It’s time to have a rational debate about NHS rationing

The NHS is broke. Those are the words that no politician dares utter in the hyperbolic fuelled days of a General Election campaign. Yet all the warning signs point to an increasing funding squeeze and an impending financial crunch.  So far throughout this election campaign the parties have looked to grandstand over who can put the most money on the table to invest in the health service. Yet just last week former NHS England Chief Executive Sir David Nicholson said that the £8bn being pledged by both the Conservatives and Lib Dems wasn’t a lavish investment but merely the minimum that was needed to keep the NHS standing still and plug a widening financial hole.

When examining the NHS finances, it’s clear the health service can’t afford to stand still. Last year’s reports show that the NHS overspent by £823m, despite the Treasury injecting an extra £900m into the system, and the deficit looks set to rise throughout the coming year. This doesn’t sound like an organisation able to cope with the status quo, let alone ready for the transformational change envisaged in the Five Year Forward View.

The case is clear for further investment in the health service but what is missing from the argument is how this money is spent. Like any other publicly funded service the NHS will only ever have a finite budget, varying in relation to overall government funds. And as demand increases, do we have the luxury of throwing more money at a free and universal health service? Unfortunately the evidence suggests we don’t.

Nowhere is this more pressing than in local budgets. In September last year Northern, Eastern and Western (NEW) Devon Clinical Commissioning Group (CCG) decided to restrict access for obese patients or smokers to certain routine surgery. The controversial decision was lambasted by many and following political pressure the CCG decided to reverse its decision.  Despite this figures released this week by the Health Service Journal’s CCG barometer, an annual survey of CCG leaders, showed that a third of CCGs would support the rationing of services. This interesting revelation doesn’t just highlight increasing financial pressures but also a recognition by CCGs that patients should bear some responsibility for their own health before placing extra pressures on NHS resources. This argument has been bubbling away under the surface for several years and has the support of several high profile clinicians, further illustrated in the number of CCGs that support the idea.

Rationing exists elsewhere in the health service, with CCGs having the autonomy to decide on how many cycles of IVF they will fund for patients, as well as requiring those patients to be non-smokers and within a certain BMI. This is sound medical logic that states the chances of conception are greatly increased when the patient, in particular the mother, doesn’t smoke and is of a healthy weight. There is an incentive for the patient to make positive lifestyle changes that will impact their chances of becoming a parent. Surely this logic can be extended to other parts of the health service.

If a smoker wants to have a hip replacement but the surgeon believes their smoking will impact on their chances of successful recovery, should this patient be given access to NHS resources without attempting to quit smoking when frontline services are being squeezed? The answer is no. Critics argue that this singles out certain groups of patients and questions the fundamental principles of a free and universal health service. No one is suggesting pulling the blanket from under certain demographics of patients and key services would always be available. However if the system is taken for granted then we will find ourselves delivering worse care to fewer patients. Restricting access isn’t a goal in itself but a growing financial reality that has the potential to incentivise the nation to better health.