ICBs aim for £8bn savings, risking NHS staff and delays 

ICB WATCH – data collection October 2024

An investigation by The Lowdown of all 42 Integrated Care Systems (ICS) in England has found that nearly all are making decisions to restrict spending by a collective total of around £8bn.

You may be forgiven for thinking the cash from the budget has eased the situation—it will help, but high demand for care, pay rises, and inflation all chip away at the rise. Two more reasons why huge savings are being made are the demand for each ICS to stay within budget and the requirement to increase their productivity by 2% across the NHS but higher in many individual instances, which is a tough ask.

Unsurprisingly, the primary focus for making these substantial savings is the NHSs most significant area of expenditure: its workforce.

Workforce savings and cuts

Lowdown researchers found that nearly all ICSs aim to restrict agency and bank staffing, which cost the NHS over £10bn last year.

However, for some ICSs to meet their savings targets, more than reducing temporary staff expenditures is required. This has caused NHS leaders to order recruitment freezes, such as in Cornwall, Sussex, Cheshire, and Merseyside, or to leave vacant posts unfilled.

In addition, we found that ICB leaders in all regions are now setting targets to reduce the size of their workforce to help cut their financial deficits and achieve efficiency targets. This is despite the NHS facing a considerable challenge in meeting demand for its services and a stated plan for its workforce to grow nationally.

This study of ICBs in England supports the findings of a poll of NHS leaders: 67 per cent of NHS trusts and ICBs plan to reduce clinical staff to meet their efficiency targets, and 90 per cent plan to reduce non-clinical staff.

Here are four examples from our investigation.

Derby and Derbyshire

Their 2024/25 Operational Plan aims to generate a workforce reduction of 3.6% (927 Whole Time Equivalents) across the system’s four Foundation Trusts. This is part of the plan to stay within the £50m deficit agreed with NHS England, but at month 4, they were £3m outside this target.

Mid and South Essex

For 2024/25, the system’s deficit plan of £96m, agreed with NHS England (3.6% of allocation) requires £154.8m of efficiency savings (5.8% of ICB allocation) – and faces “additional net risks” of £79.8m.

The providers have planned to reduce agency costs by a challenging £49.8m and Bank costs by a further £60.8m between 2023/24 and 2024/25.

NHS Bath and North East Somerset, Swindon and Wiltshire

This ICB planned to reduce the substantive workforce by 1.9%/281 WTE, bank by 39% / 418 WTE and agency by 35% / 65 WTE. Each provider within the ICS has workforce reductions listed. The agreed year-end deficit is £30 million, but by month 4 of the financial year, the ICS was already reporting a £21million deficit

Dorset

The ICB targets a reduction in the headcount for 2024/25 of 758 WTE – 26% (199) achieved in June 2024. However, November Board papers warn of “a risk-adjusted internal forecast of £67.3m against our planned deficit of £21.3m”

Breakdown for all ICBs

Top Ten ICS savings targets:

What is the impact of workforce cuts?

These workforce restrictions appear to deviate from the strategic aim of the NHS workforce plan, which is to raise NHS staff by around 3.5 % yearly over ten years.

At the moment, it is unknown how these cost-saving measures will impact precisely, and there is some evidence that recruitment freezes in foundation trusts are centred on non-clinical areas in some instances.

However, as winter approaches, attempts to reduce temporary staff must be made without implementing cuts in overall staffing levels; pressures are already high, and staff recruitment and retention are crucial.

Nurse and UNISON Royal Gwent Hospital branch secretary Andrea Prince said:

 “I cover 15 wards, ranging from an acute medical admissions unit to care of the elderly wards. I have been a nurse for 36 years and in the last decade I have seen staffing levels really deteriorate.

“Agency staff are essential just to maintain the current poor staffing levels. If we don’t act together now, this issue is going to get worse. Safe staffing levels are absolutely vital for the NHS.”

There is currently no law setting safe nursing levels in England, whereas these were introduced in Wales, Scotland, and Northern Ireland. For example, in Scotland, there is now a legal duty on NHS and care providers to make sure there are always appropriately qualified staff and enough of them safe and effective care. This duty is set out in the Health and Care (Staffing) (Scotland) Act 2019, which came into force in April 2024.

Why are trusts chasing such high savings targets?

DEFICITS

Currently, 31 out of 42 systems still have a deficit plan for the year, projecting a total overspend of £2.2 billion; NHS England has stated they will cover this agreed overspend. However, we discovered that debts are becoming more significant as winter approaches.

SAVINGS TARGETS

An NHS Confederation survey of NHS leaders concluded

“On average, NHS leaders say they are being asked to make efficiency and productivity savings of 6 per cent, with requirements ranging from 1.6 per cent up to 11 per cent. Over half of ICB and NHS trust respondents predict they will not meet their target (figure 2). Almost two-thirds say they can only meet their target with more money from NHS England within the year.”

RISING PRESSURES AND COSTS

Common factors reported by ICBs were;

The NHS is currently grappling with the critical issue of escalating prescribing costs, a situation further compounded by patients’ increasing health needs and the pharmaceutical industry’s inflationary pressures.

Integrated Care Boards (ICBs) across all regions of the English NHS note the increasing expenses associated with NHS continuing care, such as that for elderly patients with various types of dementia, which includes regular medical check-ups, medication management, and support with daily activities.

Several regions are experiencing a significant increase in mental health patients necessitating admission, a trend that often leads to expensive referrals to private providers. This is a direct result of the NHS’s insufficient capacity, putting a strain on its finances.

Hiring extra staff to provide intensive care for severely ill patients increases costs. Emergency admissions, particularly for serious Type 1 A&E cases, remain constant despite efforts to divert patients from A&E.

Many ICBs are responding to the incentivised scheme – Elective Recovery Fund, which offers additional funding for increased operations. ICBs are factoring this extra income into their forecasts, but failing to meet these financial targets could significantly impact their financial standing.

The number of available general hospital beds fell in the last quarter of 2000 (and is now 7000 less than in 2010).

Many hospitals struggle to discharge patients due to a lack of community health, primary care, or social care support.

This results in more beds being occupied by patients who have stayed for over 14 days, with over 29% occupied by such cases for the past year.

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