Our investigation, carried out across all 42 Integrated Care Systems in England, found that nearly all are making decisions to restrict spending by a collective total of around £8bn.
Unsurprisingly, their primary focus for savings is their most significant area of expenditure: their workforce.
Nearly all of the lead decision-making bodies in each area (Integrated Care Boards) aim to restrict agency and bank staffing, which cost the NHS over £10bn last year.
Replacing agency staff with more NHS staff would save money, but not enough, forcing many NHS leaders to go further and order recruitment freezes, such as in Cornwall, Sussex, Cheshire, and Merseyside, or to leave vacant posts unfilled.
We found that similar workforce cuts are being made across the country. 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 agreed £50m deficit, but at month 4, they were £3m outside this target.
Mid and South Essex
For 2024/25, the system’s deficit plan of £96m (3.6% of allocation) requires £154.8m of efficiency savings (5.8% of ICB allocation) – and faces “additional net risks” of £79.8m (a further 3% of allocation).
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
The plan is 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 is targeting a reduction in the headcount target for 2024/25 of 758 WTE – 26% (199) achieved in June 2024, but November Board papers warn of “a risk-adjusted internal forecast of £67.3m against our planned deficit of £21.3m”
Top five savings targets:
| Integrated Care System | Savings Target (£m) |
| NHS Lancashire and South Cumbria | 530 |
| NHS Humber and North Yorkshire | 520 |
| NHS Greater Manchester | 490 |
| NHS West Yorkshire | 434 |
| NHS Cheshire and Merseyside | 440 |
This study of ICBs in England supports the results and adds further detail to a poll of NHS leaders that found that 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.
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 include rising prescribing costs, driven by patients’ growing health needs and the pharmaceutical industry’s inflationary pressures, which further complicate the NHS’s financial landscape.
The rising costs of continuing care – such as for older patients with forms of dementia, are mentioned by ICBs across England.
Several areas report a rise in mental health patients requiring admission, often leading to costly referrals to private providers due to the NHS’s inadequate capacity.
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.
Several areas state that their Level of elective activity is not high enough to generate the planned income, responding to financial incentives to access funding from the elective recovery fund by raising the number of operations performed.
Promised increases in hospital beds have yet to materialize, and 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% of these beds occupied by such cases for the past year.
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