Our third poll was conducted between 24 November and 19 December 2014, via an online survey. In addition, a small number of responses were received in early January 2015 due to personnel changes amongst the panel.
In total, 80 of our 100 panellists responded. Of the 80 respondents, 35 are senior NHS managers, 25 are clinicians or clinical leaders, 12 are from local Healthwatch bodies and eight are from the social care sector. Of the health service managers and clinicians, 26 are from acute hospitals; 13 from CCGs; five from acute mental health providers; five from NHS ambulance trusts; six from NHS community trusts; and five from private or voluntary sector providers. The panel members are named on our website, but their individual responses to the survey are anonymised.
This survey is accompanied by a separate policy briefing, Rationing in the NHS, which explores in more detail some of the issues and themes raised in the survey. This briefing is the second in a series on the issues and challenges facing the political parties in the run-up to the General Election.
- 68% think people should get the same package of NHS services wherever they live
- Over half also think commissioners should be able to tailor decisions to local circumstances
- 48% think that budget considerations should not limit the services provided by the NHS
- But 53% disagree with the idea that the NHS should not limit access to services
- 7 in 10 say that the Cancer Drugs Fund should be wound up
- 14% say that obsolete or ineffective procedures are still taking place in their area
Question one: Are you aware of any clinically effective procedures/ medications/ devices available in the NHS elsewhere in England that are not available in your area?
Fewer than one in five respondents (19%) said they are aware of clinically effective interventions that are not available in their area, suggesting that, if rationing of effective services is taking place, it is having a limited impact at present. However, respondents identified some important services that are unavailable locally, including:
- mental health crisis teams
- National Institute for Health and Care Excellence (NICE)-approved psychological therapies
- specialised bariatric surgery
- more than two cycles of IVF
- specialist eating disorder services.
In some cases, for example specialist rectal surgery, provision has been centralised, but it is unclear from responses to the survey whether this is for clinical or cost reasons.
Question two: Are you aware of any obsolete or clinically ineffective procedures that are still being carried out routinely in your area?
Although a majority of respondents (61%) said they are not aware of obsolete or clinically ineffective procedures still occurring routinely in their area, 14% of panel members did report that obsolete and ineffective procedures are still taking place. Examples include:
- knee wash-outs
- cosmetic procedures such as pinning back ears, and breast enlargements and reductions that had been funded via individual funding requests.
Question three: Which factors do you think, at present, have the greatest impact on restricting access to clinically effective procedures/medications/devices?
The financial pressures facing the NHS are seen by respondents as having the greatest impact on restricting access to clinically effective care; 30 out of 79 rated financial pressures as the most significant.
Providers undertaking their own priority-setting is viewed as having the least impact, with 38 out of 79 respondents ranking this last. This could be because, at present, payment systems tend to reward providers for undertaking additional activity, rather than for remaining within a budget, which might weaken the incentives for providers to ration.
Question four: To what extent do you agree/disagree with the following statement: The NHS should limit access to health services in order to remain within the budget allocated to it by the government?
Views about this question are mixed, with 48% of respondents either disagreeing or strongly disagreeing, and 37% agreeing or strongly agreeing.
The additional comments provided by respondents illustrate the difficulty of the challenge. Several argue for provision to be based on need; others emphasise the role of priority-setting to control expenditure.
Question five: To what extent do you agree/disagree with the following statement: The NHS should not limit access to services - funding should be made available by the government to meet the cost of services that clinicians decide should be provided?
When the question was reversed, 33% of respondents said they agree or strongly agree that the NHS should not limit access to services, while 53% said they disagree. The lack of consensus revealed in the panel’s answers to these two questions illustrates the scale of the challenge faced by those who are tasked with setting policy about how the NHS should operate within its budget.
Once again, views are diverse and often passionately held. One respondent said:
“That is a ridiculous statement. It is practically impossible to separate demand from need. There is always more that clinicians can - and want - to do, which in every system in the world outstrips supply.”
But another suggested that separating the decisions made by patient-facing clinicians completely from judgements about how best to use available funding (as implied by the question) is preferable:
“Clinicians are not in the best position to decide - a decision to limit or differently manage public resources should be discussed and made at distance from the potential patient”
A third panellist’s response reflects the concerns of patients and taxpayers at large, rather than simply a health service perspective:
“I think we need a national debate over things that we now define as healthcare which are not illness, injury or life threatening, e.g. IVF”
Question six: There are a mix of national and local processes used to determine which treatments are funded by the NHS, including NICE appraisals and guidelines, commissioner priority setting and the Cancer Drugs Fund. Do you think this mixed approach is a) fair, and b) efficient?
Opinion is split on whether this system is fair, with just under half of respondents (43%) agreeing that the current approach is very fair or quite fair, but more than a third (37%) viewing it as quite unfair or very unfair.
Interestingly, when asked to consider the efficiency of the mixed approach, a greater proportion of respondents think it is inefficient, compared to those who think it is unfair. Exactly 50% view the approach as either quite or very inefficient. This contrasts with 32% who see it as quite or very efficient.
Question seven: Are you aware of any other rationing/priority-setting processes that you believe are better than those currently in use in the NHS? For example in other countries or public services.
Only one in five respondents (20%) said they know of an international approach that they believe is better than current NHS practice.
Respondents cited the US state of Oregon’s approach, which includes a public consultation exercise where members of the public are invited to rank procedures in importance, and the International Liaison Committee on Resuscitation (ILCOR)’s online public commenting process, which aims to provide transparent and rigorous treatment recommendations based on high-quality systematic evidence reviews.
Question eight: To what extent do you agree/disagree with the following statement: "Patients should be able to access the same package of NHS services regardless of where they live in England?"
A significant majority of respondents (68%) either agree or strongly agree that patients should be able to access the same package of NHS services regardless of where they live in England. More than a third (35%) strongly agree. Only 18% of respondents disagree or strongly disagree with this statement.
Question nine: To what extent do you agree/disagree with the following statement: “Local commissioners should be able to tailor decisions about which services and treatments should be available to local communities, even if this results in national variation”?
Even though this statement is at odds with the previous question, just over half of respondents (52%) either agree or strongly agree that local decision-making should be permitted, even if this results in variation. The proportion disagreeing or strongly disagreeing is 41%.
Once again, the juxtaposition of responses to this and the previous statement illustrates the difficulty of designing a coherent approach to rationing that can command widespread support. It also demonstrates that senior leaders working in the sector can feel just as conflicted about the local decision-making versus national consistency debate as politicians and members of the public.
Question ten: Which of the following statements most closely reflects your opinion about the Cancer Drugs Fund?
The majority of health leaders responding to our survey (70%) believe that the Cancer Drugs Fund should be wound up. Of those, 59% think that the responsibility for determining access to cancer drugs should be transferred to NICE, and 11% think the responsibility should be transferred to another body.
Only 7% of respondents support retaining the fund in its present form.
Criticism of the fund is harsh, with one respondent describing the drugs it pays for as: “all about hope and nothing to do with evidence”. Another described it as a: “political slush fund”.
A third respondent stated:
“I think we need a complete overhaul of how we make these decisions, as it feels confusing, and not fit for purpose”
On the basis of these responses, politicians should give serious thought to whether the fund is fit for purpose.
The health leaders’ responses to the questions regarding rationing in the NHS clearly illustrate the challenges inherent in rationing policy. A majority of respondents express support for both local and national decision-making processes, even where these would be at odds with each other. A minority of respondents view the current processes as fair and efficient, but even fewer think better approaches exist internationally, suggesting that current approaches to rationing may be seen as the best of a series of imperfect options.
The one area where respondents are able to reach a consensus is the over future of the Cancer Drugs Fund. The lack of support for this initiative among our panel members suggests serious questions should be asked about its appropriateness. It is noticeable that panel members, despite their sector expertise, experience many of the same dilemmas about how best to ration care that exist in the wider public debate about these issues, which again illustrates the difficulty of arriving at neat solutions to these problems.
Find out more about our General Election work.
We are also asking a series of survey tracker questions to assess whether there are shifts in the views of the health and social care leaders over time. These questions cover access to health and social care, any perceived changes in the quality of both health and social care, and the long-term viability of comprehensive, publicly funded healthcare. You can look at the trackers as they shift over time here.
Crump H and Thorlby R (2015) Health leaders' panel survey three: rationing health and social care. Nuffield Trust, 19 Feb 2015.