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Tuesday 19 September 2017

Your stories – managing care in the age of austerity

By Craig Ryan

As part of our NHS funding campaign, we're asking MiP members to talk about their personal experiences of managing NHS services under financial pressure.

We all know the figures. The NHS is treating more patients than ever before – emergency admissions, outpatient appointments, elective admissions, GP contacts and prescriptions are all at record levels, following steep rises over the last ten years. At the same time, the money has dried up. The NHS is experiencing unprecedented austerity, with funding set to grow by an average 1% per year for the whole of this decade – way below the near 4% the service had been used to since it was founded in 1948.

"We believe the NHS needs more money. We make no bones about that," says MiP chief executive Jon Restell. "That doesn't mean the NHS should stop making itself more efficient, or stop reforming itself. But it does mean that politicians need to take the decision to devote a bigger slice of our national resources to healthcare."

MiP has called for the government to raise healthcare spending over the course of this parliament to the same level as France and Germany – around 11% of GDP. This year, that would have given us around £23bn more to invest in transforming services and providing better care for patients.

Let's talk about people

But to win the argument for better NHS funding we need to talk about people, not just statistics. We need to talk about patients and the services they rely on, and about the NHS staff who do their best to deliver quality care however tough it gets.

That's why, in the next few months, MiP will be talking to managers across the UK about how funding cuts and rising demand are affecting the services they provide for patients. We want to hear your personal stories (in complete confidence, of course) about what it's like managing services under financial pressure and how you would use a bit more money to improve patient care.

Are you critically short of staff? Are treatments being withdrawn or restricted? Are staff so overworked the quality of patient care is at risk? Are cuts to social care blocking beds and using up precious NHS resources? Are clinics being closed or having their opening hours restricted? If so, we want to hear about it.

To kick things off we spoke to two groups of managers working in services under severe financial pressure: community nursing and mental health (see below). They told us how staff shortages and inflexible funding arrangements have led to treatments being restricted, staff spending less time with patients and transformation plans being put on the back burner. In the coming months, we hope to publish many more stories like these in Healthcare Manager and on the MiP website.

How the funding squeeze hits patient services

Faced with funding pressures, NHS organisations have three choices: overspend, improve productivity, or cut services. Regulators will not tolerate persistent overspends and, as the NHS is already one of the most efficient health services in the world, there's only so much juice you can squeeze out of the productivity lemon. The longer the financial squeeze continues, the more the burden will fall on patient services.

In its report Understanding Financial Pressures in the NHS, published earlier this year, the King's Fund identified six ways in which funding pressures can hit patient care:

  • Deflection: one part of the system shifts responsibility to another part. For example: medically-fit patients detained in hospital while awaiting a care package from social services.
  • Delays: patients wait longer for treatment or diagnosis – the traditional NHS response to funding pressures. For example: unacceptably long waiting times for neurology and cataract surgery.    
  • Denial: patients are denied certain treatments because CCGs won't fund them or providers don't think they're worthwhile. For example: a range of NICE-approved mental health therapies are not available to patients in some areas (see below).
  • Selection: treatments are denied to specific groups of patients who don't meet certain criteria. For example: restricting IVF treatment to women under a certain age.
  • Deterrence: barriers are put up – deliberately or inadvertently – that make it harder for patients to access services. For example: reducing the availability of GP appointments or making it harder to book them.
  • Dilution: the quality of the service provided to patients is reduced, whether planned or not. For example: community nurses and social workers spending less time with each patient (see box above).

Waiting times can be measured, and policies on denying treatment or selecting patients usually attract publicity. But it's hard to get a handle on how cuts have affected the quality of services or the impact on patients of deterrence or deflection. There is also a dearth of research on the performance of community and mental health services, where outcomes are harder to measure, and the emphasis on prevention and early intervention means less measurable activity can actually be a mark of success.

Why we need your stories

Despite seven years of austerity, we still know remarkably little about how the funding squeeze is affecting patient care. In today's fragmented NHS, funding pressures interact in a wickedly complex way with changes in demand and still-evolving reforms, making it difficult to predict which services will be worst hit or when the cuts will bite.

Official figures shows average waiting times have reached alarmingly high levels for neurosurgery, cataract removal, trauma and orthopaedics, plastic surgery and ear nose and throat procedures. Research by the King's Fund identifies particularly severe pressures on district nursing services, where referral criteria have been tightened and visiting times reduced, and Genital-Urinary Medicine (GUM), where sexual health clinics have been closed and advice and prevention services cut back. Everyone knows about the financial pressure on social care, but there's very little hard data on how it has affected the NHS services on the ground.

This is why your personal accounts are so important. MiP members are uniquely well placed to tell the story of what's happening on the NHS frontline. As managers, you understand where the financial pressures are, you see the impact on a wide range of staff across the whole organisation and you have the ultimate responsibility for providing patient care. With your help, we can build up a clear picture of how the funding squeeze is affecting patient care, and make a far stronger case for investing more money in our NHS.

Scares in the community

Community nursing services face a triple whammy of funding cuts, rising demand and policy pressure, making them particularly vulnerable in the current climate.

"We're seeing a steady rise in patient acuity – more older people with multiple conditions, but more pressure not to admit to hospital," says Jane, a manager working for a trust in a largely-rural part of England. "Caseloads are ridiculous sometimes. We can't cope with any more workload, but we know the need's going to keep on going up."

The impact is is obvious to patients or anyone working in the service, Jane explains, but isn't necessarily picked up in statistics or inspection reports. "You just can't do patient-centred care on these kind of caseloads. Nurses can't spend time with patients when something's wrong or talk about how they feel. It's just about getting the tasks done – giving them the medication, changing the dressing, then getting back in the car. That's not patient centred. It upsets a lot of people that they can't do their jobs properly.

"More and more we're limited to serving people who are housebound," she adds. "We can't respond to patients outside their allotted appointments. We can't help them manage their own care. But I think the worst thing is patients want to talk and [the nurses] have to say, ‘Sorry, I've got to go.' That's heartbreaking."

Jane says her working days are dominated by staffing problems – pushing important work like staff development, redesigning services and implementing new care models to the margins.

"As managers, we spend most of our time juggling staff, plugging holes, on recruitment and finding agency people and so on," she explains. Around 20% of nursing posts are vacant at the moment, she says, and the service relies heavily on "pretty variable" agency staff. "We have to keep chopping and changing the people who go in," she says. "And the patients don't like it, especially the older ones. They want to see the same friendly face."

Jane's colleague Dan, a senior manager at the same trust, says teams are under constant pressure to take patients off the list. "As soon as we're starting to get on top of a problem we have to scale back the visits and then stop them altogether," he explains. "But the patients are still old and frail and they just don't understand why the nurses can't come anymore."

Dan takes particular exception to the block funding regime, under which community trusts receive a fixed sum for covering a particular area, regardless of the number of patients or the level of need. "The move from hospital to community has already happened. Demand is rising. And we're still on the same block funding as before. How's that supposed to work?" he says.

Reversion therapy

With funding failing to match rising demand for mental healthcare, ambitious plans to transform services and achieve "parity of esteem" with physical health risk coming to nothing.

"We have these very big plans for transformation – recovery-based care, early intervention, prevention, integration with social care and the like," says Philip, a manager at a mental health trust in southern England. "But we can't implement them properly without more money. We don't have the time, we don't have the management resource… It's as simple as that."

Philip says new government money for transforming mental health services hasn't yet appeared on the frontline, leaving managers and clinicians feeling they are "desperately running to stand still – but still feeling like they're slipping back".

He explains: "We've been cutting back on psych beds for years, but we're not really seeing referrals going down, and we're getting more detentions [under the Mental Health Act]. Our CRHT [crisis response at home team] have also been reduced, so we can't really respond urgently – people get a call back hours later rather than a visit, which is what they want and expect."

His colleague Sue, who leads a multidisciplinary community team, says many NHS-approved therapies just aren't available locally. "We can give people a consultant appointment if they can wait a few weeks, or we can give crisis support – but not always as quickly as we'd like. But there's nothing much in between. The ongoing care isn't always there.

"We had to scale back our early intervention [for psychosis] service, which was very successful, when it was integrated into the main team," Sue adds. "I think we're already seeing an increase in our caseload down the line from that. I can't prove it – but you can draw your own conclusions."

Despite rising workloads, mental health trusts have proved better than acute trusts at keeping their finances in the black, leading to some resentment about the renewed pressure they find themselves under.

"We've done our bit," says Philip. "We're more productive. We're trying to implement all these initiatives – and we know they're good, they're right. But you can't go on getting more efficient forever. You get to a point where it's just about cutting back – and not doing the job properly. We're at that point now, maybe beyond it."

The names of participants have been changed to protect their identity. Pictures do not show the actual people interviewed.

If you'd like to tell us your story, email funding@miphealth.org.uk and we'll get in touch.

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