Rationing
An inevitable consequence of underfunding of the NHS is that some element of rationing creeps into the services that are offered. As NHS organisations struggle to fund services they are increasingly seeking to reduce their spend by rationing services.
Rationing presents itself in two forms: either NHS organisations refuse to pay for treatments or they change the eligibility criteria so less people are eligible to receive the service. Both these forms have become more severe and widespread in the last few years.
Rationing of physical treatments
Rationing of physical treatments has been ongoing for many years as the NHS struggled under the Conservative government, with inadequate funding settlements.
Now rationing seems set to continue under the new Labour government as it continues the underfunding of the NHS. In May 2025, it was reported that hospitals in England are cutting staff, closing services and planning to ration care in order to make “eye-watering” savings demanded by NHS England. Sir Jim Mackey, NHS England’s new chief executive, has ordered them to make unprecedented savings during 2025-26 to avoid a projected £6.6bn deficit becoming a reality.
In 2018, NHS England scrapped four surgical procedures and a further 13 only to be commissioned when certain criteria was met. These surgeries include grommets for Glue Ear, trigger finger release, breast reduction and many more that are deemed to be ‘ineffective’ by NHS England.
Despite opposition from the Royal College of Surgeons, NHS England pushed ahead with this rationing of treatments with plans in 2019/20 to stop 100,000 procedures a year to avoid spending £200m. GPs argued that such measures do not save money in the long-run and simply prevent patients from accessing necessary treatment.
IVF services are another service that have faced cuts due to rationing with only 1 in 10 areas offering the recommended three cycles of treatment. The rationing of IVF services also significantly affects cancer patients. A report published in The Breast Journal in 2020, found that only 30% of CCGs surveyed offered cancer patients unrestricted access to fertility preservation treatments. This goes against recommendations from NICE.
In 2020, a Pulse investigation revealed that even before the pandemic, an increasing number of procedures were considered of low clinical value, and were being rationed by CCGs.
The investigation found that a year on since the 2018 changes were added to the 2019/20 NHS standard contract, the repercussions were being felt by both GPs and patients.
The guidance obliges GPs to argue why their patient should be considered for any of the 17 treatments – which include breast reduction, tonsillectomy, and haemorrhoid surgery. GPs have found that the ‘prior approval’ processes effectively see patients blocked from both treatments and consultant opinions.
Figures collated by Pulse’s investigation indicate increasing numbers of patients are being put through this process. Using data Pulse obtained through freedom of information (FOI) requests, it estimated that almost 17,000 referrals were rejected across 57 CCGs last year, compared with just under 9,000 in 2015.
In 2024, an investigation by the BMJ found that rationing of obesity treatments was common across the NHS. The investigation found budget cuts to local services fell disproportionately on obesity care, with patients living with the condition often deemed less worthy of care than others.
Patients in nearly half the country are unable to book appointments with specialist teams for support and treatments such as weight-loss jabs. The restrictions amounted to the NHS “rationing” obesity services. Patients in one in six local healthcare areas could not access bariatric surgery, one of the most clinically effective treatments for obesity, according to the investigation, which analysed responses to freedom of information requests from all 42 of England’s integrated care boards (ICBs).
Rationing of mental health services
One major result of years and years of underfunding and increasing demand is that accessing mental health services is becoming harder and harder. The services are associated with long waiting times for appointments, particularly in the area of children and adolescent services. Waits of as long as 18 months have been reported. It has also been reported that the threshold for receiving treatment has increased, with people having to be suicidal before they are referred for treatment.
The waiting list for mental health services was estimated to be 1.8 million in 2023, but in reality much higher as the 1.8 million figure does not include those waiting for inpatient care and other services. In late 2021, the official waiting list stood at 1.6 million people and NHS Providers estimated that there are around eight million people in England that are denied access to mental health services because they do not have severe enough symptoms to get put onto a waiting list.
The eight million figure is based on the known prevalence of mental health conditions and the thresholds dictating who gets access to treatment; NHS England considers it an accurate figure for the number of people who are missing out on care because services are not adequate. So the true figure of people waiting for mental health services is around 10 million.
As a result, the number of A&E attendances by young people with a recorded diagnosis of a psychiatric condition has almost tripled since 2010 and an increasing number of GPs are now advising parents to seek private mental health care for their children.
Journalists at the HSJ recently obtained data on waiting times for community health services, which showed a massive increase in the number of children waiting two years (104 weeks) or more for a community health service; the number more than tripled between February and October 2024, to 7,946. Of this number, 80% (7,053) were waiting for the “community paediatric service”, which primarily deals with diagnosis and treatment for neurological issues, predominantly ADHD or autism, and potential mental health problems.
The STADIA trial, recently published in the Journal of Child Psychology and Psychiatry, highlighted that children with high-level mental health needs are being left without specialist care as almost half of referrals (44%) in the trial were rejected by NHS child and adolescent mental health services (CAMHS). Then, 35% required a re-referral to CAMHS, which delayed them receiving help.
The study across eight trusts in England involved 1,225 children and young people with emotional difficulties who had been referred to CAMHS for help and followed them up over 18 months to see how they got on.
The children and young people in this group were found to have high levels of mental health needs, with 67% scoring very high for at least one emotional disorder, most commonly depression or an anxiety disorder. Despite this level, the authors were shocked to discover that only 44% of children and young people had their referral to CAMHS accepted.
Professor Kapil Sayal, from the School of Medicine and the STADIA Chief Investigator, noted:
“We are very concerned that many children and young people with high levels of mental health needs, particularly conditions such as depression and anxiety disorders, for which NICE-recommended evidence-based interventions are available, are struggling to access help and have their difficulties appropriately recognised. One year is a very long time in a child’s life – delays in accessing the right care mean that their difficulties and distress, and the associated impact on their day-to-day lives and activities, are being unnecessarily prolonged.”
Although the STADIA trial lasted from 2019 to 2021, GPs commenting in Pulse said that although health services experienced difficulties during this time, things have not changed. Dr Richard Cook, a GP in West Sussex told Pulse that the referral rejection figure matched his experience. ‘CAMHS do not offer a useful service and the waiting list is huge. A major overhaul is needed.’
And Dr Selvaseelan Selvarajah, a GP in London, told Pulse: ‘The results do reflect our experience of CAMHS services. Children’s mental health services, like many other parts of the NHS, are underfunded. There are also shortages of child psychiatrists and mental health practitioners. The referrals are likely to be going up as well. As a result, children and parents do find it challenging to access the service in a timely manner.”
Rationing also takes the form of a short duration of treatment available on the NHS. Patients then feel that they need to go private to complete any therapy.
In September 2022, research by Dr Agnes Ayton and 22 other psychiatrists found that in 2019/20, just 31% of eating disorder services accepted all patients, regardless of the level of illness. Adult eating disorder services are so severely underfunded and understaffed that they are having to employ rationing measures and turn away patients. The researchers warned that the situation had become more serious following the pandemic, which had driven a “worsening of the demand and capacity” crisis across the services.
Experts have called for emergency funding to meet the needs of adult patients with eating disorders, and say that these services should be receiving at least £7m per million population each year to meet standards.
Concerns
A lack of timely treatment for mental health conditions is likely to be behind the increase in urgent referrals. A recent analysis of NHS data by the charity YoungMinds found 34,793 emergency, very urgent or urgent referrals to CAMHS crisis teams between April and October 2024, up 10% on the same six-month period in 2023.
Many of these children requiring emergency care are very likely to have been stuck on NHS waiting lists for months or even several years. The chief executive of YoungMinds, Laura Bunt, said: “Early support would help prevent many young people from becoming more unwell, but instead their mental health is deteriorating, pushing them into crisis and in some instances putting young people’s lives at risk.”
Rationing and long delays to children's care can lead to serious damage to their health – including chronic pain, asthma flare-ups, weight loss and developmental problems.
Doctors said the findings were “shocking” and warned that some children would endure “lifelong consequences” as a result of delays that could sometimes last several years. The details have emerged in a dossier of evidence the Royal College of Paediatrics and Child Health (RCPCH) has collated illustrating the harm that treatment unavailability causes.
The imposition of conditions on patients who smoke or who are obese has been a common theme of the changes that have implemented to reduce costs.
In 2017, charity chiefs across the country called for the NHS to stop rationing treatment for seriously ill patients. 30 health charities, including the Teenage Cancer Trust, National AIDS Trust and Motor Neurone Disease Association, raised the alarm about NHS England “restricting and rationing treatment” because of underfunding, especially for patients with rare and complex conditions.
Doctors also warned that rationing of treatments such as hip surgeries, cataract removals, and drugs such as those to treat arthritis, are leaving patients in pain. In 2019, the BMJ found that rationing of access to cataract surgery by CCGs across England was directly ignoring clinical guidelines. In fact, rationing of this surgery has increased in parts of the country against NICE guidelines published in 2017.
Doctors have also revealed that they are being prevented from prescribing the best and most appropriate drugs for treatments due to rationing. Breast Cancer Now charity revealed in 2016 that some women were missing out on a potentially life-saving drug that costs 43p a day. Bisphosphonates cut the risk of cancer spreading to the bone, but many CCGs have blocked their use.
In 2017, Diabetes UK claimed that the NHS are putting lives at risk by rationing test strips that monitor blood glucose levels in an attempt to save money. If diabetes is not monitored and controlled properly, through the regular use of test strips such as these, then health complications such as heart disease, strokes, blindness and amputations could occur.
In 2018, British Hernia Society claimed that rationing is leaving patients waiting in pain for treatment. This has led to increased risks of emergency surgery and even death.
In 2020, NHS protocol in response to the coronavirus pandemic stated cancer services should be rationed to patients with the highest chance of survival should hospitals become overwhelmed. They warned that immunotherapy treatments could be halved in frequency and long-term follow-ups postponed indefinitely.