Financial crisis adds to health providers' woes

When a group of clinicians in the west of England was faced by a deepening financial hole, they decided on a radical course of action to balance the books.

Smokers or overweight patients were to be barred from undergoing routine surgery unless or until they had tackled their problems through weight management regimes and smoking cessation programmes.

One of the GP leaders involved, David Jenner, recently said that there would have been "queues" of other clinical commissioners waiting behind them to implement similarly stringent criteria, if the scheme had worked.

In fact, within days of the decision in December 2014, the clinicians, based in Devon, withdrew the blueprint after an outcry from patients and politicians.

Explaining what went wrong at a recent debate, organised by the Nuffield Trust and the Royal College of Surgeons, and chaired by the Financial Times, Dr Jenner said their fundamental mistake had been to tie the new measures too closely to the need to tackle funding problems, rather than making the case solely on the grounds that slimming or staying smoke-free would improve the outcomes of surgery.

Nor had they conducted sufficient public consultation before unveiling the proposals, he conceded.

However, he was in no doubt that, in a world of rising demand and diminishing resources, hard choices lay ahead.

Politicians would need "to grasp the nettle of whether they are going to take some decisions about the availability of resource". Dr Jenner suggested this might mean either raising taxes, "limiting what's on the NHS menu", or introducing co-payments, "or a combination of all three".

His comments cast a light on dilemmas confronting health systems all over Europe as they attempt to find efficiency savings.

The European Observatory on Health Systems and Policies, in a paper published last year, suggested the nature of policy makers' concerns about the sustainability of health systems had changed after the 2008 financial crisis.

At one time, ageing populations, expensive developments in technology and changing public expectations had been seen as the main reasons for the growth in health spending.

The real threat, however, had resulted from the financial, economic and sovereign debt crises that had shifted the focus of anxieties "from the future to the present; from worrying about how to pay for healthcare in 30 years, to how to pay for it in the next three months".

Not all European countries were affected by the crisis. The impact on budgets varied, with some - but by no means all - experiencing "substantial and sustained falls in public spending on health", says the Observatory.

While most reductions in spending per head were small, a handful of countries experienced "large or sustained" reductions, say the researchers, so that spending in 2012 was lower than it had been in 2007. Croatia, Greece, Ireland, Latvia and Portugal were in this category.

The academics' work underlines the differences in approach being taken by various countries, even as they struggle with essentially the same problems.

Among the ways in which countries sought to cope with fiscal pressures were cutting ministry of health budgets - a course followed by almost 20 countries, ranging from Bulgaria and Cyprus to France and the UK.

Other countries introduced or tightened controls on the rate at which public spending on health was increasing. They included Austria, Belgium, France, Portugal and Spain, according to the Observatory.

However, countries also deployed other strategies to try to sustain public spending on health. Croatia, France and Hungary introduced new taxes earmarked for health, for example.

Others, meanwhile, have focused on shifting care from hospitals to primary and community care settings, where it can be delivered more safely and efficiently.

Almost all the countries surveyed had made changes to coverage in response to the crisis.

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However, another common response was to reduce user charges or improve protection from them.

Mary Harney, a former Irish health minister who now chairs the European Steering Group on Sustainable Health, sponsored by AbbVie, a US pharmaceuticals company, argues healthcare expenditure is too often seen in a narrow context purely as an economic cost.

Health expenditure can, in fact, reduce other welfare costs, speed the return to work for patients, "and generally improve productivity", argues Ms Harney.

However, she is in no doubt about what is at stake unless more emphasis is placed on prevention, early intervention and a redesign of how healthcare is delivered.

"In the absence of radical change, care rationing may be inevitable," she warns

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