As the July lift-off day for so-called Integrated Care Systems (ICSs) draws closer there is little sign anywhere in the NHS that the new system will offer any significant change or benefit.
They will not herald either the demise of the NHS, which has so often been prematurely and unhelpfully pronounced by some campaigners, or the smooth coordination and integration of services claimed by deluded advocates of this second complete reorganisation of the NHS since David Cameron’s ConDem coalition took power in 2010.
The first part of this survey warned that almost all of the ICS areas for which figures are available are already projecting substantial deficits in their first year in charge. Having now sought information on the remainder, we know that some – deliberately, or by omission – have published no information at all, but all those for which we have any data are facing deficits and outright cuts in spending this year, with no relief in sight.
Rumours that these deficits – which result from the abrupt withdrawal of “non-recurring” funding streams that helped to keep most trusts and CCGs out of the red during the pandemic years of 2020 and 2021 – could add up to as much as £4 billion have been published in board minutes.
In some cases regional totals giving credence to this level of problem have also been divulged. The initial deficits of four of the five London ICSs alone add up to over £1bn (South West London £256m; North West London £300m before being squeezed down to the current £94m; North Central London £359m; NE London £100m). Outside London several board papers refer to a South East Region total of £693m; and available ICS figures in North East and Yorkshire add up to £577m.
The Lowdown has been sounding the alarm over the grossly inadequate funding settlement in Rishi Sunak’s spending review last autumn: of course ministers have toured newsrooms to assure gullible interviewers that the NHS was going to be given plenty of money.
But now more and more finance chiefs are echoing the HSJ’s recent warning that “Every health system to face real-terms funding cut in 2022-23” which calculated the real terms inflation-driven cuts ranging from 2.1% in North Central and South East London down to 0.2% in Buckinghamshire Oxfordshire and Berkshire West.
These may seem relatively small changes, but the percentages relate to very large sums of money, and every cutback comes after years of relentless efforts at cost-saving. These reductions in purchasing power run alongside actual cuts in many ICS budgets as part of a “convergence” process to make funding more equal by spending down for most and increase it by a fraction for a few.
This real-terms cut also links up with actual reductions in budget – from the ending of funding streams for Covid patients (cut by 58%) and complete cessation of funding for the Hospital Discharge Programme. This second change is set not only to pull tens of millions from many trusts’ budgets, but also to rapidly worsen the problem of finding suitable support to enable the discharge of patients from front line beds.
The cut of HDP funding appears to be resulting in every instance in trusts and commissioners agreeing to axe the services that were provided from 2020, since even though most seem to argue that the policy was a success, they can’t face making cuts elsewhere big enough to keep it going.
This is already beginning to take its toll as hospitals fill up, lacking beds for elective patients and emergencies – as waiting lists rise to 6.4 million and A&E performance bumps along way below performance targets, apparently concealing tens of thousands of 12 hour delays to admission.
Salisbury Hospital alone reports already having up to a third of its 396 beds filled with patients medically fit for discharge. The continued unresolved crisis in social care and the axing of NHS support mechanisms mean this can only get worse, no matter what the happy clappy rhetoric about integration.
And with hospitals running at or close to 100% capacity, for many, like Frimley, the current year means that “All contracts will be block with no new money coming into the system centrally unless elective activity exceeds the 104% target.” And with no spare capacity, there is no scope even to reach 104%, let alone exceed it.
The scale and universality of the cuts imposed as core funding suddenly reverts to pre-Covid (2019/20) levels means that some Board papers are once again actually using the word “under-funding” to describe why, having worked staff so hard for so long, they are now in this predicament. Mental health budgets, too, are being squeezed, with some systems deciding not even to pretend and simply stating that there is not enough money to implement targets, for example for expanding IAPT talking therapy services.
Others state outright that they have taken on more staff to improve community services during the pandemic – and now have to decide whether to get rid of them again or find ways to cut other services to pay for them.
As CCG and trust committees are informed of the state of play, some, to their credit, express dismay at how late in the day information has been revealed, meetings convened and decisions have been taken.
What I find astounding is the number of CCGs and even Trusts that are meeting in April and even May, weeks in to the new financial year, with meeting agendas and papers focused exclusively on their performance in the last year gone by, with no hint of awareness or concern about the immediate situation and the future. We know from their neighbours that no regions are immune from the pressures to come – and ostrich tactics can only delay the recognition of the problem.
We can assume that, for at least some finance chiefs this reticence is because they are reluctant to share the information, or allow the bad news to leak out. Some trusts have opted to discuss their financial plight only in the private sessions of board meetings, or issued evasive financial reports – promising reports that don’t materialise – or resorting to publishing meaningless lists of aspirations and NHS England targets without any discussion of the financial implications, affordability or availability of staff.
As we reported in the previous survey, many of the most substantial forecasts of deficits have been cosmetically dealt with by promising ever-more ambitious and unlikely targets for CIPs (“cost improvement programmes”). Some plans aim to save as much as 6.2% of their budgets. Cambridgeshire and Peterborough ICS promises to deliver 4.8% savings for three successive years: but we all know targets above 2% per year have seldom been achieved or sustained.
But this raises another crucial issue. NHS finance wonks have for decades managed to primp figures and fiddle away deficits, or (as they did with Sustainability and Transformation Plans) use and even inflate deficits to improbable and unmanageable levels, to make the argument for changes that would otherwise be dismissed as unacceptable – only to ignore the figures later.
So if trusts across the country are this time really going to be forced by the new ICSs to cut substantial services, staff numbers, or quality of care – as the HSJ warned back in the spring would be the case – the consequences could be serious.
Fortunately it seems, at least from the current evidence, that the ICSs are more or less resigned to commissioners and providers running up deficits, although keen to keep them as small as possible. Numerous trusts report having been persuaded to find (effectively invent) more “efficiencies” to reduce their initial deficits, but none have reported any likelihood of action by ICSs to force trusts into line.
Indeed it appears that Regional chiefs within the NHS England structure are more likely to be trying to crack the whip (notably in the South West of England) than the partially-established and still powerless Integrated Care Boards, which will be left with an effective fait accompli when they take over in July.
It’s also worth remembering that for the eight smallest ICSs, with fewer than 1 million population and in most instances already run by merged CCGs covering one or at most two counties, and for a number of the others covering a single county, the trappings of “Integrated Care Systems” has always been a bit of a bluff and a fraud. They are just basically revamped CCGs – but less democratically accountable, and now since the Health and Care Act, more vulnerable to central intervention.
As the new system cranks up for July the same constraints will apply to ICB/ICSs as applied to CCGs, and perhaps even a bit more.
Cutbacks that damage patient care, even if forced through in private, will eventually emerge as a great, stinking embarrassment to local politicians: and with the formal establishment of ICBs and grudging acceptance that places on them could be taken by elected councillors rather than servile chief executives, this could now cause more ructions than before.
But to maximise the chance of ructions campaigners and the public need to get digging now through published papers of every ICB and local trust to ensure that every significant erosion of the NHS is publicised and challenged.
There are only 42 ICS to keep track of, compared with over 200 CCGs when they were first set up. There are campaigners in many areas with the skills needed to follow every move they make. And with local government taking responsibility for decisions, council leaders must also be challenged and held to account.
It’s not what the Tories planned to come out of the Bill, but their latest “reform” could have actually made it harder at local level to continue the austerity regime and the erosion of the NHS that they thought would be centrally driven through ICBs.
As the ICBs prepare to take over, let’s not pronounce the ‘death of the NHS’, organise wakes or funerals, or in any way give up on defence of the valuable services that only the NHS provides: let’s step up the fight to keep it alive and kicking through its 75th anniversary next year, and beyond!
- For space reasons the third, and final, part of this survey, focused on London’s five ICSs, will appear in our next issue.
- See the more extended area by area survey here and a summary of the full survey here.
- Author John Lister is joint author with Jacky Davis of the new book NHS Under Siege: the fight to save it in the age Covid, published May 19 by Merlin. It is reviewed by Roy Lilley here. You can purchase it online here. 25% discount with code NHS1948 until 17th July
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