Just one year after they were established as the new “local” bodies controlling health care budgets, and after twelve months of mounting financial pressure and crisis, NHS England has begun more vigorously to crack the whip over Integrated Care Boards.

Fifteen ICBs showed the extent of their financial problems when they submitted plans for 2023/24 that would result in a £750m deficit. They have now been instructed to review their staffing levels and seek ways to reduce numbers of staff as NHS England prioritise balancing the books, and likely undermine efforts to reduce delays in accessing care.

Sixteen of the 42 ICBs failed to achieve breakeven in 2022/23, but all 42 relied heavily on one-off savings that left underlying deficits unresolved, and have faced a much tougher financial situation for this financial year – with NHS England having unwisely committed to generating £12 billion in “savings” by 2025.

freezing staffing posts

This latest edict demands trusts with deficit plans review all their staffing vacancies to ‘consider where the removal or freezing of posts is appropriate’. It follows top-down NHSE pressure on trusts in April to hold down their staffing levels – despite the fact that many trust deficits have been worsened by excess costs of filling vacant posts with agency staff.

The HSJ has reported the pressure on [bullying of] ICS leaders has become up front and personal, with: “ICS leaders … being called in for meetings with NHSE to go through the measures, with the level of oversight and scrutiny dependent on NHSE’s “confidence in the leadership and the quality of their [financial] recovery plan”.

The HSJ notes that even ICBs with plans to break even are facing similar pressure.

Top-down control

Nuffield Trust director of strategy Helen Buckingham warns that the heavy-handed, top-down NHSE approach appears to show “a lack of trust and a micro-managing approach.” She emphasises the need for local leaders in full possession of the facts on the ground to “ensure patient safety alongside good financial management.”

While some campaigners have argued that ICBs represent a move to carve up and decentralise the NHS, the extent of top-down control in the context of the worsening financial situation has in practice ensured that “integrated care” has become, as Lowdown warned, a system of austerity and crisis.

This reality on the ground, with heavy-handed centralised control, and a barrage of bureaucracy facing any local system that falls into deficit, is a far cry from the theoretical increase in local/regional autonomy that was supposed to be the aim of Integrated Care Boards.

Last year’s Health and Social Care Act put decision-making in the hands of these so-called ‘Integrated Care Boards’ (ICBs), but also significantly strengthened the powers of the Secretary of State. As The Lowdown warned, this has left little if any accountability to the local communities the ICBs cover.

But the system also now works to discourage any honesty or openness in accounting which might lead to some sense of solidarity between deficit-ridden ICBs. Last November NHS England set up tough new rules to deter ICB finance chiefs from giving early reports of any negative change in their financial situation – effectively encouraging ICBs to cover up reality and delay any unpleasant news (and any consequences) until the last minute.

NHS England subsequently also bounced back revised plans for deficit budgets in 2023/24, which according to the HSJ still collectively added up to a deficit of £3 billion. ICBs facing future deficits were effectively urged to lie about the local situation to get their plans approved.

The HSJ reported in late April that NHS England was applying new pressure directly on to trusts which had failed to submit a balanced budget for 2023/24 – with around a quarter of trust submissions for 2023-24 initially deemed unacceptable.

Sources told the HSJ that NHSE had begun “turning the screws,” going through trust plans to identify further savings, and applying “intense” pressure. One acute truss boss said: “Every trust in the country is having to go back and take more out of its budget.”

However despite all of the pressure, it seems ICBs have still been unable to deliver credible plans for balanced budgets: just two months in to the financial year it seems ICBs are already £340 million adrift, suggesting a potential combined £2.75bn annual deficit.

The Nuffield Trust’s Sally Gainsbury told the HSJ: “While a proportion of this overspend will be the cost of strike cover and disruption, the bigger issue is that the ICS funding envelope for this year is a mission impossible.”

Unrealistic demands

To make matters worse, the government’s latest “Mandate” to the NHS demands systems somehow manage to reduce the 7.5m waiting list despite the capacity constraints and the staff shortages. 

Its second paragraph rattles out the latest misleading government mantra,  claiming it has “made up to £14.1 billion available for health and social care over the next 2 years,” when in fact the £3.3bn (1.8%) increase to NHS budgets each year is less than half the £7bn health bosses argued was needed to cope with soaring inflation and increased pressures. The remaining £7.5bn is allocated to social care.

Nonetheless the Mandate appears to commit the NHS to a substantial increase in services, setting an England target of 76% of patients being admitted, transferred or discharged within 4 hours by March 2024, and promising improved ambulance response times for Category 2 incidents “to 30 minutes on average over 2023 to 2024.”

Perhaps most implausibly the Mandate goes on to offer another promise that is backed by neither funding nor staff: “This will also include increasing capacity, with 5,000 more beds as part of the permanent bed base for next winter and 800 new ambulances on the road, including specialist mental health ambulances”.

The setting of a national target of 5,000 more beds appears to lack any more detailed breakdown, leaving open the debates at every local trust about exactly what is affordable, and what is clinically viable given staff shortages. The Lowdown will be closely monitoring the numbers of front line beds that are actually made available, and comparing with previous years.

Interestingly the Mandate, apparently oblivious to NHSE’s clampdown on staff numbers, and the problems of recruitment and retention that have been worsened by ministers choosing to provoke strikes rather than negotiate fair pay, argues that its expanded provision “will be aided by increasing the size and flexibility of the workforce.”

However on finance, the Mandate again makes clear that the government “expects that NHS England will ensure that overall financial balance is delivered for the NHS each and every year,” regardless of the impact on patient care. The Secretary of State underlines the prime responsibility of ICBs – to do as they are told by the bullies-in-chief at NHS England, and balance the books, insisting:

“NHS England will ensure that all ICBs exercise their functions with a view to delivering financial balance. Where deficits occur an agreed recovery plan will be in place to return to financial balance over time.”

And while the covert threats and misleading promises continue, we are still waiting for any of the 42 ICBs to reveal any detail on exactly how they will make the “savings” they require, what services may be axed or cut back, what staff may find their jobs at risk … and how all this will be done while opening another 5,000 beds.


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