Tough task ahead for the NHS

Phillippa Hentsch, head of analysis at NHS Providers, paints a stark picture of NHS finances, workforce pressures and unsustainable targets for the coming year unless firmer action is taken by the government.

We wanted it. We campaigned for it. So it would be churlish now not to give a very warm welcome to the prime minister’s commitment to a serious long-term financial settlement for the NHS. But that does not alter the fact that what the NHS is being asked to deliver in the here and now looks well-nigh impossible.

A new report by NHS Providers, ‘Tough Task: The NHS delivering for patients and staff in 2018-19,’ presents a stark and worrying assessment of the challenges facing NHS trusts this coming financial year. It warns that patients’ experience of care will continue to fall below the standards trusts consider acceptable, with growing risks to quality and safety, adding to the burden on an already-hard pressed workforce.

This is not where trusts want to be. Looking back over the last 12 months, so much has been achieved in extremely difficult circumstances. The NHS helped more patients than ever before in A&E, it made progress in implementing ambitious plans for mental health, and it delivered more than £3bn of savings. But still it fell short of the demands placed on it. Waiting lists for routine surgery continued to grow, delays in A&E rose to record levels, and NHS trusts are now on course to record a £1bn deficit. In the year ahead, it is clear that we are setting the NHS up once again for an undeliverable task.

The planning guidance for the health service published last month set out a requirement for trusts to balance their books this year. That will require over £4bn of efficiency savings (20% more than for 2017-18). Trusts have also been told to substantially improve A&E performance and ensure waiting lists for routine operations don’t grow any longer. That is a very tall order. It is right to set the NHS challenging and stretching targets. But these objectives are – to say the very least – optimistic. Unfortunately, there is a glaring mismatch between the resources currently available and the political and public expectations for the NHS.

As a result, we risk damaging public confidence in the health service as trusts once again are seen to fall short. There is a real danger that this will demotivate and demoralise staff as they work towards targets that they know they cannot meet.

Next year

The message from trust chief executives and financial directors is clear. Only 5% of trusts are confident that their area can meet the four-hour A&E target next year, and more than half are worried they won’t be able to keep the lid on waiting lists. And, based on projected levels of demand and performance, the NHS would need to treat an extra 2.4 million people within four hours to meet the target of 95%. We estimate by the end of March next year the number of people breaching the 18-week constitutional standard for routine hospital treatment will reach 560,000 – a rise of nearly 80,000.

Given the widespread capacity challenges the NHS has seen this year in terms of beds and staff, affecting hospitals, mental health, community and ambulance trusts, we see little prospect of the health service meeting the performance objectives set for 2018-19. The scale of the financial challenge is also daunting. Despite an additional £1.6bn from the budget and a further £540m eked out of Department of Health and Social Care (DHSC) funds, the NHS’s budget is only increasing by 1.4% next year: that’s just 0.7% per head of the population. This is well below the 1.2% per person spending rise in 2017-18.

Trusts have been asked to sign up to and deliver financial targets (known as control totals). Our analysis suggests that doing so would imply – on average – a 5.7% cost improvement plan, equivalent to overall savings in excess of £4bn. This is 20% more than trusts are on track to deliver this financial year.

Where do we go next

The NHS is a can-do organisation. But we need to break the cycle of setting the NHS an undeliverable task, and then asking why trusts fall short.

So what must be done? We need to ensure that NHS trusts become a key part of the planning process, alongside the DHSC and the NHS’s central bodies. This will require significant cultural and practical change, but it is no longer credible to negotiate targets behind closed doors and then expect trusts to deliver them. We have argued consistently that the resources currently available to the health service – in terms of funding and workforce – mean it is being set up to fail. So thank you, prime minister, for committing to sustainable long term funding for the NHS. Let’s make sure to remember that workforce pressures get the same priority. And let’s see words backed up with action.

(Top image c. Marbury)


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