Ever since Sir David Nicholson put a timescale and a figure to the NHS's pressing need to make efficiency savings, funding constraints have been at the very top of the health service's agenda.
While ministers and civil servants may have been distracted by the politics of the health act and the bureaucratic minutiae of rebuilding the NHS from the ground up, PCTs, CCGs and practices have been desperately trying to work out what they can keep paying for.
The first part of Pulse's rationing survey, which we publish this week, sets out the alarming extent to which large parts of the NHS are now being forced to routinely ration care in a desperate bid to meet punishing cost-cutting targets.
Andrew Lansley may have flatly denied in July that rationing was on the rise, describing a Labour party dossier of treatment restrictions as ‘meaningless' – but coalface GPs tell a different story.
Most reported they had seen an increase in the rationing of care in their area over the past year. Examples include not only the usual suspects – bariatric surgery, cataracts, hips and knees – but also gallstone surgery, cognitive behavioural therapy and child mental health services, as well as more subtle methods of managing patient demand. It is not very surprising that patients are now routinely sent back to their GP if they miss hospital appointments, but much more so that one in three GPs believe hospitals are deliberately overemphasising the risks of surgery to avoid operating.
Such findings are deeply worrying for patients, politicians and the profession alike – but for the profession there is one particularly unwelcome twist. Increasingly, as the NHS does less, it is being left to GPs to explain why. A clear majority of GPs told us their relationship with patients has suffered as a direct result of rationing. In the absence of explanation from politicians or a central list of rationed treatments, GPs are being forced to play, as one put it, ‘the big, bad ogre'.
GPs have long been aware of their crucial gatekeeper role, and being able to say no to a patient is part of being a good doctor. But there can be little doubt the NHS reforms have upped the ante – and when GPs take on full commissioning responsibility and start receiving the quality premium next year, the blame game is only going to get worse.
Significantly, the leaked emails from senior BMA figures highlighting concerns about the NHS reforms, which we cover this week, centre largely on rationing. Even GPC chair Dr Laurence Buckman, the voice of moderation on talk of boycotting commissioning, warned ‘the public will blame GPs for the mess that will result from a shrinking health economy'.
Responsibility for rationing is the sharp end of GP commissioning, the point at which abstract political arguments over the merits of the NHS reforms elbow their way into
the GP consultation room. What we can pay for – and we can't – is going to remain at the very top of every GP's agenda for quite some time.
