Back in May The Lowdown surveyed the plans being drawn up for the launch of Integrated Care Boards (ICBs) as the new “local” bodies holding the purse strings of the NHS and charged with implementing the renewed government austerity limits on spending.

We warned that the 42 new bodies to take over from July were being created in conditions of crisis – but also that few of them appeared willing to face the grim financial realities, which have since got even worse.

We warned that despite bowing to NHS England pressure to submit largely fictional and hugely optimistic plans projecting financial balance, Integrated Care Systems face combined deficits and spending constraints that would required billion of “efficiency savings” or in the jovial NHS parlance “cost improvement programmes” (CIPs). 

And we also warned that, judging from the draft plans that had been published, it was clear that a very large proportion of these “savings” would be either “non-recurrent” (one-off measures that leave the underlying problem untouched), or simply left “unidentified” –  as a problem kicked down the road while management hoped against hope some more cash would turn up.

Having now surveyed the available Board papers for more than half (22 of the 42 ICBs) it’s clear we were right on all counts. But since we ploughed through the chaotic array of widely different financial projections in May things have got much, much worse.

NHS England’s October Board papers set out a challenging outlook, having already committed to deliver annualised savings of £12bn by 2024/25, and it is expected that inflation, still in double digits, could add a cost pressure of a further £6-7bn

However Chancellor Jeremy Hunt’s autumn statement made clear just half of this (£3.3bn) will be covered by extra funding this year and next.

In addition:

  • NHS nurses and ambulance staff are striking for more pay;
  • almost 7,000 hospital beds in England are filled with Covid patients (December 14) while the government’s allocation of additional Covid funding is falling back towards zero;
  • An average of another 13,000 front line beds are filled with patients who cannot be discharged for lack of social care or community health services to support them, 
  • and at the same time, NHS trusts are expected to deliver an incredibly ambitious elective recovery programme with no additional capital, hospitals needing £10 billion-plus of backlog maintenance.

But with insufficient funding and capacity, NHS England have been trying to bully their way through. They have sent out draconian orders seeking to whip reluctant ICBs in to line, threatening various bureaucratic controls over those who fail to deliver a balanced budget despite the runaway costs faced by providers, soaring pharmaceutical budgets and the rising cost in almost every area of employing bank and private agency staff to fill the growing numbers of unfilled posts.

However there is still little evidence that many, if any of the first 22 ICBs surveyed (in East of England, London and Midlands regions) have kept up at all with the events and decisions taking place at the top. The usual pre-Christmas letters listing impossible demands in even less likely timescales seem to have less and less impact each year as they appear even further out of step with the situation on the ground.

The aim since the formal reorganisation into Integrated Care Systems now appears to be to threaten to inundate ICBs and trusts that overspend with pointless paperwork and more meetings. 

Coventry & Warwickshire ICB has revealed that on 7 November, NHSE issued to systems the “Protocol for changes to in-year revenue financial forecast” document (which has also been leaked to the HSJ, but is not published on the NHS England website). 

This sets out the required actions to be taken by: 

  • any provider considering a deterioration in forecast but which the system can absorb, in which case the operation of the protocol will be overseen by the system; or 
  • any system forecasting for a deficit, in which case the operation of the protocol will be overseen by the region.

Any NHS provider wishing even to report a forecast deterioration is expected to:

  • Complete a ‘variance analysis’ to be presented to local system leaders
  • Complete a detailed review of any uncommitted expenditure.
  • Prepare a ‘recovery plan’ showing the steps that have been and will be taken to reduce expenditure.
  • Include any shortcomings identified from the Health Finance Management Association’s ‘financial sustainability checklist’ – and how they are being addressed.
  • Provide evidence of sign-off of the above by the whole of the ICB’s executive team.
  • Submit to a suitably independent review – with, for example a neighbouring provider – to confirm all possible mitigating steps are being taken
  • Provide evidence of non-executive scrutiny of the above, and sign off by the board, including a board assurance statement signed by the chair, Chief executive, Chief Financial Officer and a relevant Non-Executive Director to confirm adherence to the protocol and their commitment to the delivery of the recovery plan.

Any ICB and/or system wishing to report a forecast deficit position is required to go through all of the above – overseen by NHS England regional team (who apparently have nothing else to do). These obscure, bureaucrats are likely to be kept pretty busy with this nonsense as the financial wheels come off into the new year in ever more local ICBs.

The HSJ also reports that over-spending trusts must get ‘sign-off’ from their integrated care board for all revenue investments over £50,000, while integrated care boards and systems forecasting a deterioration face “a triple-lock sign-off process for any revenue investments above £100,000, with sign-off required by the organisation, system and NHS England regional team”.

None of this of course does anything to address the under-funding and increased cost pressures that would have driven the ICB into deficit in the first place.

But it’s not at all clear from ICB agendas that such correspondence even reaches the Board members who NHS England want to bully into line, and even less evidence so far of Boards other than Coventry & Warwickshire taking much notice. Even if they do, it’s not at all clear how they are supposed to squeeze still more effort out of exhausted and inundated staff, crumbling hospitals, and clapped out equipment.

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