Health leaders' panel
Health & social care leaders share their views on headline issues
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
Our fourth poll was conducted between 17 August and 7 September 2015, via an online survey.
In total, 75 of our 100 panellists responded. Of the 75 respondents, 27 are senior managers, 29 are clinicians or clinical leaders, 11 are from local Healthwatch bodies and eight are from the social care sector. Of the health service managers and clinicians, 27 are from acute hospitals, 16 from clinical commissioning groups, three from private or voluntary sector providers, five from mental health providers, two from NHS ambulance trusts and three from NHS community trusts.
The panel members are named on our website, but their individual responses to the survey are anonymised.
- Although most respondents are involved in planning for reduced spending, many leaders do not see how the efficiency savings required to free up an additional £22 billion for the NHS can be achieved: two thirds of survey respondents are not confident that their area has a credible local plan to make the efficiency savings needed this year, with half of respondents saying their area’s savings plans are dependent on reducing agency staff spend.
- Longer-term efficiency plans often appear to be premised around achieving savings in notoriously challenging areas, with three quarters of respondents citing admissions avoidance and demand reduction as a main source of projected savings in this longer-term plan, and 58.6% identifying reconfiguration. 60% of respondents lack confidence that their area has a credible five-year plan in place to deliver efficiency savings.
- Asked to choose from a list which non-NHS public service most deserved to be ring-fenced, 53.3% selected spending on older people's social care: many panellists expressed the view that NHS and social care budgets should be viewed as being interdependent.
- Just over half of respondents (52.7%) thought adhering to government guidelines was causing their own or their local providers to compromise on quality elsewhere: some but not all said they felt empowered to veto national directives where perverse consequences were likely, implying significant differences in how autonomously organisations feel able to behave.
- 96% of respondents thought it should be a high or moderate priority to deliver improved urgent seven-day services in line with NHS England clinical standards: the quality benefits of seven-day urgent services were clear to respondents; the cost implications less so. However, only 37.8% believed seven-day elective services should be a high or moderate priority.
Targets and regulation
More than half of our panellists told us that the burden of government directives and guidelines is causing compromise on quality elsewhere. The burden of the current regulatory system in particular was singled out by eight respondents, and just under half of panellists thought NICE safe staffing guidance had a significant or moderate effect on provider costs.
Q1. To what extent do you feel that adhering to government directives and guidelines has caused your organisation/your local provider to compromise on quality elsewhere?
Just over half of respondents (52.7%) felt that adhering to government guidelines had caused their local provider to compromise either a little or a lot on quality elsewhere. One respondent criticised a focus that shifts back and forth from quality issues to safer staffing “depending on the most recent crisis”. They added:
"There is no joined-up policy direction that takes account of clinical outcome, the patient experience, staff engagement, research, innovation and education and the money."
Of those who reported that quality had been compromised “not a lot”, one said that their organisation had been able to anticipate directives in areas such as staffing levels and weekend medical covers. Another reported that their chief nurse and medical director had a power of veto if they felt that a new initiative would compromise quality. A further respondent said:
"We do not trade off our commitment to quality and quality improvement against the financial impact of policy directives and try to keep enough flexibility in reserve to meet in-year pressures - that of course is getting harder."
However, they added:
"Recent government statements (e.g. on seven-day working) appear to be policy soundbites with no implementation (and cost) plan attached."
Q2. What impact has NICE guidance on safe staffing for nursing in adult inpatient wards in acute hospitals had on your organisation/your local provider’s costs?
Just under half of respondents (48.0%) felt that this guidance, which applies to acute trusts only, had a significant or moderate impact on provider costs. One respondent reported that an investment of £3.5 million not covered by tariff or through increased commissioner funding had been required to achieve compliance. Another stated that investing to comply with the guidance had resulted in their local acute trust publishing a deficit plan for the 2015/16 financial year, as despite achieving good patient outcomes, the tool had demonstrated a significant nursing shortfall. The respondent said:
"A proportionate and risk-based approach has been adopted.”
A respondent working in social care reported that ward closures stemming from a local provider’s inability to staff wards had placed more pressure on community services, which were having to look after patients with greater needs at home.
However, others reported little or no impact as they were already complying with the guidance, and one respondent made the point that the guidance “was not now being pursued nationally”, adding:
“The limiting factor in increasing nurse numbers is availability of candidates for posts, rather than other constraints or compliance with guidance from external bodies.”
Q3. Are there any other government directives/guidelines that have had an impact on your organisation’s/your local provider’s costs in the last 12 months?
The impact of the regulatory burden was cited by eight respondents, with one describing this as inflationary.
Three commissioners and one acute provider highlighted the impact of new cancer guidelines. Two respondents cited the specialist services tariff as causing particular problems. In mental health care, requirements relating to the Improving Access to Psychological Therapies (IAPT) programme and targets for first-episode psychosis were described as having an impact.
One respondent reported that changes in Clinical Negligence Scheme for Trusts (CNST) premiums and the removal of the NHS Litigation Authority discount had amounted to an additional cost of £2 million for their trust. In local government, adherence to Deprivation of Liberty Safeguard (DOLS) requirements was highlighted.
Achieving planned efficiencies
Most panellists lacked confidence that their local areas had credible plans in place to make the efficiency savings required of them either this year or over the next five years. However, there was a little more optimism about the possibility of achieving the five-year efficiencies. Admission reduction and demand management was the most popular strategy to drive the savings across five years, followed by reconfiguration.
Q4. The NHS is required to make £22 billion of efficiency savings by 2020. How confident are you that your area has a credible local plan to make the savings needed this year?
Two thirds of respondents (66.7%) were either not very confident or not at all confident that their area had a credible plan to make the required savings this year. One respondent based at an acute trust, who was not at all confident, said:
“It’s like being a dairy farmer - our costs are simply not covered.”
The respondent added that access targets and quality requirements meant very little could be done to save the required amounts and income for emergency care was particularly inadequate. Both the trust in question and the clinical commissioning group were in the red.
A respondent at a community provider, who was not at all confident, said:
“These are not efficiency savings - they are severe cuts. We are now drawing up lists of services which can be cut with as little impact on the public as possible. The main reason that we aren't able to plan effectively for the future is general practitioners’ complete reluctance to change. They accept that major change is required, they just seem to hope that if everyone else changes they won't have to!”
A respondent from a mental health provider who was not very confident said: “The low-hanging fruit has long gone and our plans have been disrupted by recruitment difficulties.” And a Healthwatch representative, also not very confident, said: “There is no real clear board commitment to co-production working within the health and social care economy.”
Of those who were neither confident nor unconfident, one provider representative said their plan was dependent on commissioners not collecting money where an unexpected drop in demand had meant activity was below the contracted level, as well as full delivery of the cost improvement plan.
The 16% of respondents who were confident in their areas’ local 12-month plans spoke of the significant levels of effort and local collaboration that had enabled the documents to be drawn up. One respondent described a “ huge amount of joint working between [the] CCG, all trusts and the local authority”. They said:
The Health and Wellbeing Board has become a clearing house in developing service changes going forward including [the] agreed locality plan which awaits the Treasury Autumn statement."
One commissioner said: “We have credible plans in place and are making real change.” They described the “main issue” facing them as the annual business planning cycle making it more difficult to take out costs from acute providers, which could take as long as four years. “Positive changes are happening but will there be time?” they asked. Another commissioner said:
“We are financially on target at present, but there are no reserves to cover unforeseen events.”
Q5. To what extent are the savings in this year’s local plan (as described in Q4) dependent on a reduction in agency staff spend?
When asked to what extent this year’s local plan savings are dependent on reducing agency staff spend, 16% of respondents said this was to a significant extent, 34.7% to a moderate extent, 24% to a slight extent and 4% not at all.
Q6. How confident are you that your area has a credible five-year plan to make the savings needed?
Asked whether a credible five-year plan was in place, 60% of respondents were either not very confident or not at all confident. This is a slightly smaller number than were pessimistic about the 12-month plan, but is still a majority of respondents. By contrast, 26.6% were either very confident or somewhat confident.
One acute provider representative who was somewhat confident said the area had a very focused management and quite a motivated workforce but the scale of savings required was “very challenging”. Another respondent said they were very confident in their local area’s ability to deliver the plan, but added:
“The cost will be too high a price to pay. The new types of service provision in prevention, rehab, specialist housing, 24/7 services , quality personal budgets , 24/7 access to mental health, drug and alcohol services [are] likely not to happen, child and adult protection services reduced to minimalist levels of access.”
A commissioner, who was neither confident nor unconfident, said: “There are a number of high-risk strategies which we hope will deliver the long-term plans.” But they described concerns over “top-down directives which are knee-jerk responses to issues and not tailored to individual regional difference”, and also warned that currently applied funding formulae disadvantaged some communities.
A representative of an acute trust, who was not very confident, said:
"We do have a plan and it is very innovative. But it won’t save the money that is required."
Q7. Please indicate which are the main sources of projected savings within this five-year plan.
More than three quarters of respondents (75.7%) said admission reduction and demand management was one of the main sources of projected savings within their five-year plan, while more than half (58.6%) identified reconfiguration as a main source. Given the increasing demand for services and lack of success in releasing funds through reconfiguration to date in the NHS, this finding illustrates the challenge facing local health economies. Several respondents highlighted integration proposals, pathway-led redesigns and risk-sharing arrangements.
Almost all respondents felt supporting seven-day urgent care services in line with NHS England clinical standards was a high or moderate priority, but there was less support for seven-day elective services - with just over a third supporting this.
Q8. How much of a priority do you think it should be to deliver improved urgent seven-day services in line with NHS England clinical standards?
96% of respondents believed it should be a high or moderate priority to deliver seven-day services in line with NHS England clinical standards. Many respondents said their trusts were already focusing on this. One acute provider respondent said:
“It has been a high priority for us for the past 10 years and we believe has made a major difference to patient flow, safety and training.”
"Whilst some of the national pronouncements on care at weekends have been inaccurate and simplistic, it is clearly essential that inpatients receive the same level of care on every day of the week. In addition to improving the quality of care and patient experience, improvement in urgent seven-day services also offers opportunities to deliver efficiencies by shortening length of stay.”
One respondent at a trust that is piloting improved seven-day services said the benefits to patients were already apparent, but added:
“We have got to do lot more to see the benefit on cost. We need more community beds with good facility and the CCG is struggling and [social services] is struggling. CQC inspection has dented confidence in local care homes which we use a lot.”
A further respondent said:
“It is important but needs resourcing! The national debate at present is failing to highlight the mutual incompatibility of quality and financial goals.”
Q9. How much of a priority do you think it should be to deliver elective seven-day services?
When asked to consider how much of a priority it should be to deliver elective seven-day services, only 37.8% believed this should be a high or moderate priority. One acute respondent said: “Our service users are requesting this of a modern-day service”. A respondent at a mental health provider said:
“From a patient perspective it is a high priority to have access to elective services seven days a week. In the current economic climate the NHS faces I would rate it as a low priority. That said I fail to see how we could deliver the real intent of seven-day working without seven-day access to elective services, particularly in diagnostics.”
Another provider warned: “Currently the staffing demands, without significant reconfiguration, will not allow this to happen to the standard we wish under the financial constraints that we have.” And a further respondent said: “It’s good to use plant [facilities – e.g. operating theatres] 24/7 but it’s unaffordable since we are meant to be saving money not spending it.”
“We have credible plans in place and are making real change…. Positive changes are happening but will there be time?”
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“Opportunities to make yet more savings within this year will be very difficult to identify”
NHS Providers, the body representing acute trusts, has predicted that the hospital sector will end the financial year with a £2bn deficit, but the Government has stated that it expects NHS providers to “live within their means” ( Department for Health, 2015). The majority of our panellists thought this unfeasible.
Q10. Thinking about your local NHS provider(s), to what extent do you think it will be feasible for it to “live within its means”, or stay within budget, this year?
70.3% of panel members thought it would be either very or somewhat unfeasible for their local provider(s) to “live within its means”. Just 14.9% thought it would be very or somewhat feasible.
Many of those who thought staying within budget was not feasible said that their local providers were already overspending, and one clinical commissioning group respondent said: “they are already running a deficit – planned but they are effectively ‘not living within their means’”. A panellist from an acute trust said: “Most organisations in our local patch have a ‘planned deficit’ for 2015/16 – and we’re talking about big figures”. Another clinical commissioning group respondent went further, saying that: “All local providers and commissioners locally are in deficit and off plan, whatever they report”.
Some panellists also highlighted the consequence of trust deficits on patient care. An acute trust respondent said: “The current financial gap cannot be bridged without compromising patient safety/quality.” A Healthwatch representative said some providers in their area had “made public statements about not being willing to compromise on quality to save money and will find it impossible to balance the books in the future”.
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?
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).
In preparation for the Comprehensive Spending Review in November 2015, non-protected Government departments have been asked by the Treasury to outline potential cuts of up to 40% by 2020. The Government has pledged to protect the NHS and has made a commitment to increase spending by £8 billion by 2020, but a majority of panellists thought the Government should invest even more money in health care.
Q12. Which of the following statements most closely matches your view?
- The NHS budget should not be ringfenced
- The NHS budget should be ringfenced and receive no further resources
- The NHS budget should be ringfenced and receive £8bn extra funding by 2020
- The NHS budget should be ringfenced and receive a greater sum than £8bn extra funding by 2020
A majority (62.2%) of our panel felt that the NHS budget should be ringfenced and receive more than the £8 billion extra funding pledged by Government by 2020. Just under a quarter (24.3%) said that the ring-fence should apply and the NHS should receive the £8 billion sum. Just five respondents felt that the NHS budget should not be protected, and five thought it should be protected but should receive no further money.
Despite the high level of support for protecting and increasing the NHS budget, respondents frequently mentioned the difficulty in protecting healthcare at the expense of social care. One HealthWatch representative in favour of both ringfencing and increasing spending on the NHS said this came “with the caveat that the NHS budget should be seen alongside the social care budget”. Another respondent in favour of increased NHS spend beyond the £8bn said that we “need to view social care and wellbeing spend as part of health budgets”. One of the few respondents who did not favour ringfencing explained their stance by saying that “seeing healthcare in isolation, with no thought to social care is silly… Not ringfencing is not the same as not increasing the budget”.
Some respondents also highlighted the need for the NHS to improve services in exchange for extra funds. One respondent not in favour of ringfencing said:
“The system requires reform rather than ringfencing”.
Another, who was in favour, said the NHS “also needs to address transformational change as part of the deal, not just another bailout”.
Many respondents pointed out the relatively low level of public investment in health care in the UK compared to other countries.
Q13. If you could choose to ring-fence spending on one of the following areas in order to improve the health and wellbeing of the population, which would it be?
Panellists were presented with a range of options for services to protect, including public health programmes, social care for older people and benefits.
The majority (53.3%) opted to protect spending on social care for older adults, which one respondent said would “offer the best chance of targeting health and social care resources appropriately”. Another said that social care for older adults is “consuming hospital acute resources as [there is] nowhere else as a place of safety”. The same respondent added that “80% of the need is social; 20% medical”.
Public health programmes commissioned by local authorities, such as smoking cessation, alcohol and drug misuse services, were chosen by just over a quarter of respondents (28%). A respondent from social care said:
“[We] must focus on the long term and have a difficult conversation with the general public about their own responsibilities for their health”.
Another respondent, who opted out of picking one of the choices given, suggested that what is needed is:
“A massive programme to tackle obesity (not silly little local authority public health programmes) with legislation like seatbelts and alcohol.”
Our latest survey reveals significant concern among senior leaders over the ability of the NHS to achieve the efficiency targets that will be expected of it, both in the short term and the long term. Long-term savings plans often feature a reliance on demand management and reconfiguration – two areas where it has been very difficult to achieve significant savings in the past. A significant majority are doubtful that local providers will be able to stay within budget this year.
Just over half of panellists thought that adhering to government targets and directives was causing compromise on quality elsewhere in the service – a finding that will highlight questions over the cost of complying with all aspects of the monitoring regime at a time of financial pressure.
Leaving aside the NHS, panellists thought the public service that most needed to have its income protected was older people’s social care. This is perhaps unsurprising, given the impact that cuts in adult social care are having on NHS services.