currently unknown, and doubtless clouded anyway in recent years by the impact of the pandemic on both the NHS’s activity and care-seeking behaviour by patients. Unfortunately it does seem likely that when patients encounter barriers to obtaining care, whether as a result of these restrictions or because of the rationing described earlier, they are likely to pay privately if they can, and simply suffer the consequences for their health if they cannot – exactly the situation that having a National Health Service is supposed to prevent.