The Nuffield Trust survey of health leaders – fails to ask the “ideology” questions and feel “managed decline” is inevitable

The Nuffield Trust survey of health leaders – fails to ask the “ideology” questions but feel “managed decline” is inevitable. There are no questions on “regional differences ” in philosophy and outcomes either

Since July 2014, the Nuffield Trust has regularly surveyed a panel of 100 health and social care leaders in England for their views on a range of issues including: finance, general practice and rationing.

Below we present the views of 100 health and care leaders on the pressures facing the NHS and social care ahead of the Comprehensive Spending Review.

Survey five: the state of the NHS and social care ahead of the Comprehensive Spending Review

An example is Q 11:

Q11. In April, former NHS Chief Executive David Nicholson expressed concern that financial pressures could mean “managed decline” for the NHS, for example patients waiting longer for treatment, new drugs not being made available straight away and it becoming more difficult to see a GP. To what extent do you agree with this view?

Managed Decline

More than four fifths (82.7%) of respondents agreed with Sir David’s view, with just 10.6% disagreeing. Those that agreed with the statement were asked to comment on which services or areas were at risk in their locality. Some respondents simply said all services were at risk. Of those that did specify, one of the most frequently mentioned examples was access to elective services, with many panellists highlighting concerns either over lengthening waiting times or raised thresholds for access to drugs or treatment.

One acute trust panellist said: “Waiting times for elective procedures are already lengthening according to ad hoc clinical prioritisation”, and another highlighted “access for elective care restricted by new filters (BMI [body mass index] etc.)”. A social care representative said there was an “increase in waiting times or raising of threshold for access to treatment in other areas, [and] more sophisticated rationing techniques – formal and informal – being used.”

Panellists also highlighted pressures on primary care, with many drawing a direct line between financial pressures and recruitment issues in general practice. One clinical commissioning group panellist said:

“There is a shortage of GPs and GP access is being affected”.


A social care representative said that GP services were at risk in their area “due to recruitment problems”. Other examples of managed decline mentioned included service reconfiguration, pressures on mental and community health services, and a reduction in coverage of specialist services.

Some panellists took the opportunity to comment more broadly on the policy implications of financial pressures. One respondent said:

“We are back to the bad old days of Thatcher and Major when waiting lists were up to two years, with deteriorating patient experience and quality.


An acute trust manager said that the ‘managed decline’ was “starting to happen in exactly the way Sir David predicted”, saying that the ‘Monitor letter’ “almost went as far as instructing us to do it” (referring to a letter sent by Monitor’s chief executive David Bennett asking trusts to revisit their financial plans due to ‘unaffordable’ financial forecasts).


This entry was posted in A Personal View, Rationing, Stories in the Media on by .

About Roger Burns - retired GP

I am a retired GP and medical educator. I have supported patient participation throughout my career, and my practice, St Thomas; Surgery, has had a longstanding and active Patient Participation Group (PPG). I support the idea of Community Health Councils, although I feel they should be funded at arms length from government. I have taught GP trainees for 30 years, and been a Programme Director for GP training in Pembrokeshire 20 years. I served on the Pembrokeshire LHG and LHB for a total of 10 years. I completed an MBA in 1996, and I along with most others, never had an exit interview from any job in the NHS! I completed an MBA in 1996, and was a runner up for the Adam Smith prize for economy and efficiency in government in that year. This was owing to a suggestion (St Thomas' Mutual) that practices had incentives for saving by being allowed to buy rationed out services in the following year.

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