More cash but yet more rationing

NHS funding has risen but PCTs are delaying operations to balance their books.

Billions of pounds have been poured into the NHS in recent years in an attempt to achieve European average levels of health spending.

The cash injection was expected to cut waiting times and transform the NHS into a consumer-focused service. Words like 'rationing' would be a faint echo from years past.

However, it now appears that so much money has gone into boosting capacity that there is little left to pay for using it.

Patients across England are being kept waiting for hospital treatment while consultants twiddle their thumbs, according to GPs and hospital doctors.

In the past, rationing of NHS treatment was forced on managers and clinicians by a lack of funding. NHS spending has more than doubled to £76.3 billion a year since 1997, but still rationing persists.

Financial problems

Academics and GPs believe there are two reasons for the current problems. The first is the statutory requirement for PCTs to balance their books at the end of a financial year.

Then there is the effect of the Payment by Results policy, which introduced set tariffs for each hospital procedure.

Professor Alan Maynard, professor of health economics at the University of York, said that Payment by Results incentivised hospitals to treat more patients which provided an opportunity to drive down waits.

However, he added: 'We introduced inflation into the system, but we have discovered we can't afford it. Managers are telling hospitals not to treat people in under five months.'

The rigid financial rules for PCTs also force managers to try to ration care.

'PCTs are looking to make savings around the margins,' said Professor Maynard. 'For managers these savings might save their job. You might say "what about next year", but they will worry about that then. The best analogy might be a drowning man clutching at straws.

'The health secretary says get into balance, and if you don't, you'll be sent to Siberia.'

Many PCTs are using referral management centres to intercept GP referrals to secondary care and control care. More than 100 centres exist across England, and the GPC believes at least half are behaving in a way that gives cause for concern.

Longer waits

A BMA report, published last week, shows that PCTs have written to GPs and hospitals ordering them not to treat patients faster than waiting time targets require. They have imposed short-term suspensions of routine referrals or barred specific non-urgent hospital treatments (GP, 3 March 2006).

Hillingdon and Bedfordshire PCTs and those in West Hertfordshire have told consultants that payments for operations will be withheld until the next financial year if patients are seen within 10 weeks. A hospital consultant told GP that as a result surgeons are sitting idle.

The BMA report on referral management centres quotes an anonymous doctor at Hammersmith Hospitals NHS Trust reporting that the PCT has redundant surgical capacity due to restrictions placed on referrals for financial reasons.

It has struck many as counter-intuitive for an NHS organisation to save money by not making use of surgeons whose time is paid for by the NHS.

GPC chairman Dr Hamish Meldrum said: 'It is mad that you have patients who require surgery and you also have the resources to do it, but managers are putting in artificial delays.'

He accepted that budgeting was necessary, but pointed out that patients would need to be seen and paid for eventually.

Cost-effective treatment

'A patient could need more expensive treatment six months down the line. They might also be unable to work,' said Dr Meldrum. 'It is inefficient to have surgeons sitting idle.'

NHS Alliance GMS contract lead Dr David Jenner said: 'In the big picture, there are consultants doing nothing and patients getting worse. 'The thinking is not about NHS UK. PCTs have a different budget stream and for them it's all about their financial balance.'

An NHS Alliance survey found that 30 per cent of managers and GPs said hospitals were 'gaming' or manipulating the Payment by Results system and, in some cases, refusing to hand over money owed to community care to boost their income unfairly.

A further 50 per cent of respondents suspected hospitals of gaming (GP, 3 March 2006).

A DoH spokesman said referral management centres had nothing do with rationing care and that decisions were based on 'clinical needs'.

But Professor Maynard said: 'From 2008 funding growth will drop and decisions will get tougher.'

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