Midlands – ICBs

December 2024

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Birmingham and Solihull

Control Total (24/25)	Current variance from C Total	Month	YTD Deficit (£ million)	Savings Target
Break-even	51.3	6	70	£220m

 

Birmingham & Solihull has submitted a plan to break even in 2024/25 on the basis of delivering £220m of efficiencies. (p213)

By Month 6 the ICS had a £69.9m deficit, an adverse variance of £51.3m compared to plan. There are significant overspends on both provider pay and non-pay, partly offset by additional income.

By month 4, the system had a £51.4m deficit, £35.6m adrift, although the rate of growth of the deficit appeared to be slowing. (p102)

Good progress had been made on continuing to reduce agency spending, but substantive and bank spending exceeded planned levels.

The system delivered £47m of savings in the first 4 months of the year, just 73% of the planned target. (p102)

Reasons for the deficit include:

• Efficiencies – slippage on efficiencies.
• Substantive pay growth – Substantive pay exceeds the plan by £23m year to date.
• Mental Health Pressures – continued impact of level/case-mix of Out of Area beds (p108)

3+ Rating

The Board are asked to note that Birmingham & Solihull ICS has now been rated as a 3+ system for financial performance by NHSE – this requires submitting a detailed plan ahead of Month 7 submissions setting out the actions being taken to address our current financial position and return to plan

Black Country ICS

Control Total (24/25)	Current variance from C Total	Month	YTD Deficit (£ million)	Savings Target
£90m deficit	10	6	39	£248m

November

Organisations are reporting a £39m YTD deficit at month 6 following receipt of a £119.2m deficit funding allocation at M6, which is £10m adverse to plan. All organisations are forecasting to meet financial plans at year-end, albeit there are significant risks at a number of Trusts.

“The financial plan is challenging, and relies upon assumptions in respect of dental underspends, use of allocations, impact of enhanced financial controls, increased efficiencies, and receipt of ERF allocations.”

NB ERF – Elective Recovery Fund – funding for carrying out additional elective operations

July

The July Board meeting heard that the system was planning to deliver a £119m deficit in 2024/25 including an ICB surplus of £34m: but NHS England had not accepted this and attempted to impose a control total of -£90m. (p20)

Black Country ICS was proceeding with their original deficit target and was forecasting to hit the deficit plan at year-end, although warning that “current performance trajectories suggest this will be challenging to achieve.” (p86)

The ICB carries additional pressure and is the lead commissioner for the West Midland Ambulance Service (WMAS). (p17)

By month 2 organisations were reporting a £40m deficit £3m adverse to plan. (p17)

By month 4, the system had a deficit of £80m (7.6% of turnover), £15m adverse to its financial plan, and £30m adrift of the control total set by NHS England.

NHS England has assessed the ICS as being at high risk of overspending.

“With the support of NHS England, the system has engaged external support to urgently review the financial position of the system and develop interventions to mitigate risks and enable deliver the system plan. The first phase report is presented to the Board under separate cover.” (p90)

Despite monthly Finance and Workforce Assurance meetings with providers, at month 4 there had not been the expected reduction in workforce required to meet the plan. So the ICS People team has to focus on “workforce reductions and improved productivity,” meaning “engagement with the wider system partners including social care and voluntary sector is likely to reduce.”

Pressure

The Black Country has seen a significant increase in Urgent and Emergency Care (UEC) activity inflows since 2019/20, with a gap of over £30m between the level of contract funding associated with UEC and the value of this activity under pre-Covid Payment by Results (PBR) arrangements.

Therefore, through the 2024/25 planning round, the system has been in discussions with neighbouring ICBS to seek additional funding to reflect the increased costs of Black Country Trusts treating these patients.

Three out of the four systems approached have now agreed levels of funding, resulting in additional income of £25m for Trusts from Staffordshire and Stoke on Trent, Birmingham and Solihull, and Shropshire, Telford and Wrekin ICBs.  Discussions with Herefordshire and Worcestershire in respect of the contract gap of £2.6m ICB are ongoing. (p107)

Coventry  & Warwickshire

Control Total (24/25)	Current variance from C Total	Month	YTD Deficit (£ million)	Savings Target
£20m deficit	3.1	6	12.7	£124.5m

 

Unlike some other systems that are seeking to cut staff, Coventry & Warwickshire has a workforce shortage of close to 1000 full time across the System. But it also faces a severe financial situation, coming into the year with a £160m financial gap to close on a total system budget of just over £2bn. (p25)

November

The ICB had a £12.7m deficit (Month 6) a £3.1m adverse variance against the £9.6m deficit plan; however it was still forecasting to deliver its plan.

£19.97m deficit funding was received and reported in month 6.

The system efficiency programme is £2.1m off track.

To date, 66.5% is being delivered non-recurrently and just 33.5% recurrently.

September

The path to financial recovery was to be the focus of the September meeting and:

“Some difficult decisions needed to be taken and their justification would need to be well articulated to patients and the community. The System was in a high-risk situation and preparation for detrimental consequences was required.”  (p25)

A plan for a £27m deficit was submitted to NHS England In June, but discussions were ongoing with NHSE to try and meet a funded deficit control total of £20m. But CW is one of the more secretive ICSs, and so “Balance sheets and controls would be discussed in the confidential meeting to follow.” (p26)

By month 4 the deficit was £20.3m against a plan of £18.3m representing a variance to plan of £2m mainly as a result of industrial action costs in Quarter 1. (p92)

The ‘system-wide people plan’ seems to be less of a plan than an aspiration. Despite its priority on transformation:

“the objectives within this priority are not particularly well defined and consequently progress and oversight of new roles, new ways of working and upskilling could be further developed.” (p114)

It seems more clarity and consistency is needed on the finances too. On page 128 the ICB reports that “The underlying pressures mean that the system has a planned deficit on £20m for 2024/25 even with a challenging efficiency requirement of c6%”. (p128)

But two pages further on the figures seem to be rather different: “The CW ICS Business as Usual (BAU) efficiency programme for 24/25 totals £124.5m or 5.2% of allocation.”

Another problem is that the efficiency plan only delivers 59% of the required efficiency target recurrently, and so pressures will continue into the next financial year. (p130)

The Medium Term Plan Review notes:

“The Finance and performance committee concluded from the various scenarios that the system status quo is unaffordable, without an allocation increase above the historic average of 3%, even with the system partners’ continued commitment to deliver a minimum of 4% Business as usual efficiency (BAUE) year on year and additional system transformation workstreams valued at c£27m above BAUE.”

“In order for the system to break even, total expenditure would have to remain flat less 4% year on year efficiency for the full three years, in order for allocation growth over time to offset current cost pressures”

Given inflationary and demographic pressures:

“this is considered highly unlikely over that extended time period. …  the system as a whole is being asked to consider difficult decisions and prioritise expenditure in order to live within the funded allocation. (p137)

“A straight-line run rate forecast based on month 6 however results in a forecast [deficit] of £105.6m.”

 

Derby & Derbyshire

Control Total (24/25)	Current variance from C Total	Month	YTD Deficit (£ million)	Savings Target
£50m deficit	2.8	6		£169.7m

 

JUCD (Joined Up Care Derbyshire) has submitted a 2024/25 financial plan to deliver a £50.0m deficit in line with the limit set by NHSE, underpinned by a 5% CIP across all organisations (£169.7m).(p79)

In the last financial year 2023/24 the system wound up with £59.8m deficit against an initial plan of break-even, despite delivering total system efficiencies of £134.7m (5.4% of system allocation). Just £59.0m (43.8%) if the efficiencies were recurrent, increasing the efficiency requirement for this and in future years. (p37)

At month 6 the system is reporting a year-to-date adverse variance to plan of £2.8m (14.1%)

Elective Recovery Fund (ERF) income –

“we are using too much insourcing and outsourcing capacity to deliver performance targets, and as a consequence we are losing significant ‘margin’ on ERF income”

Workforce targets

In 2023/24 the workforce grew by 1,783 Whole Time Equivalent posts (6.2%) – 1,353 above the original plan. The ICB was warned that

“The original 2023/24 plan had been to increase the workforce by just 430 WTE (1.5%). The levels of actual workforce growth above plan are not sustainable and further grip and control is required to deliver the 2024/25 plan.” (p37)

The 2024/25 Operational Plan aims to generate a reduction in WTEs of 3.6% (927 WTEs) across the system’s four Foundation Trusts. (p79)

At month 4, the total workforce across all areas (substantive, bank and agency) was 422.05 below plan. A decrease of 50WTE substantive positions came with a bigger increase in bank (+166WTE) and agency usage (+17 WTE). …

“This position suggests that the vacancy and agency control processes which have been put in place are leading to increased bank staff usage instead; this is being investigated further.”

But the future is looking bleak: “Assuming 24/25 delivers on plan, a shortfall of c£250m exists for 25/26 after application of NHSE funding/penalty regimes assuming a 3% Cost Improvement Pian target.” (p81)

Delivery of efficiency savings remains the largest underlying risk for the system.

 

Hereford & Worcester

Control Total (24/25)	Current variance from C Total	Month	YTD Deficit (£ million)	Savings Target
£80m deficit	3.8	6	8.7	£118m

 

The ICS is working to a planned deficit of £80m, which requires efficiency savings of £118m. (page2)

At Month 6, after receiving £80m deficit funding, the Integrated Care System has reported a YTD deficit position of £8.7m against a phased deficit plan of £2.6m – an under-delivery of £6.1m

The plan includes a full-year deficit of £57m at Worcestershire Hospitals and £31m at Wyve Valley Trust, balanced by an £8.8m surplus for the ICB. Recovery plans are in place across all areas with oversight through the range of ICS programme boards. (p3)

However, from a workforce perspective, the Month 4 position shows that recruitment of substantive posts is behind schedule across all providers, reflecting the challenges in the healthcare labour market.

The usage of Bank staff is over the plan, signalling a shift from agency to bank usage, in line with the workforce strategy. (CEO report p2)

The financial position at month 4 was £3.7m adverse to plan, of which £0.65m was direct costs and loss of Elective Recovery Fund (ERF), linked to the recent Junior Doctors’ industrial action.

The remaining variance is linked to failure to deliver ‘efficiencies’, mainly in Wye Valley NHS Trust (WVT), together with “the year-to-date impact of a Private Finance Initiative (PFI) accounting change, which has not been reflected in the plan.” A Financial Recovery Board has been established at WVT to address the non-delivery of planned efficiencies and to identify new schemes. (p2)

The ICB argues that

“Whilst the identification of non-recurrent mitigations to offset under-delivery is welcomed, this does present a further financial risk to future years financial plans; as such, further work is required to identify recurrent mitigations in the remaining months of 2024/25.” (p3)

 

Leicester, Leicestershire and Rutland

Control Total (24/25)	Current variance from C Total	Month	YTD Deficit (£ million)	Savings Target
£80m deficit	18.8	5	65.2	£45.9m

 

The LLR ICB system has a £80.0m deficit plan for 24/25. This is made up of £(64.9)m University Hospitals Leicester (UHL) £24.1m ICB, with Leicestershire Partnership Trust at break-even, plus a £9m system-wide “stretch savings requirement.”

However, the overall year-to-date (YTD) system position at month 5 is a deficit of £65.2m, which is a £18.8m adverse variance to plan. (p281)

This follows from last year (2023/24) when the system’s reported financial performance was £68.4m deficit against an initial plan of a £10m deficit. … For financial performance management purposes, the applicable financial position was £78.4m deficit.

This was despite delivering total system efficiencies of £137.3m, (6% of system allocation). However, just £45.9m (33.4%) of the total was recurrent, increasing the recurrent efficiency requirement in future years. Agency costs also increased, surpassing the plan by £8.4m and the agency cap by £18.8m. (p52)

UHL has remained in the National Recovery Support Programme (RSP) and has undertakings in relation to finance in place, and NHSE continues to work with the ICB and UHL to agree on the Transition criteria to exit the RSP programme and oversight of the delivery of their financial recovery plan. (p52)

The system has planned efficiencies of £173.6m, of which we are ahead of plan and currently forecasting full delivery, with £64.4m achieved year to date. Note over achievement and additional schemes are required to address the expenditure variance to date with existing cost overspends or income shortfalls. (p358)

 

Lincolnshire ICB (Sep Board)

Control Total (24/25)	Current variance from C Total	Month	YTD Deficit (£ million)	Savings Target
Break even	3.6	5	18.6	£84.8m

 

The ICS’ plan is to deliver a break-even position against in-year allocations and income for the full financial year, based on a full-year cost improvement plan of £84.8m, on which it expects to break even by the financial year-end. (p73)

At month three, while the ICB was on plan, the system position was off plan by £2m. (p18)

In July, the Board was advised that the finance report only included the highlights. The more detailed document had been presented to and considered by the Finance and Resource Committee, which discussed it at some length at its meeting the previous week.

By month 5, the ICS reported a deficit of £18.8m, a £3.6m adverse variance to the plan, while the ICB reported a year-to-date deficit of £2.1m—improved on the planned £3.7m deficit. (p72) £22.5m cost improvements had been delivered against a plan of £20.9m—a £1.6m favourable variance to the plan.

Lincolnshire may be doing well on the financial front, though their discussion of the detail behind closed doors must arouse suspicion. The ICB also wins the Lowdown’s October prize for ICB gobbledygook” – with a prize for any reader who can explain the meaning of this paragraph:

“The level of accuracy used in financial reporting for the ICB is informed by the materiality concept. A transaction can be material by the impact it has on the financial duties of the ICB, but also the reputational and legal implications for the ICB and its internal and external stakeholders. Where judgements and estimates have been made in the preparation of the financial statements, the concept of materiality has been used. However, it should be noted that the concept of materiality has not been applied to disclosures required by law and accounting guidance, precise figures have been used for these disclosures.” (p217)

Northamptonshire (August Board papers)

Control Total (24/25)	Current variance from C Total	Month	YTD Deficit (£ million)	Savings Target
£55m deficit	12	5	42	£90.5m

 

October Board papers show Northamptonshire aiming to deliver a £55m deficit by the end of the year, but reported lagging £12m behind plan at month 5. (p54)

The £42m deficit at month 5 is due to bigger-than-planned deficits in all three trusts: Northampton General (£20.5m), Kettering General (£17.7m), and Northamptonshire Healthcare Foundation Trust (£3.7m).

Last year (23/24) total system efficiencies delivered were £93.9m, a hefty 5.7% of system allocation, although 40% of this was non-recurrent, leaving a bigger problem for this year.

The Annual Assessment of the ICS warned that

“The original finance and workforce plans were not achieved for 2023/24. There is a need for increased ICB leadership in this area and for partners to work together collaboratively to balance financial sustainability, enforcing workforce controls, alongside the delivery of high-quality, safe services.

“Robust medium-term financial plans are necessary alongside short-term delivery assurances. This approach will need to be scaled up and accelerated to return the system to balance.” (p116)

The ICS is aiming for £90.5m of efficiency savings in 2024/25, of which £19.6m was still unidentified by month 5, and £42.5m is non-recurrent, stacking up more problems for next year. (p59)

Spending on agency staff is above target in both of the acute trusts but expected to level off. (p61)

 

Nottingham and Nottinghamshire

Control Total (24/25)	Current variance from C Total	Month	YTD Deficit (£ million)	Savings Target
£100m deficit	2	4	70.1	£251m

 

The system agreed to reduce its forecast deficit from £106m to an agreed control total of £100m, including Nottingham University Hospitals £51.6m, Sherwood Forest FT £14m and Nottinghamshire Healthcare £16.5m.

By month 6 the system was £9.6m in deficit after receipt of £100m deficit funding, £9.6m worse than planned.

“A number of risks exist in delivering the reported position. Delivery of the efficiency target (£12.1 million) and pressures on continuing healthcare, prescribing and section 117 packages (£13.8 million) are the key risks. Total risks are £33.8 million and identified mitigations are £23.6 million … The ICB continues to look for additional solutions/mitigations to cover off this net risk.”

The deficit has brought with it an £8.2m deduction from the ICS capital allocation, making it “challenging” to deliver against system priorities.

There was considerable risk in the plan, particularly around the delivery of the required efficiency target of £251 million, and tighter control and grip measures and governance arrangements had been put in place to support delivery. (p29)

By month 4 the system had an actual deficit of £70.1 million, £2 million adverse to plan, but “remains on forecast to deliver the year end plan of £100 million deficit.”

Efficiency delivery was £11 million ahead of plan at month four, with £54.5 million delivered to date. The planned efficiency forecast is to deliver £257 million in savings; £2.6 million is unidentified at month-end close.

The ICB itself is continuing to forecast to deliver the planned £17.8 million deficit, with key forecast overspending areas continuing healthcare (CHC) costs at £7.7 million, prescribing costs at £6.0 million and acute independent sector costs at £2.5 million.

The ICB financial plan requires £68.5 million of efficiencies. Year to date actual delivery is £21.6 million (31.5% of the required target). The latest risk-adjusted year-end forecast is estimated to be £54.1 million (78.9%). (p105)

The Nottingham and Nottinghamshire ICS is one of nine NHS systems nationally required to commission a delivery partner to support the delivery of the 2024/25 financial plan. The ICB has engaged P.A Consulting to undertake this work.

Phase one of this process has focussed on stress-testing plans to identify and quantify the key risks to delivery. (p108)

System partners were beginning to collaborate more on matters such as vacancy controls, service reviews, and decommissioning plans.

There was a commitment for organisations to work together in additional areas such as:

• consistency of approach to subsidised staff meals and car parking income
• reviewing high-cost, low-volume services for the potential for consolidation,
• seeking a collaborative solution to direct access to pathology
• and identifying areas for back-office collaboration.
• Members were assured that progress had been made, but on the basis of current plans and evidence of delivery, the [Finance and Performance] Committee could not provide the Board with an assurance level higher than partial. (pp119-120)

Shropshire Telford and Wrekin

Control Total (24/25)	Current variance from C Total	Month	YTD Deficit (£ million)	Savings Target
£90m deficit	4.7	5	56.2	£89.7m

 

The ICS has a target of restricting its deficit to £90m in 2024/25, which requires delivery of an efficiency programme of £89.7m. £10.1m of these savings had not been identified in Month 2. (p72)

By month 5 the system deficit was £56.2m, £4.7m adverse to plan, but the forecast was still to deliver an £89.9m deficit – in line with plan.

However, the system has reported risk to the value of £40.6m for which no mitigation is currently available, and efforts continue to either reduce risk or find alternate mitigations if costs in excess of the plan were to materialise

The two main performance pressures were finance and Urgent and Emergency Care (UEC).

Although there had been an improvement in 4-hour A&E, 12-hour breaches, ambulance offload delays, super stranded patients and Category 2 response time, and there was improving performance across mental health metrics, long waits are an issue. The system is not on track to deliver 65-week waits by the September 2024 deadline. Early indications are that the 78-week wait position has also deteriorated

Community waits exceeding 52 weeks are reported for the first time, and cancer backlogs continue to increase. (P48)

The planned ramp-up in efficiency savings in the latter part of the year makes the forecast becomes more challenging to deliver. (P72)

 

Staffordshire and Stoke-on-Trent

Control Total (24/25)	Current variance from C Total	Month	YTD Deficit (£ million)	Savings Target
£90m deficit	29.8	6	25.2	£203m

 

The ICS year-end plan target deficit is £90m; however, the system has assessed the position and highlighted £100 million of risks that are being worked through. The minutes of the September Board meeting confusingly report that

By month 6,

“at a system level we are reporting a year-to-date deficit position of £25.2m, which is a £29.8m adverse variance against the revised plan.”

“the efficiency plan for the year is £203 million and with the additional work which has been undertaken over the past few weeks, this has increased to £180 million, which is still not enough, but is the highest the system has ever achieved.” (p13)

From this, The Lowdown deduces that the target has been reduced to £180m. However this will be tough enough, after reports that the ICS overspent by £91 million on its £2.7 billion budget in 2023/24. (p22)

By month 5, the actual deficit was £63 million against a planned deficit of £37 million, £26 million adrift from the plan, and the financial position continued to be “very challenging.”  The bulk of the year-to-date variance to plan sits with the ICB (£15.1m) and University Hospital North Midlands (UHNM) (£11.4m).

The ICS has appointed a system Recovery Director, who reports to all four NHS Chief Executives across the system. Additional controls around payroll have also been put in place and “are working well in addition to increased control of non-pay spend and additional scrutiny of all non-pay costs.” (p13)

The main drivers for the deficit include efficiency slippage (£16.8m) industrial action (£3.9m) and Continuing Health Care (£4.5m). These are partially offset by Dental underspend (£2.7m) and other non-recurrent mitigations (£8.5m).

Led by the Turnaround Director, a “recovery plan” has been developed. The system is also required to commence weekly reporting as part of the investigation and intervention process. Work is underway to refresh the medium-term financial model where the focus on addressing the underlying financial pressure of c£200m through clinical models, productivity and demand management will be developed over the coming weeks. (p32)

• A large driver of the position is the shortfall in the efficiency programme. The total plan of £203m has £51m reported as high risk as of month 5. Work is ongoing to identify further schemes. Year to date, there is a slippage of £16.8m, with recovery actions forecasting a full-year slippage of £23.5m. This results in the need to go further to recover against the plan.
• The workforce numbers (substantive + bank + agency) were 24,378 in March, and they have now fallen (end of August) to 24,156. Within that, we have achieved a reduction in agency equivalent to 136 WTEs. Overall, the trend demonstrates the pay controls of organisations are impacting.

However, it should be noted that the ICS non-pay overspending is MUCH higher than pay overspending; £17.6m compared with £1.9m across the system (p111)

To support improvement in 24/25 and beyond, a Demand Management Collaborative has been created with Chief Operating Officer (COO) Senior Responsible Officer (SRO) leadership. This collaborative will work with the Urgent and Emergency Care Portfolio to lead the development of a demand management plan across the system to identify areas for efficiency and to mitigate the identified bed deficit of 85 beds to agreed manageable levels.

Continued focus on the in-hospital improvement programme and “right-sizing” of medical capacity at UHNM, which unusually seems to mean expanding it rather than reducing it;

“Funding was received in 23/24 for a modular unit at Royal Stoke University Hospitals, to establish a new Acute Medical Rapid Assessment Unit (AMRAU). This unit provides both additional assessment and bedded capacity at the Royal Stoke site. (p133)

System recovery includes: “Considering any further opportunities to repatriate patients from the Independent Sector to NHS Providers, while fully bearing in mind Patient Choice.” (p115)

 

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October 2023

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Coventry and Warwickshire ICS covers just over 1m population.

Hard information is hard to come by, but South Warwickshire FT filled in some of the gaps in April:

“The entire ICS is in deficit and hence is required to make additional efficiency savings to aim to move close to break even. … Whilst we are expected to manage financial risk as an entire system, we are also expected to operate a financial regime which holds each constituent organisation to account for its own performance, which in turn contributes to the whole.” (p151)

Its May papers give an update: “The Planning cycle is still ongoing with a further submission expected at the end of May as the system has submitted a deficit plan of £37.9m.” (p83)

Herefordshire and Worcestershire ICS covers a widely scattered population of 812,000, and seems locked in a timewarp. The ICS url listed by NHS England goes to a page that prominently features documents from 2017.

However the two county CCGs have merged, and their March meeting discussed the scale of “savings” or cuts required to deliver the required balanced budget as an ICS. The merged CCG has a cumulative deficit of £7.8m and requires £15.9m of “efficiency” savings (1.1%) to break even (p2).

Things look even less rosy for Wye Valley NHS Trust, whose chair has noted the tough times to come:

“The current plan leaves us with a forecast deficit of just over £30m. As the Board is aware, we have previously proven that the extreme rurality of the County creates an unavoidable structural deficit of between £20m-25m.  … The entire ICS is in deficit and hence is required to make additional efficiency savings to aim to move close to break even.” 

“Within the H&W ICS, the two acute providers are reporting deficit plans, which is driving an overall system deficit plan.” (p100)

Joined up care Derbyshire covers 1.1m people across the county, and is beset by financial woes. NHS Derby and Derbyshire CCG papers for May 2022 explain:

“The system moves into 2022/23 with an in-year planned deficit of £196.8m. Efficiency opportunities have been identified but there remains £89.9m forecast deficit plan to be agreed with NHSEI. This in year position is supported by a considerable amount of non-recurrent benefit.” (p276)

 “… the System started with a £200m deficit, and we had either identified or were in the process of identifying, savings that would bring that deficit down to just short of £90m for the System. 

“• It was noted that in a national and regional context, that was not out of line with other Systems. We were not the worst in the Midlands, and the Midlands was not the worst in the country. There were comparatively sized Systems elsewhere who had larger initial starting points and had finished with larger mitigated deficits for this first draft submission. 

“• Within that savings target, of £110m we had identified £40m that we could rag rate as green that currently we believed we could deliver. There was probably £10-20m that we could rag rate as Amber, and currently there was probably £50m to find.” (p308)

University Hospitals Derby & Burton Trust Board hopes to deliver a small “surplus” but notes “This is, however, after financial support from the Derbyshire System of £12m, which further demonstrates we are ‘living beyond our means”, given, as the Trust Board knows, we have an underlying annual operating deficit of circa £100m.” (p99)

Leicester, Leicestershire and Rutland ICS covers 1.175m people with a total allocation of £1.6 billion for 2022/23. It sounds a lot, but it’s clearly not enough according to the Integrated Care Board April meeting:

“The system plan currently shows a deficit of £27m and a further £77m of risk that is not mitigated. The committee has asked for further mitigations to be worked through and will receive an interim update mid-April. The final plan will be submitted on 28th April. Aiming for UHL to exit financial special measures in 2022/23.” (p124)

Lincolnshire ICS covers a scattered population of 801,000 in a county with notoriously poor roads.

The NHS England link to the ICS leads to page in which About Us features an ‘Our Story’ timeline that begins before the NHS – but ends in 2020. Information is hard to find on prospects for 2022/23. Lincolnshire CCG has apparently had no discussion of future pressures.

United Lincolnshire Hospitals May trust board papers note that that the Trust had delivered the 2021/22 year-end position as required, but the operational plan for 2022/23 was more problematic, and discussions were ongoing with NHSE in respect of the system deficit plan submission.” (p300- 301)

“… The Committee noted the overall CIP requirement of £25m”. 

Birmingham and Solihull ICS, which for reasons we can only guess prefers to be known as ‘Live Happy Live Healthy’, covers a population of 1.57m.

It is one of the systems that has benefited most from the additional funding during the Covid pandemic:  “… prior to the pandemic, the NHS locally was planning for a deficit of £103.6m in 20/21 – a position which has worsened in underlying terms during the two-year pandemic, although the provision of additional non-recurrent resources for elective recovery and to cover Covid costs has resulted in the system planning for a forecast deficit of £48m in our draft plan for 2022/23.” 

University Hospitals Birmingham has some of the country’s worst waiting lists, and its Trust Board April 28 reveals a trust substantially in surplus, but which

“has delivered a reduction in activity across all points of delivery compared with 2019/20 levels notably for Elective (30%), Daycase (22%), First Outpatients (28%) and Outpatient Procedures (37%). A&E activity has increased steadily over the course of the year from (9%) below plan in April to (5%) at the end of March with levels of Non-Elective activity within (5%) of 2019/20 values.”

Northamptonshire Health and Care Partnership covers a population of 807,000. The ICS website is almost entirely composed of abstract aspirations and waffle.

However Northamptonshire CCG’s April Governing Body meeting published a Financial Plan 2022/23 that is admirably up front on the scale of the problems:

“The CCG financial plan achieves a breakeven position in 22/23 but only after a £10.9m efficiency programme on top of the core tariff efficiency of 1.1% is applied to the budgets. … . The planned system position is a £49.7m deficit.”

The underlying position is even worse:

“On the 17th March 2022 the system submitted the draft financial plan which identified a system deficit of £75.7m. The CCG accounted for £0.8m of this deficit with the trusts making up the remaining balance.”

£46.1m of this deficit is attributed to Northamptonshire University Hospitals (Kettering and Northampton General Hospitals) (p4). 

Northampton General Hospital Trust’s March Board received an even more worrying initial 2022/23 Planning Summary from the shadow ICS:

“The system financial plan was briefed to the NHCP development session  in draft last month and was estimated at c.£118m deficit …  “Further changes at system level have been discussed with Directors of Finance and  CEOs and this position has now moved to £75.7m deficit” (p147)

“The minimum efficiency expectation for the system to deliver a breakeven  position is 3.9% or £46m”. (p152)

Nottingham and Nottinghamshire: ICS covers a county population of 1.2 million: it is one of the few ICSs to have established a board that has met in public and published Board papers, and one of very few that actually reveals some actual problems.

Its March Board heard that the system” is forecasting a £23.2m year-end shortfall [2021/22] (p165).

And the Partnership Board “is requested to note that the 2022/23 NHS operational plan is based on optimal national assumptions and will include significant delivery risk.” (p71)

“… draft allocations include a clear efficiency requirement as well as an expectation to return to pre-pandemic levels of productivity through increased utilisation of existing capacity and resource levels. 

“This will be challenging ask for the whole system … ” (p171)

Nottingham and Nottinghamshire CCG April Governing Body meeting heard about the CCG 2022/23 draft Financial Plan, which: 

∙ Delivers in year £breakeven – …. 

∙ Has an underlying deficit of c £13.5 million 

∙ Requires £31.8 million QIPP savings

Nottingham University Hospitals Trust projections were gloomier still, going forward to 2022/23:

“The [Interim Finance and Performance] Committee were informed that a £96.7m system deficit had been forecasted for the next financial year (£59.4m attributed to NUH), which would result in the system being in the top 15 with the highest deficit. A meeting would next take place with the Chief Finance Officer for the NHS to understand this.” (p342)

Shropshire and Telford and Wrekin ICS, one of the smallest in population but large in area, covers just 520,000 people.

With no more recent Governing Body meeting papers published due to a stupid error on their website the most recent CCG financial update dates back to the January 2022 meeting:

“The CCG control total for 21/22 is a £9.984m deficit, the current forecast actual position against this plan at M8 is a deficit of £9.783m.” (p68)

“… the system as a whole is currently forecasting a £13m deficit against the 2021/22 system envelope ….” (p73)

The Board Assurance Framework had recorded an improved rating for the risk of “System failure to deliver overall long term sustainability plan,” from purple (“Almost Certain x Catastrophic = Extreme 25) to red (“likely x major = High 16”) (p82)

Shrewsbury & Telford Hospitals Trust Board meeting in April was told that: “The financial position, while showing an improved cash flow, is one of an increased adverse deficit position. The forecast remains in line with the submission to NHSE/I and the ICS at the end of Q3 2021/22, and it sits within an overall STW system position, which is within the approved plan.” (p3) 

The Black Country ICS, which wants to be known as ‘Healthier Futures’, covers 1.27m people  in Dudley, Sandwell, Walsall, and Wolverhampton. West Birmingham, which was initially included, will be transferred in July when ICSs gain statutory powers to Birmingham & Solihull.

According to the Royal Wolverhampton Trust’s Performance and Finance Committee in March 

“The deficit at ICS level after the initial budget submissions is £48m. Both the Trust and the ICS have been challenged to produce a balanced budget.” (p245)

“An initial draft of the [Trust] budget has been prepared showing a deficit of £16.6m. In order to reach this position, a £12.8m CIP target has been included and c. £17m of costs need to be removed from those identified in budget-setting.”

The Dudley Group of Hospitals is warning of a “significant potential deficit in 2022/23 of the order of £20m, highlighting the need to reduce the cost base.”

Walsall Healthcare Trust April Board papers reveal the Trust plan (as part of the £48m deficit) for a £6.6m deficit position, inclusive of £5.3m efficiency programme delivery. (p33)

Staffordshire and Stoke-on-Trent: ‘Together We’re Better’ is chosen title for this ICS, covering 1.67m people. It is one of the minority who have formed a board, met in public and published papers with significant content in advance of the Health & Care Act giving ICSs legal status.

An April Board meeting received a Finance report whose candour made up for its dodgy grammar:

“The system have submitted a £48m deficit plan (2.2% of ICS allocation), 91% (£44m) of which relates to the ICB. … 

… “The system received a significant income uplift in 20/21 and 21/22. However in 22/23 cash is broadly flat, and as a system we have lost £10m TSA support for the County site. 

“Our plans for 22/23 currently show costs rising by 3.5%. Flat income and rising costs are driving the deficit. 

“The plan includes 3.2% efficiency from a combination of provider efficiency and system savings.”

Staffordshire and Stoke on Trent CCGs add more detail: 

“… We have also modelled the underlying position and currently have assessed an underlying deficit of £133.4m. The position is expected to materially deteriorate between years due to the fall away of non recurring allocations and limited offsetting expenditure. Addressing the level of underlying deficit will form a major part of the ICS work programme during 2022/23.” (p118)

“The improvement from the previously reported deficit of £78.4m to the current £44m deficit has come from a number of reviews as well as assumptions both from a recurrent and non-recurrent perspective … 

“… Efficiencies built in to the draft plan total c£36.7m when factoring in assumptions regarding containing growth and restricting price increase. 

“… In addition, and in line with the delivery of the flat cash / activity strategy, an additional £32.1m has been assessed as savings on activity growth / avoided admissions associated with unplanned care as part of the system savings.”

“The system received significantly more income in 20/21 and 21/22 than 19/20, when we posted a deficit of c£80m. Income is now flat in 22/23, however we are currently planning for costs to rise by 3.5% and this is driving the 22/23 deficit.” (p104)

“The system inherits a balance sheet deficit of c£300m and if we can post balances in our first two years, that would be written off by the NHSE/I. In addition, we know that if we can achieve balance in this first year of the ICS, it will be more feasible to retain that balanced position, than to need a strategy to claw back from a deficit position. 

“So the work to try and reduce the planned deficit will continue.” (p105).