The worsening financial plight of England’s 42 Integrated Care Systems (ICSs) is widening the gulf between NHS England issuing demands for further cutbacks to balance the books and trusts struggling to make ends meet on the ground.

The situation has been worsened by the government (Treasury) refusal to allocate any additional money to the NHS to cover the extra costs of keeping services going during the repeated rounds of strike action, even though these were triggered and prolonged nationally by the government’s own stubborn refusal to negotiate on NHS pay, especially junior doctors.

NHS England has now estimated these costs as totalling around £1 billion. So in the absence of additional funds, they have had to hold back efforts to reduce the 7.7 million-strong waiting list and further cut back already pared-down plans for digitisation in order to free up £800 million to allocate towards the costs of the strikes.

But with ICS deficits estimated as £1.5 billion worse than planned in the first six months of the financial year (and the plans already skewed by ridiculous assumptions of massive savings to balance the books in many ICSs), NHS England’s new priorities until April are “to achieve financial balance, protect patient safety and prioritise emergency performance and capacity.”

ICSs were given just two weeks to complete “a rapid exercise” to identify and agree ways to balance the books, with some telling the Health Service Journal this means setting out “unpalatable” options for cuts in spending, and another talking of “nuclear options” being discussed that would be “catastrophic for quality of care and/or nigh-on impossible to deliver.”

The most recent Lowdown survey of Integrated Care Board (ICB) meeting papers showed the worsening situation, but also warned that few if any ICBs have actually spelled out how they and local providers intend to save the tens, or hundreds of millions needed to balance the books. Giving these bodies just two weeks to agree on new plans ensures there could be minimal if any consultation or public debate on what is to be cut, by how much, and why.

Some have discussed the need for radical change in scary broad-brush terms, notably Lancashire and South Cumbria ICB, which needs to “save” £450m to bring its deficit down to £80m by April. Its chief executive has made no bones about his ambition to “reconfigure” hospital services – closing at least half of the current six A&E units and leaving just two or three elective sites, along with major non-clinical reconfiguration.

However, none of this has yet come forward as detailed proposals.

In Hampshire and Isle of Wight, on the other hand, which has one of the larger ICB deficits, it seems health chiefs intend to open a rapid 12-week consultation on plans to close A&E services at Royal Hampshire County Hospital in Winchester, and develop a brand-new hospital in Basingstoke.

This would mean emergency patients in Winchester having to travel 20 miles to Basingstoke – or 13 miles to Southampton, which is expected to face the biggest impact.

The plan, which centres on the promise of between £700 and £900 million to invest in a new hospital – seems to have run well ahead of the actual availability of the cash. As yet there is no timescale for this, and not even a business case in place to ensure the money is released.

Indeed Hampshire Hospitals was one of the eight schemes that back in May the then Health Secretary Steve Barclay announced would be postponed until the next decade, after ministers agreed just £20bn of capital funding would be available for the laughingly labelled “New Hospitals Programme” by 2030, rather than the £35bn cost of the full list.

We may now begin to see more tangible and dramatic proposals on how to make the spending cuts necessary to balance the books: but with just four months left to the end of the year, three of them the toughest months of the winter, only the most draconian measures could deliver the scale of cuts required.

Even now the further £350m of cutbacks NHS England has made to the Frontline Digitisation programme, coming on top of the £630m reduction announced in August, means the original £2.6bn scheme has been slashed by 40% to £1.6bn.

Website explains that the cutbacks mean that only the trusts in the very weakest position, those lacking any electronic patient records system, and those with only a business case but no functioning system, will now get any funding. Another 132 trusts that had been promised funds to optimise or extent their EPR systems will get nothing.

Meanwhile the bodies representing NHS and foundation trusts are increasingly warning of the dire consequences if there is no extra capital funding for England’s NHS.

The NHS Confed argues that NHS capital budgets need to nearly double from £7.7bn to £14.1bn – an extra £6.4bn in all three years of the next Spending Review – if the NHS is to clear the building repairs backlog and overhaul the estate to enable greater productivity and faster patient care.

It warns that capital budgets continue to be raided, “with the latest raid being used to plug the rising deficits in the day-to-day NHS budget caused by strike action and other cost pressures.”

Matthew Taylor, chief executive of the NHS Confederation said: “Some of our members have parts of their estate that are barely fit for the 19th century, let alone the 21st, so any future Secretary of State for Health and Social Care must make the physical and digital condition of the NHS a priority, if the health service is to reduce backlogs and get productivity levels to where the government want them to be.”

The Confed’s November 28 press release cites examples of the progress and cash savings that can be made from investment – and the setbacks that follow when there is no capital to invest in improved diagnostics, noting the cancellation of a £25m planned diagnostics centre in Bedfordshire, Luton and Milton Keynes.

It warns that not only does the government not have a capital strategy for the NHS, but that the UK has consistently spent less money on capital investment than comparable countries for more than half a century, resulting in healthcare productivity increasing at an average of 0.9 per cent annually over the past 25 years:

“In the ten years to 2019, Health Foundation analysis suggests that had England matched the EU14 OECD average for healthcare capital spending, we would have spent another £33bn on capital. Instead, we have leaking roofs, broken lifts and outdated IT systems waiting to be fixed …”

It’s not just acute services: the Confed argues that almost one in every six mental health and learning disability sites in England were built before 1948 and 20% of GP practice premises are not fit for purpose.

So bad is the situation that “In one case up to 15% of staff time was wasted on estate problems, like putting buckets under leaky roofs, which could be spent on patient care.”

While the Confed’s urgent plea for action came too late to make any impact on Jeremy Hunt’s tight-fisted budget that continued to starve public services of investment to hand out tax cuts, its rival NHS Providers got in earlier with a November 14 warning that trust chiefs believe this winter could be even tougher for the NHS than the last:

“Money worries continue to mount with more than three in four trust leaders (76%) saying they are set to be in a worse financial position than last year. Funding pressures are fuelling concerns about future patient safety and the quality of care as well as threatening to hit trusts’ ability to ramp up services as they brace for winter.”

Its survey of trust leaders found almost universal gloom:

  • Eight in 10 leaders (80%) say this winter will be tougher than last year (66% said last year was the most challenging they had ever seen).
  • 95% are concerned about the impact of winter pressures.
  • Most (78%) are worried about having enough capacity to meet demand over the next 12 months – higher than before the pandemic in 2019 (61%).
  • Most are concerned about the current level of burnout (84%) and morale (83%) in the workforce.
  • Almost nine in 10 (89%) are worried that not enough national investment is being made in social care in their local area.

Hunt, as we know and could have predicted, remained unmoved by the crisis created by 13 years of under-funding by a succession of Tory chancellors. But as the Confed and NHS Providers warn, the cost of this will be felt by patients.






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