NHS Devon is the most financially challenged ICS in England. In June 2024, the chair of the ICB (Integrated Care Board), Sarah Wollaston, resigned, saying she felt unable “to sign off on a further cut” because the “elastic had already stretched too far.” She said she was “not happy” with new plans promising “unachievable” results that would only be possible with “unacceptable consequences” for patients.
The ICB holds public meetings every two months to discuss aspects of the healthcare system in Devon and present plans. The meetings are part of the ICB’s efforts towards ‘transparency’, and the public can attend in person or online. The public can also question the ICB, but only by submitting questions in advance. The ICB decides whether to answer the questions.
Devon is highly concerned about the ICB’s plans to save money and its lack of transparency about how it will accomplish this.
In December 2024, frustrated by the lack of detail in the ICB reports and concerned about how NHS Devon was going to save money, Honiton and Sidmouth Lib Dem MP Richard Foord wrote an open letter to the ICB warning that vague terms like ‘reducing the workforce’ and ‘reducing continuing healthcare costs’ are not good enough explanations.
He requested a written reply with “a detailed breakdown of precisely which services are set to be cut to balance the budget.” Plus, “a thorough explanation of the reasons why the NHS in Devon is in this financial position, along with comprehensive information on how NHS Devon has prepared for winter, including the resilience of facilities within community hospitals across East Devon in particular.”
In a public reply to the MP, NHS Devon told him to look in the public papers published by the ICB and the providers, particularly the Royal Devon Universities NHS FT.
So is it possible to find details of savings programmes and cuts in the ICB papers? The following is a summary of the papers from the latest ICB meeting in public on 30 January 2025.
Progress Report on the Requirements of the NHS Oversight Framework – Segment 4
A large part of the meeting papers concerns how NHS Devon will exit from what is termed Segment 4 of the National Oversight Framework (NOF4). As a result of NHS Devon’s extremely poor financial performance in previous years, NHS England put the ICS in NOF4, under which it receives the highest level of support from NHS England (NHSE) as set out in the national Recovery Support Programme (RSP). NHS Devon did not meet its original timeline for NOF 4 exit of Q1 of 2024/2025. The new date forecast for exit is the first quarter 2025/26.
The ICB was presented with a report on the progress NHS Devon has made in improving its finances, leadership, strategy and patient care to enable it to move out of NOF4.
NHS Devon can only move from Segment 4 to Segment 3 when certain criteria agreed with NHS England have been met. NHS Devon’s ICB and all the NHS providers that are part of the ICS will need to present evidence to the NHSE South West Regional Team that these criteria have been met if a move to NOF3 is to occur.
The assessment covers the following areas: local strategic priorities, leadership and capability, quality of care, access and outcomes (urgent and emergency care and elective care), and finance and use of resources.
The ICB reported that at month 8 (November 2024) none of these areas are considered to be ‘On track and with clear evidence to meet the exit criteria by the planned date.’ All the areas are instead rated as ‘Emerging risk of inability, or no clear evidence of ability to meet exit criteria by the planned exit date’ and ‘Off track with high risks of inability to meet exit criteria by planned date.’
The most concerning areas are urgent and emergency care (UEC) and finance, both of which are rated ‘Off track with high risks of inability to meet exit criteria by planned date’.
This is followed by elective care, which is rated as ‘Emerging risk of inability or no clear evidence of ability to meet exit criteria by the planned exit date.’
By the forecast exit date – 1st quarter 2025/26 – Finance is forecast to be rated ‘Emerging risk of inability, or no clear evidence of ability to meet exit criteria by the planned exit date’. Meanwhile, UEC remains as ‘Off track with high risks of inability to meet exit criteria by planned date’ and is forecast to have actually worsened.
Situation with UEC
The ICB is most concerned about UEC’s performance. In month 8, UEC did not improve as projected in previous months against any key indicators, including 4-hour performance and ambulance handover delays.
Performance worsened across all three providers in November – University Hospital Plymouth NHS Trust (UHP), Royal Devon University Healthcare NHS Foundation Trust (RDUH), and Torbay and South Devon NHS Foundation Trust (T&SD). The system recorded its lowest 4-hour performance position in the current financial year, with 68.43% of patients meeting the standard. Time lost due to ambulance handover delays improved from October to November but totalled over 9900 hours lost.
The situation with elective care
Despite rating elective care at month 8 as ‘Emerging risk of inability, or no clear evidence of ability to meet exit criteria by the planned exit date,’ the ICB has forecast that it will achieve the level needed for an exit from NOF4.
The reason given is that the Devon providers have improved their treatment of long-waiting patients. However, by October 2024, NHS Devon did not achieve its submitted trajectories for 78-week waits or 65-week waits. Despite the risks that providers won’t reach the target by year-end, the ICB believes it can “support an improvement in the assurance rating and take satisfactory assurance that the elective NOF4 criteria will be met.”
Finances
The ICB’s financial situation is outlined in the papers on the exit from NOF4 and in separate finance reports. Finances were reported in November 2024, month 8 of the 2024/25 financial year.
The background to the financial situation is that in early 2024, the ICB submitted a financial plan to NHS England predicting a deficit plan of £85.4m and expecting that £207.9m of efficiency savings would be made to meet that plan. NHS England rejected this plan, and a new plan had to be submitted with a deficit of £80.0m. Due to this change, the ICS efficiency savings target increased from £207.9m to £213.3m.
NHS England gave the ICS £80.0m in month 6, expecting the funding to enable the ICS to break even by year-end. The £80.0m was non-recurrent funding phased in the year’s second half. However, the ICS will have to repay the £80.0m deficit support in subsequent years.
The plan revision meant that the ICS efficiency savings target increased from £207.9m to £213.3m.
At month 8, the Devon ICS reported a deficit of £14.3m. The ICB reports that this is according to plan. The forecast for the year is that the ICS will break even.
The papers then go on to note that if the NHSE extrapolation formula is applied, the year-to-date spend actually predicts a £89.5m deficit by year-end. According to the ICB, however, it expects to hit break-even when “non-recurrent allocations and efficiencies to be delivered in months 9 to 12 are taken into account,” with the main income it hopes to be from the Elective Recovery Fund (ERF).
At month 8, all three of Devon’s NHS hospital providers were in deficit: Royal Devon Universities NHS FT had a £10.3m deficit, Torbay and South Devon NHS FT £15.2m deficit, and University Hospitals Plymouth NHST £16.1m deficit.
Devon ICB and Devon Partnership NHS Trust, which cover community, primary care and other areas, were reported to be not in deficit at month 8.
However, as of month 8, the ICB papers note that there are projected overspends in many services, including in Acute Services, Mental Health, Community Health and Continuing Healthcare. There is a risk that finances will be hit by growth in Continuing Healthcare costs, an overspend in the Better Care Fund (BCF) with Devon County Council and what the board terms ‘efficiency challenges’.
Efficiency savings or CIP (Cost Improvement Programmes)
Devon ICB must make £213.3 million in savings to achieve its 2024/25 plan of a breakeven position by year-end (31 March 2025). Ideally, recurrent savings should deliver as much of these savings as possible.
The ICB had planned for 70% of savings in 2024/25 to be recurrent, but by month 8, it reported that only 56% were recurrent.
By the end of month 8 (November 2024), there was a shortfall in recurrent savings of £12.3m, which the papers note, has been offset by delivery of non-recurrent savings. The year-end forecast is to achieve delivery of £210.7m of the £213.3m efficiency target. However, papers presented to the ICB from the ICB’s Finance and Performance Committee show that it has ‘limited assurance’ around delivering the full efficiency requirement particularly in relation to levels of recurrent delivery.
The problem with non-recurrent savings is that they can not be repeated yearly. Common non-recurrent savings include delaying recruitment to vacancies and using technical accounting measures to improve the financial position on paper.
The meeting papers give little detail about how these savings have been made. The report notes that there is a “System Vacancy Control Panel in place to prevent an increase in workforce growth and to support a reduction in running costs” and there is also a Triple Lock Sign-Off Process in place for all revenue investments above £100k, with sign-off required by the organisation, system and NHS England (NHSE) regional team. The report notes the following on CIPs, which supplies no detail or substance:
“CIPs in place that contain cost reduction strategies that aim to identify and implement measures to achieve cost savings and efficiency improvements while maintaining or enhancing the quality of healthcare services provided to patients.”
Workforce
The ICS is reporting a “0.1% (£16.3m) adverse expenditure against plan on workforce expenditure at month 8” or the providers have spent £16.3m more than they should have on staff.
Workforce is a major cost control target. The approach to reducing workforce costs includes reducing the use of bank and agency staff, increasing the substantive workforce, and implementing workforce controls that challenge the need for all new staff (System Vacancy Control panel). Changes in rostering are also mentioned.
According to the documents, the most significant area of concern is the high levels of agency and bank usage at Torbay and South Devon Hospital.
Precise details on staff cost reduction are missing from the papers, but in the public papers from the Royal Devon University NHS FT’s meeting, the following was found:
“Ongoing reconciliation work between ESR and Unit 4 regarding workforce information as clinical shifts are never over-established. It has been identified that approximately 70% of midwifery and support staff in North Devon work short shifts. In contrast, the roster is templated for long shifts, therefore creating an overlap of staff each day. This follows a historical agreement which was supported by the unions, however, this is currently being explored by the senior midwifery team. Staffing deep dive in progress.”
According to the ICB papers, whatever changes are planned at the provider level, the ICB’s Finance and Performance Committee considers that the workforce controls and priority areas will deliver the workforce cost and WTE reductions.
Primary care access recovery plan
At a meeting on 24 October 2024, the ICB was presented with a report on the Primary Care Access Recovery Plan (PCARP) 2023/24 and 2024/25. The report was presented, which was primarily a performance review of actions taken to improve access to GP appointments and encourage the use of the NHS app.
The report notes that performance is far ahead of the target to deliver 4% more appointments compared to pre-Covid levels, with levels 14% of Aug 2024). The report recommends that the ICB should “take satisfactory assurance” that the PCARP delivery is on track in Devon.
Quality report
The ICB was presented with a ‘Quality report’ that contains key quality information, both quantitative and qualitative data sourced from patient experience and from the NHS Devon Nursing and Quality Directorate teams being embedded in partner meetings, groups, quality
committees and other key forums.
This report’s major issue is the situation in Urgent and Emergency Care (UEC), with long waits in ambulances and emergency departments.
The public’s primary complaints concern dental and primary care access, but the ICB was pleased with the increased turnaround time for complaints.
Waiting list recovery in Neurodiversity and Speech, Language and Communication is discussed, which can be summarised as data validation has been completed across all areas for waiting over 52 weeks and an assessment has been made as to why there are long waits. Progress has been made in some areas.
Committee Chair’s Report – Quality and Patient Experience Committee
This report considered community waits, transfers of care, and an overview of vaccination services.
Under Community Waits, a significant number of adults, children, and young people were waiting for 52+ and 104+ weeks. The report then outlined what had been done, including data collection, best practice, and developing Clinical Reference Groups (GRGs) / clinical pathway improvement groups.
Under Transfers of Care (ToC), the committee members were assured that improving the quality and safety of discharges from Royal Devon University Healthcare NHS Foundation Trust (RDUH) to care homes was a priority for the North and East Locality. Changes were being implemented to improve the experiences of residents and care home providers.
Under Vaccination Services, the report familiarized the Committee with how vaccination services are currently provided and the role of the NHS Devon Vaccination Optimisation team. Starting in April 2026, vaccination commissioning will be delegated to Integrated Care Boards.
2024/25 Annual Plan – Delivery Assurance
This report looks at how well the ICS achieves its objectives in the 2025/26 plan. Of the 128 objectives being monitored, 88 (69%) are fully assured (project on schedule), 38 (29%) are partially assured (some delay in schedule) and 2 (2%) have limited assurance (significant delay in schedule).
Delays to achieving the objections are due to various issues, including capacity, finance and workforce. This is a selection of the objectives that are partially assured, as in delayed:
- The implementation of the three-year maternity and neonatal delivery plan, focusing on safety, personalisation, and workforce development, which has been delayed due to a lack of capacity within the team;
- Embedding reforms for the Special Education Needs and Disabilities (SEND) of children and families across Devon ICS;
- Development of a comprehensive plan to support the recovery of community services, with a target to reduce the autism pathways waits over 52 weeks by April 2025;
- Address significantly poorer outcomes for care experienced children and young people by tackling access and equity issues in care delivery.
- Adults and older adults who need to be admitted to hospital for treatment of a mental illness will be treated in a hospital in Devon whenever it is clinically safe. The objective that by March 2025 there will be no more than 2 people inappropriately out of area, for acute care, is delayed due to increasing demand and local bed closures.
- The development of an alternative community physical health monitoring service for eating disorders patients to enhance outpatient support is significantly delayed due to a lack of funding. Only if funding is identified can providers proceed to implementation and recruitment.
- Increase the proportion of A&E patients seen within four hours to at least 78% by March 2025 – this objective is “off track” and “A&E performance remains volatile and despite seeing marginal improvements overall, this has proven difficult to sustain.”
- Achieve an average response time of 30 minutes for Category 2 ambulance calls during 2024/25
- Eliminate waits of over 65 weeks for elective care as soon as possible and by September 2024 at the latest. The iCB notes that this objective is “Off track” and the ICB “have actioned everything in their control and is reliant on providers meeting their obligations.”
ICB and One Devon (ICS) Finance Reports Month 8
Much of the finance was outlined within the NOF4 report, except for a discussion on capital expenditure.
Devon providers have a total allocation of £105.4m for system capital. However, providers have spent £33m below plan on system capital expenditure, one reason being that they had to change plans when capital allocations were less than in the plan.
Providers report that capital limitations are impacting operational delivery. In December, the ICB reviewed the situation, wrote a report, and made recommendations to the System Leadership Group.
2025/26 Planning and Transformation
NHS Devon is refreshing its Joint Forward Plan (JFP) and developing both the Transforming Devon Programme (TDP) and NHS Devon Annual Plan objectives. NHS Devon notes that due to the number of planning assumptions that have had to be made and the late release of Planning Guidance, “it may be that the emerging Plan will not be sufficient to meet NHS England’s expectations.”
Reducing Autism Waiting Lists for Children and Young People (CYP)
The ICB received a report produced by Su Smart, Director of Women and Children’s Improvement, and John Finn, Interim Chief Operating Officer, on what is being done to reduce the number of Children and Young People (CYP) waiting for an autism assessment across Devon.
As of 31 December 2024, the number of children waiting for an autism assessment on the various waiting lists across Devon was 7,848 children and young people.
Of these, 4,667 (61%) children are waiting over 52 weeks or one year for an autism assessment. The recovery work has succeeded, with a 119% increase in the number of assessments.
However, the report said that continued improvements will be limited by capacity due to an insufficient clinical workforce and diagnostic capacity and a lack of funding.
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