Cheshire & Merseyside ICB (C&M)
Local campaigners are challenging the ICB Chair’s announcement at the July Integrated Care Board (ICB) meeting of a move from meeting in public every month to every two months, with unspecified “other Board meetings” in private.
The campaigners note that:
“It’s unclear if this means there will be no public access to Board papers, agendas, reports or minutes for any Board meetings in between the public meetings. A member of the public asked the Chair to clarify this as the Chair was closing the meeting, but the Chair and CEO stood up to pack their bags. The Chief Executive of Warrington Council spoke to us to say this was the first he’d heard of it.”
Certainly the ICB is likely to have a number of things it would like to keep from the local public as it wrestles with cash pressures in one of the largest ICBs.
The May Board received the financial plan for 2023/24, which plans for a £51.2m deficit, made up of provider deficits totalling £120m combined with an ICB surplus of £69m. (p145)
The Finance and Resources Committee noted the proposed cost improvements and non-recurrent savings required to deliver this result were “high to medium risk”.
Indeed by Month 3 (end of June) the system was already reporting the plan failing, with a deficit of £75.4m against a planned deficit of £54.9m – an “adverse year to date variance of £20.5m.”
The challenge facing C&M is especially severe as a result of the reduced level of growth year by year as part of the “convergence” to bring previously better-funded ICBs into line with those that were previously funded below target:
“The total convergence adjustment for an ICB depends on their distance from target allocation. Systems consuming more than their fair share will have a greater convergence ask and therefore a lower level of growth than the national average.
“For 2023/24, C&M ICB has received a convergence adjustment … which equates to a reduction in its recurrent allocation of £36.5m. It should be noted that our system convergence adjustment increases to £72.1m in 2024/25.” (p137) Local campaigners point to ICB figures warning that the total loss of revenue could add up to £350m over the next few years.
This year’s projected £51.2m deficit target can only be achieved by means of massive packages of “efficiency savings” totalling £58m for the ICB (including a hefty £23m unexplained saving from commissioning and procurement of “all-age continuing care” and £19m of cuts in spending on primary care subscribing, as well as £2m from “demand management” – i.e. reducing numbers of referrals). (p141)
But the bigger problem is the huge £331m target for efficiency savings by providers, of which £264m is supposed to be recurrent savings. Unlike many other areas the targets for savings don’t just fall on the main acute providers, but also mental health trusts (Mersey Care FT £37.2m and Cheshire and Wirral Partnership FT £12.8m (p294).
No details have been given on how such large sums can be “saved” without cutting services, and holding alternate meetings in secret seems designed to keep any details closely under wraps.
Greater Manchester ICB (GM)
GM’s method of minimising scrutiny and public awareness of their plans include making the Board papers extremely hard to find on a website with a poor search facility that keeps steering towards the Integrated Care Partnership, the largely toothless body that creates an impression of taking local government involvement seriously.
Minutes from the March Board revealed that the Month 10 position for the system was a deficit of £32.9m against a planned deficit of £4.9m, representing a year to date overspend of £28.0m. The Board was told this equated to a “£34.8m improvement within the year to date (YTD) position,”, from the position reported at month 9, and that this improvement was predominantly driven by increased delivery of efficiencies in both NHS GM and providers. (p8)
Based on this underlying problem the plan submitted to NHS England in March projected a 2023/24 deficit of £240m. This was revised sharply downwards the following month, which outlined plans for a £159m deficit, which “received significant challenge by NHSE,” and resulted in the ICB revising the figures yet again – to “a breakeven position, with support from NHS England.”
However this was only achieved by including “unidentified system savings of £115m.” (p53)
And by month 2 things were already going predictably wrong. The system was £62.7m in deficit against plan of £14.5m – a variance of £48.1m against plan. This was a combination of providers falling £23.5m short on planned savings “relating to CIP/QIPP delivery, pay award and industrial action,” while the ICB itself (“NHS GM”) was £24.6m adrift, “of which £20m relates to system wide efficiency target hosted by NHS GM.” (p81)
This is scarcely surprising given the full year combined target for efficiency savings is a staggering £606.2m.
According to the July Board papers, the ‘gross risk’ to delivery of this total savings target is £258.8m, while “potential mitigations” may reduce the risk to £140.8m.
The Finance Report warns: “There are also significant assumptions within plans around the delivery of remaining £463.5m of efficiency savings forecast to be achieved.” (p84)
The May Board made clear that increased activity within the non-NHS (private) sector in mental health and ophthalmology was a factor driving overspending (p68). Nevertheless one independent provider of mental health services which closed in April had been replaced by another (p97) and GM was continuing to work to tackle elective waits over 65 weeks through mutual aid “and the use of the Independent Sector.” (p103/4)
Lancashire & South Cumbria ICB (LSC)
The ICB chief executive Kevin Lavery has published an honest assessment of the state of the health and care system in the region, which begins:
“I want to be up front with you. We are a system approaching a cliff edge and will need to make fundamental changes to avoid falling off.”
Mr Lavery, who wants to make the case for reconfiguration (and reduction) of acute services across the geographically large ICB is keen to stress the scale of the financial challenges ahead. He explains:
“Prior to the COVID-19 pandemic, the Lancashire and South Cumbria health and care system was consuming more financial resources than it was allocated.
“In the financial year 2019/20, the hospital trusts were overspending by a total of £171 million.
“During the pandemic, funding was provided to cover all the costs in the system but this masked the true underlying position that has not been addressed. The underlying financial risk at the beginning of 2022/23 was more than £300 million and the additional funding we are receiving is being tapered out over the next three years.” (p12)
He also has shocking figures on the level of dependence on agency staff: “As a system, we are currently spending more than £300million on expensive agency staff rather than employing people.” (p16)
Only one of the ICB’s five main providers has not been rated by the CQC as requiring improvement, and three of the four are rated by NHS England as requiring “significant support”, while the fourth is rated as “in actual or suspected breach of licence.” (p17)
Mr Lavery warns “The health and care system has never been more fragile. The workforce is tired, morale is low and the threat of even more challenging months ahead is growing.” (p27)
This is also underlined by minutes of the March Board which showed the system was not working. With 124 extra escalation beds open, there was still an increase in 12 hour waits in A&E. 351 beds (one in eight of all occupied beds) held patients who were reported as ‘not meeting medical criteria to reside’ on March 24. 50% of beds were occupied by people who had been in hospital for over 7 days and 17% had been in for over 21 days.
At the end of 2022/23 savings of £153.1m had been delivered across the system, leaving a shortfall of £33.7m against plan: but only 43% of the savings delivered were recurrent.
May’s CEO report warned that things were going to get worse:
“The ICB had the largest financial risk out of the six NHS organisations within Lancashire and South Cumbria at the start of the 23/24 financial year. … the challenge is significant and there are going to be some difficult decisions we need to make as part of our recovery stance that will impact services.”
However the frankness ends there: the CEO goes on to state that the outcome of discussions between ICB leaders and NHS England on the financial and non-financial challenges would be reported behind closed doors in part 2 of the May meeting.
By July the ICB papers were noting that LSC is “one of 14 systems in England that has confirmed that we will end the year with a budget deficit, having been one of the original five ICBs that had forecasted this outcome,” with the CEO explicitly arguing for reconfiguration to reduce to just two or three elective sites, and major non-clinical reconfiguration with a single platform for shared services and the collaboration bank – with yet another warning of the need for “strong leadership and making difficult decisions.” (p6)
Nor is there any relief in sight through the promise that the ICB was in line to have two new hospitals as part of the “40 new hospitals” promise: the latest information suggests these will be delayed “from 2030 to 2035” – and in any case the ICB is expecting the new buildings to have fewer beds. (p10)
The Finance report reveals that the final ICB plan is for a deficit of £80m, agreed with NHS England, “but with an expectation that we continue to strive for a breakeven position given this is a statutory duty.”
The catch is the “high level of savings” (£457 million) that are required even to deliver a deficit of £80m:
“a high level of savings totalling £287m to be delivered through each organisation’s operations,
“a stretch on top of this of £168m which remain high risk and requires a system approach though the recovery work being developed;
- £76m stretch for the ICB
- £72m across the provider acute trust and
- £20m for out of area placements .
£287m represents 6.8% of the total allocation for the system. (p5)
Once again, however the discussion on exactly what tough decisions are proposed and what will be decided was to take place behind closed doors in part 2 of the meeting, leaving the local public and health staff completely in the dark on the implications.
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