Greater transparency is needed over which patient services are funded by the NHS ahead of reforms that will hand more power to local GPs

85 per cent of GPs predict that the financial challenge facing the NHS will eventually force the Government to set out more clearly what care is – and is not – freely available on the NHS in England.

This is according to a regionally representative survey of 821 English GPs carried out by Doctors.net.uk, the largest online professional network of doctors, and the Nuffield Trust, an independent health think tank.

Other key findings from the survey include that:

• Only half of GPs either believe that the NHS will be able to improve efficiency enough over the next five years to avoid having to scale back on the services that are currently funded; and

• The vast majority of GPs (83 per cent) believe handing responsibility to local clinical commissioning groups (CCGs) for setting priorities for spending NHS funds will be likely to lead to greater variations in what services are provided to patients throughout England.

The findings are released alongside a report published today by the Nuffield Trust, which examines the feasibility as well as advantages and disadvantages of setting out explicitly the care patients are entitled to.

The NHS is headed into a new era, with considerably constrained budgets and greater decision making by local clinicians which could result in more variation in the care that is provided to patients

Nuffield Trust Director of Policy, Dr Judith Smith

The report: Rationing health care: is it time to set out more clearly what is funded by the NHS? draws out learning for the NHS from countries that have sought to set out explicitly the health care benefits that are paid for by their publicly funded health system.

Recent political debates over the Secretary of State’s duty to promote ‘a comprehensive health service’ suggest there is considerable uncertainty in relation to how the NHS interprets national guidance at a local level, and therefore how much services reflect local need.

The Nuffield Trust report assesses in detail the advantages and disadvantages of the current system for determining which treatments are, and are not, funded by the NHS. Drawbacks include: a lack of transparency around how spending decisions are made and variations in funding decisions (the 'postcode lottery'), resulting in perceptions of unfairness.

But important benefits include local discretion and flexibility, in particular by clinical staff, to respond to the needs of patients. The report also examines international experience.

The report does not recommend the Government draws up an explicit account of what health care is or is not funded by the NHS. This is ruled out for three main reasons.

First it would not be practically feasible to do so given the cost and information requirements necessary to do it properly. Second, given the lack of information on which to base it on, its rigid application across a whole range of services for individuals would be inappropriate. Third, it risks unnecessarily compromising the principle of solidarity on which the NHS relies.

The main advantages are that it allows doctors to respond to the needs of individual patients and enables commissioners to set local priorities within a fixed budget. Disadvantages include a lack of transparency around how spending decisions are made, and a tendency towards variations in funding decisions (the 'postcode lottery'), resulting in perceptions of unfairness.

However it stops short of recommending the Government draws up an explicit account of what services would be funded by the NHS, concluding that an explicit account would be technically difficult and risks compromising the principle of solidarity on which the NHS relies.

Instead, the report makes several recommendations for how the system could be improved so that, among other things, perceptions of unfairness could be avoided. These include:

• Establishing a set of principles that would shape how public money is spent in the NHS and, conversely, inform decisions about what care and treatments will no longer be paid for. These principles could be enshrined in the NHS Constitution, and also restated in the annual Secretary of State for Health’s mandate to the NHS Commissioning Board (now NHS England) (and in turn to the new clinical commissioning groups). This would remind NHS commissioners of what should underpin their decision-making about which services to fund.

• Producing a national list of the treatments that public money should not be spent on in the NHS (unless there are exceptional circumstances). Local commissioning groups should be expected to report on instances where they have diverged from national guidance.

• Ensuring decisions in clinical commissioning groups are transparent, and where possible, clinicians are ‘nudged’ towards clinical and cost effective care, so that any proposed divergences from national guidelines and NHS commissioning principles would be subject to proper scrutiny before they are finalised.

Dr Judith Smith, Nuffield Trust Director of Policy said: ‘The NHS is headed into a new era, with considerably constrained budgets and greater decision making by local clinicians which could result in more variation in the care that is provided to patients.

‘The current system for defining what is in and out of the NHS ‘offer’ is far from ideal – many people believe it is opaque and that your postcode can determine whether or not you get access to certain treatments.

‘That’s why the NHS Commissioning Board should work closely with clinical commissioning groups to ensure they are not deviating from national guidelines about what to fund and what not to fund, unless there are good reasons for doing so, and that any decisions made locally are subject to proper public scrutiny.

‘As our survey with Doctors.net.uk shows, a failure to get this right could lead to greater calls for defining at a national level what is funded on the NHS and what is excluded, which we believe would have significant drawbacks in terms of limiting the autonomy of local clinicians to make decisions based on what is best for their communities.’

Commenting on the survey findings, Dr Tim Ringrose, Doctors.net.uk Chief Executive said: 'Health care inequality is already a divisive issue and the changes in funding, with clinicians making decisions locally, will only serve to create more of a patchwork quilt. Minimum standards set out in guidance at a national level, and engaging doctors and trusting them to act in the interests of their patients locally, seems the right balance to strike. In order to do that, the NHS Commissioning Board must start a fully reciprocal dialogue.'