Many of our NHS trusts are weighed down with year-on-year financial pressures. To investigate, we conducted an in-depth survey in one region, analysing a year’s worth of public board papers from all 31 NHS Trusts in the North West and the three integrated care boards that oversee them. It shows a damaging, repeating cycle which undermines hospitals and community services across the NHS.
Unrealistic savings targets are being set, leading to plans to cut staff costs; some cuts are achieved, but demand for healthcare and safety prevent further cuts. Recorded risks rise, and pressure on staff increases. At year-end, missed financial targets mean more savings are required, and the cycle repeats.
Key points
- The North West’s three health systems squeezed £1.47bn in savings out of 2025/26, but all three still fell short of what appear to be unrealistic savings targets.
- 20 of the 31 trusts set a target to cut posts. At least 13 finished the year with more staff than their own workforce plan allowed.
- Posts were cut. Between April 2025 and April 2026, 1,560 clinical support posts were lost across the region, while the number of registered clinical staff grew by 1,634.
- Boards rate 93 of their own risks as very high to extreme, and patient care and safety is the biggest group.
- At least £1.09bn of savings is already earmarked for 2026/27, and 20 trusts plan to cut staff again.
Starting point
Each spring, NHS Trusts must submit and agree a savings plan for the year with NHS England. Last year, the North West health system as a whole made £1.47 billion in savings. Their end-of-year finance reports show that all three health systems fell short of what they were asked to find.
Staff pay is the NHS’s biggest expense, so making workforce changes becomes central to saving money, Especially as the financial squeeze on the NHS, aside from the pandemic, has been unrelenting for a decade so easy options for waste reduction or income from the sell-off of land have, for most trusts, already been done.
In 2025-26, 20 of the North West’s 31 trusts (hospital, mental health, and community) targeted workforce reductions. These cuts are measured in full-time equivalents (WTE) rather than individual job losses, allowing trusts to reduce staffing hours without necessarily cutting specific people.
Board papers reveal how trusts went about making these workforce savings. At least 18 trusts ran a voluntary redundancy scheme or a mutually agreed resignation scheme, where staff are paid to leave by agreement.
At least 26 used a vacancy control panel or a recruitment freeze, heavily restricting or completely stopping new staff from joining the trust. Both figures are minimums, as they count only trusts whose papers mention it.
Trusts rarely say which of their cuts came from these schemes, so their papers don’t show how many posts the schemes removed. Some systems also set out to cut temporary staff. Cheshire and Merseyside planned to cut bank staffing by 16.6% and agency staffing by 35%. Bank staff are the NHS’s own pool of flexible workers, essential to cover holiday, sickness and shortages in other areas.
North West NHS workforce review
When the money tightens, the workforce pays
31 trusts, 3 integrated care boards, a year of board papers. Every figure sourced to the page.
Explore the review →
1
Cuts made, targets missed
Which trusts set targets, who delivered, who missed, and how the cuts were made.
Read more →
2
The risks boards are carrying
Every risk scored at the top of the scale, board by board, in their own words.
Read more →
3
What staff say
Staffing, burnout and sickness, trust by trust, from the NHS Staff Survey.
Read more →
What happened next?
Posts were cut, but often not on the scale planned. Of the 20 trusts with a target, 16 reported a reduction of some kind. But most missed their target: 13 trusts finished the year above their workforce plan, paying for more staff time than planned. Seven trusts appear in both groups, because a trust can hit one target, such as agency spending, while missing another, such as bank or permanent staff. Thirteen is a minimum: for Morecambe Bay, the latest position we hold is from January 2026.
National figures show the cuts falling on clinical support staff: the healthcare, nursing and therapy assistants who give hands-on care but are not registered professionals. Across the 26 North West trusts that can be tracked on the same basis, 1,560 clinical support posts were lost in the year to April 2026, and numbers fell at 19 of those 26 trusts. Over the same time, the registered clinical workforce of doctors, nurses, midwives, and scientific and therapeutic staff grew by 1,634.
In our study of board papers, we found it difficult to identify stated reasons why plans to cut workforce costs often fell short. Where trusts did explain, they pointed to patient demand and safety.
Mid Cheshire, which ended the year 314 posts above its plan, says part of that came from extra beds opened to meet demand. Pennine Care met its target to cut agency staff but missed its bank target, “due to continued high bank usage on inpatient units.” Lancashire Teaching Hospitals’ risk register warns that pressure on urgent and emergency care, and patients arriving more seriously ill, may mean the workforce must be maintained rather than cut. Managers can only go so far while responding to patient demand and safety.
The cycle starts again
This year’s plans are already set. At least £1.09bn of savings is already earmarked across the North West for 2026/27: £665m in trusts’ own savings programmes and £422m in the three integrated care boards’ own targets. That is a minimum, because only 16 of the 31 trusts have published a figure. Twenty trusts plan to cut staff again this year. Fifteen have published a reduction figure, three have limited theirs to part of the workforce, and two have said they will reduce without giving a number.
What it means for risk
Every NHS board keeps a register of the most serious risks it faces, usually called its board assurance framework. Each risk is scored out of 25: from 1 to 5 for how likely it is to happen, multiplied by 1 to 5 for how much harm it would do. Across the region, boards rate 93 of their own risks very high to extreme (15 or more), and 30 are scored 20, the top of the scale. The biggest group is patient care and safety, with 38 risks, followed by money, with 24. No staffing risk is scored that high, but 17 sit just below the line, and 33 of the high-rated risks name both a financial cause and a workforce cause.
NHS Greater Manchester Integrated Care Board scores this risk at 20 out of 25:
“There is a risk that key health and care services become unsafe and unstable due to growing and changing demand, pressures faced by other sectors and workforce, estates and technology gaps. This will result in poorer health outcomes for the GM population and a reduction in quality of care and patient safety and an inability to deliver operational delivery standards.”
Lancashire and South Cumbria NHS Foundation Trust, the area’s mental health and community trust, scores this risk at 20:
“Failure to deliver adequate patient flow due to insufficient capacity, workforce challenges and delays in discharge leading to prolonged wait times, reduced access to services impacting quality and safety of patient care.”
NHS Cheshire and Merseyside Integrated Care Board scores this risk, on the safety of the services it pays for, at 20:
“The increased focus on the challenging system financial position, availability of resources and our need to increase productivity in 2025-26 makes it imperative to mitigate any potential impact to the quality and safety of commissioned services.”
The high-rated risks are not only about money and staff. East Lancashire’s register includes “Delays undertaking elective caesarean sections” (planned caesareans), scored 20. Stockport, and Tameside and Glossop, each score “Failure to maintain suitability of premises and environments” at 20. Northern Care Alliance also scores 20 for the risk that its digital infrastructure, with “1000+ applications, ageing hardware”, “cannot reliably support the delivery of safe, efficient services”.
What staff say
The NHS Staff Survey 2025 found that, on average across the North West’s trusts, only 31% of staff said there are enough of them at their organisation to do their job properly. At the Countess of Chester Hospital, it was 1 in 5. Around three in ten (31%) said they often or always feel burnt out, and about four in ten (42%) had felt unwell because of work-related stress. Three in ten (31%) said they often think about leaving.
Staff also have doubts about the care itself. The survey asks whether they would be happy with the standard of care if a friend or relative needed treatment. At 19 of the 31 trusts, staff were less positive than at similar trusts elsewhere in England, and at 8 trusts, fewer than half agreed. The lowest were North Cumbria (45%), East Lancashire (48%) and Blackpool (48%). At 21 trusts, fewer staff than at similar trusts agreed that the care of patients is their organisation’s top priority.
What patients face
Since June this year,NHS England has published monthly figures on corridor care. Several North West trusts have some of the highest figures.Northern Care Alliance, which runs hospitals in Salford, Oldham, Rochdale and Bury, averaged 52 patients a day in May, the 13th highest of 162 trusts.East Lancashire averaged 93 a day: 62 in A&E and 31 on its wards. It fell in June, but it is still the highest in Lancashire.
Waiting lists are edging back up. The North West list fell by 3.5% during 2025. Since then,it has crept back up to 1,024,735 by August 2026. Trusts vary very widely:Blackpool’s list grew by almost 10,000 in 2025.
A&E waits have improved slightly,with 71% of A&E patients seen within four hours last winter, up from 68% two winters earlier. But things are far worse than in December 2018, when only 0.2% of North West patients admitted through A&E waited more than 12 hours for a bed after doctors decided to admit them. By December 2025, it was nearly 18%.
Patient experience is improving slowly, but from a low base.Patients in Greater Manchester, Lancashire and South Cumbria, and Cheshire and Merseyside all found it easier to get through to their GP by phone in 2026, but around four in ten still don’t find it easy.
The high-rated risks are not only about money and staff.
East Lancashire’s register includes “Delays undertaking elective caesarean sections” (planned caesareans), scored 20. Stockport, and Tameside and Glossop, each score “Failure to maintain suitability of premises and environments” at 20. Northern Care Alliance also scores 20 for the risk that its digital infrastructure, with “1000+ applications, ageing hardware”, “cannot reliably support the delivery of safe, efficient services”.
Gathering evidence on nationwide NHS job cuts and funding.
We plan to repeat this review across England. But the North West already gives a powerful indication of what is happening elsewhere. UNISON’s own research found more than 20,000 NHS posts being cut across England against a £1.1bn deficit. In our latest look at integrated care boards beyond the North West, every system that has published a workforce target for 2026/27 plans a reduction. The same pressures, the same choices and the same risks are likely to be found in every region.
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