The prime minister, David Cameron, his health secretary, Andrew Lansley, and the NHS's most senior figures have all stressed that the government's drive to make £20bn of efficiency savings in England by 2015 should not prompt hospitals and primary care trusts to cut services provided to patients. Instead, they say, the money should be saved through reducing bureaucracy, ending waste, adopting innovative ways of working and restructuring services.
Yet the growing evidence from the NHS is that its frontline is being cut, and that NHS organisations are doing what they were told not to do – interpreting efficiency savings as budget and service cuts. While restricting treatments of limited clinical value – such as operations to remove unsightly skin – is uncontroversial, reducing patients' access to drugs, district nurses, health visitors or forms of surgery they need to end their pain arouses huge concern.
This Guardian investigation details the latest evidence of increased cuts – the cuts that, according to the government, should not be happening – being implemented across a wide range of the NHS's many care services. With £20bn due to be saved by 2015, and the NHS receiving only a 0.1% budget increase each year until then, experts predict that tough decisions – about the availability of services and treatments, staffing levels and which clinics and hospitals provide care – will become increasingly common.
Pain treatment
Patients in serious pain are being denied the drugs they need to relieve their suffering and access to specialist clinics, according to the Patients Association.
"A pain management clinical nurse specialist told us recently that she had received complaints from five different patients in the space of a few weeks of GPs refusing to prescribe particular pain medications because they are too expensive, medication that they would have prescribed in the past," said Katherine Murphy, the association's chief executive.
A male patient told its helpline how, after being discharged from hospital following a hip replacement operation, he experienced major problems obtaining pain relief. When he asked his GP to refer him to a specialist pain clinic, he was told it would be several weeks before he would be seen.
"Another caller had been a long-term patient at a pain management clinic, funded by Lincolnshire PCT. But completely out of the blue she was told by the PCT that they would no longer treat her there because of changes to their policy," added Murphy. "And despite repeated requests another lady, who was suffering from fibromyalgia [serious musculoskeletal pain], remained unable to get referred to a pain relief clinic by her GP because of PCT policy."
Hospitals
Hospitals are bearing the brunt of the NHS's £20bn efficiency drive. Heatherwood and Wexham Park Hospitals trust in Berkshire, for example, is considering closing or reducing services at Heatherwood hospital in Ascot to reduce its £10m debt. That could see services such as surgery, orthopaedics, scanning and children's services cut or closed. It has already closed its birth centre owing to financial problems and staff absence. The trust, which has 3,500 staff and a £220m turnover, needed an £18m government loan last year to stay afloat.
The troubled Stafford hospital, subject of a continuing public inquiry into hundreds of patients' deaths because of poor care in 2004-07, is considering closing its A&E unit at night, and possibly at weekends. It is having such serious problems recruiting doctors to work in the unit, especially consultants, that partial closure may be necessary to ensure the safety of care.
"One short-term option until we resolve the recruitment issue could possibly be to continue to provide an A&E service except for out of hours. As always our first concern is to provide consistently safe care for our patients," said a trust spokeswoman.
The Care Quality Commission, the NHS regulator, last week issued Mid Staffordshire NHS trust with a formal warning over the lack of properly qualified and trained nurses it found on duty in A&E there during two recent spot checks.
The hospital is also planning to close beds and shed 541 staff, about 20% of the total, between now and 2015 because it expects moves to treat more patients in the community to result in a 17% drop in the number of patients it sees. Graham Shaw, the interim head of human resources, said the hospital had drawn up a money-saving clinical services implementation plan (CSIP), which sets out how it will achieve its share of the NHS's savings drive. "We need to ensure we are as efficient as we can be, for example reducing patients' length of stay. The CSIP and our increasing efficiency will mean fewer patients, less income, fewer beds and a reduction in posts."
Neonatal units and birth centres
A third of neonatal units in England, which care for ill newborn babies, are reducing their number of nurses, according to a new study from the charity Bliss. Its chief executive, Andy Cole, warned: "The lives of England's sickest babies are at risk by needless cuts to the neonatal nursing workforce." A year after Bliss found that 1,150 more neonatal nurses were needed for units to comply with minimum health department standards, 140 posts have been lost.
"It is deeply shocking that at a time when extra nurses are needed to meet even the most basic standards of neonatal care, some trusts are making reckless cuts to posts, which will undoubtedly have an impact on the care of premature and sick babies," said Janet Davies from the Royal College of Nursing. One in five units plan to cut nurse numbers in the next year, according to Bliss's survey, while one in 10 are having their training and education budgets cut and cannot let nurses join training courses because of staff shortages.
Birth centres, where care of mothers-to-be is overseen by midwives rather than doctors, are central to NHS efforts to deliver on government promises that pregnant women in England can choose where to have their baby. But two have closed recently: the Jubilee birth centre in Hull and one "temporarily" at Heatherwood hospital in Ascot. Some hospital trusts, such as North Cumbria University Hospitals NHS trust, are reducing their complement of midwives even though the RCN says the NHS needs several thousand extra midwives to ensure that all women giving birth have a good, safe experience.
Children's health
The Department of Health (DH) has scrapped Birth to Five, a long-established guide given to about 700,000 new parents a year, which contains helpful advice on bringing up their child, such as feeding and immunisation. Previously distributed by midwives, health visitors and community nurses, it is now online-only. Children's health specialists fear that means it is less likely to be read by those who use the internet the least, especially poorer families. "Our members are clear that Birth to Five is an important resource that needs to continue to be available to families in hard copy," said Unite union official Dave Munday.
A decision by the department to stop printing physical copies of many health advice leaflets has also resulted in the demise of Reduce the Risk, a leaflet advising parents on how to avoid cot death. Reduce the Risk is estimated to have prompted take-up of advice that has helped save 19,000 babies since it was first published in 1991. Like Birth to Five it was traditionally given to mothers soon after they have come home from hospital with their baby. But it too is now available only on the web.
"We were very disappointed when the DH decided to suspend printing Reduce the Risk, a vital resource in the prevention of cot death in the UK", said Francine Bates, chief executive of the Foundation for the Study of Infant Deaths, which helped produce the booklet. It had contributed to a 70% drop in unexpected infant deaths in the last 20 years, she said. The DH said a reduction in marketing spending across government had produced savings of £400m for reinvestment in services. "Rationalising paper products, to focus only on those which will be of most interest to the public, saves costs without unduly restructuring access to the information itself," said a DH spokeswoman. Most leaflets remain available online to download, she added.
Nurses
Thousands of nursing jobs are disappearing as hospital trusts shrink their workforces to cut costs. Some hospital trusts are deciding to shed as many as 300 nursing jobs over the next few years. Whether through natural wastage or redundancy, the result is fewer nurses available to care for patients.
Nursing posts are being shrunk despite the close links between the number of nurses available and patients' safety. A recent survey by the Royal College of Nursing (RCN) found that one in 20 nurses expect to be made redundant in the next 12 months, 54% have seen nursing staff levels reduce in their workplace in the last year, 52% say they are too busy to give patients the level of attention they would like and 32% say quality of care is falling.
Recent examples of NHS cuts collected by the RCN's Frontline First campaign include 40 nurses' and midwives' posts going at West Cumberland hospital in Whitehaven and Cumberland infirmary in Carlisle in the last year, and Central and North West London NHS Foundation trust's plan to cut its matrons and lead nurses from 15 to seven in its acute mental health inpatient services. The number of specialist nurses, who help patients with conditions such as cancer, multiple sclerosis or Parkinson's disease, is also falling.
Alcohol
While alcohol problems and their impact on the NHS are growing, many agencies which treat problem drinkers are experiencing problems.
"Some services are being shut due to cuts in local health budgets, others are being redesigned to work additionally with illicit drug users, which may put some problem drinkers off. In some cases the threshold of need is being raised so that support is not available until it's almost too late," said Don Shenker of Alcohol Concern, which represents drink services.
Mount Carmel, an abstinence-based alcohol rehabilitation project in south London, has seen the length of treatment programme for many of its clients reduced from six to three months. "The NHS and local authorities are making cuts and alcohol treatment as always is the poor relation," said chief executive Ruth Allonby. There are 1.6 million dependent drinkers in England, yet nine of Mount Carmel's 18 beds are empty. "Twenty-four rehabs have closed nationwide in the last 24 months. Many detox units have closed or are struggling to get referrals," added Allonby.
Alcohol Concern itself has had to halve its staff and sell its offices after losing all its £300,000-£400,000 annual Department of Health funding. Some see that as the DH's revenge for the influential charity pulling out of health secretary Andrew Lansley's controversial attempt to improve public health by inviting food and alcohol companies to help devise policy through the so-called Responsibility Deal.
Obesity
Despite soaring obesity rates the organisation Mend, which helps overweight and obese children and adults lose weight, is getting less and less work from the NHS and local councils. In 2009 the social enterprise ran 806 family programmes focusing on exercise, nutrition and diet. But this year that has fallen to 697. It has lost contracts in Brent, Hackney and Kensington and Chelsea in London, for example, and recently made five of its 50 staff redundant and froze some other posts. "It's a difficult landscape for obesity programmes such as Mend at the moment", said its chief executive, Harry MacMillan, who complained that confusion over the coalition's policy of handing responsibility for public health from the NHS to local councils had left it facing "a declining and uncertain market".
While it still works with 74 NHS primary care trusts and local councils, "some who have successfully used Mend's obesity prevention and treatment programmes to help local families manage their weight are sadly unable to renew their contracts this year. Many more are reducing the length of contract or the number of sites running programmes due to funding cuts and uncertainty," MacMillan said. Similarly, the Child Growth Foundation has delivered only five training courses to dieticians and school nurses so far this year, compared with an average of 80 courses, again due to NHS budget cuts.
Smoking
One in five Britons still smokes despite the public smoking ban. No Smoking Day is a key element in efforts to bring down smoking rates even further. Despite its success in helping to encourage 250,000 people a year to try to quit smoking and 2 million others to seek advice about kicking the habit, the health department is axing its £250,000 annual grant. It received that sum every year until 2011-12, when it is getting £125,000, but its funding will cease next April.
"No Smoking Day is one of the UK's longest-standing and most successful public health campaigns," said Amit Aggarwal, its chief executive. The campaign helps thousands of schools, employers and GP surgeries across the UK stage their own quit-smoking day, usually in mid-March. Some 6,000 of the 250,000 give up for good, at a cost of about £125 each. That is money well-spent, Aggarwal said, because smoking – 9 million Britons still light up – costs the NHS an estimated £2.7bn-£5.2bn a year. Happily the campaign has merged with the British Heart Foundation (BHF) instead of going under. "No Smoking Day has a world-class reputation for delivering quitters, and we knew we could not only protect it but build on its success," said BHF spokeswoman Betty McBride. Public health experts fear that scrapping funding for bodies such as NSD and Alcohol Concern undermines Lansley's claims to be passionately interested in public health.
Walk-in centres
NHS walk-in centres were promoted by the Labour government as letting patients access healthcare quickly and conveniently while easing the pressure on GPs and A&E units. But the service's financial squeeze has seen a spate of them across England close, either partly or totally, this year.
Manchester has lost several and will soon have just one, in Market Street in the city centre. Its primary care trust is re-opening non-emergency drop-in units in hospitals instead. "Medical professionals have advised us that the quality of patient care will significantly improve if walk-in services are co-located with A&E departments. We recognise that people do value community-based walk-in services, but it is not possible to continue these as well as developing the new, enhanced services on the hospital sites," said a spokesman.
Two Nottinghamshire walk-in centres, in Nottingham and Kirkby-in-Ashfield, closed last month. NHS Nottinghamshire County wants patients to access primary care services via GPs, pharmacists, dentists and opticians and receive "the right care, in the right place, first time".
