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 Boardis 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).

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