The Lowdown has been working hard in the last year or so to find evidence of what services have been cut back as a result of the most recent (ongoing) cash squeeze on the NHS.
But given that many Board meetings publish little, if any, hard facts on how ‘efficiency targets’ are expected to be achieved, and ICBs and Trusts now seem to restrict detailed discussion of financial plans to closed sessions with the public and press excluded, this has proved hard to do.
The cuts also impact local authorities, which might be assumed to have greater access to financial details, but despite this, few councils seem willing to dig beneath the bland surface of published reports.
One worthy exception has been Stoke-on-Trent City Council, which commissioned the Nuffield Trust to examine the Staffordshire and Stoke-on-Trent Integrated Care Board’s (SSOT’s) 2025/26 financial plans to understand the implications for local services, not least “the possibility of potential cost-shifting to councils and rising unmet need.”
The chief executives of both Stoke-on-Trent and Staffordshire County Council opposed the ICB’s plan, especially the likelihood that costs would be shunted from the NHS onto local government alongside an increase in unmet need.
The full report, by a team headed by Sally Gainsbury, who has consistently probed the reality of NHS funding constraints, was published towards the end of March. It reveals a number of ways in which the cutbacks are affecting patients, and potentially local authorities, which have the responsibility of funding and commissioning social care.
However, it’s worth noting that even with the cooperation of ICB leaders and access to data which campaigners may well not have been able to see, and with the combined expertise of a 4-person team, the Nuffield Trust report only manages to account for a relatively small portion of the £277m cuts required of the SSOT system.
This may in part be because the main concern of the two local authorities was to identify extra costs being dumped on to them to generate apparent “savings”: but it’s also because any public scrutiny of cutbacks to balance the NHS books locally and nationally remains extremely limited given the lack of any concrete detail in publicly available documents.
Huge targets for savings
The report notes that one of the reasons the Nuffield Trust took on the commission was “not because of the unique aspects of SSOT, but because, in very many respects, the financial and operational challenges it faces are shared across the rest of the NHS in England.”
The first important finding draws attention to the huge size of the targets for “efficiencies” that applied right across England’s NHS last year:
“Nationally, health systems were tasked with savings of 7.1% of their allocations, leaving the SSOT system [target 9.5% savings] with the second-largest financial challenge in England at the start of the financial year.”
It quotes from the NHS England Board paper in May last year, which spelled out the sheer size of the financial challenge, in which only two of the 42 ICBs faced saving targets of less than 5% and nine faced targets of 8% and above.
NHS England’s 2025/26 Operating Plan position explained that the cash cuts were to be substantially achieved through job losses:
“Plan system efficiencies average 7.1% supported by reductions in temporary staffing, and corporate costs. The total workforce across substantive, bank and agency staff is planned to be 2.0% lower than in 2024/25, with agency use planned to reduce by 40% by March 2026.”
Nor is there any immediate relief from this tightening squeeze: it is set to continue this year and next: “Funding plans set out in the 2025 Spending Review mean that nationally, funding levels for the NHS in England will only return to 2020/21 levels in 2028/29.”
Funding lagging behind
The second important point drawn out by the Nuffield Report is that the spending squeeze has been so tight it resulted in the budget for health care falling below local demand:
“SSOT NHS system’s total saving requirement for 2025/26 was £277m, to fill a budget shortfall primarily driven by demand for health care growing at a faster rate than funding, and relatively high costs, particularly for acute care.”
This phenomenon applies to all ICBs:
“the gap between actual funding levels and the long-term trend for health care consumption … rises considerably faster than we would expect to stem from population growth and ageing alone. This gap is partly driven by rising demand for health services to adopt new treatments and medicines, and for services to expand treatments and diagnostics into areas previously not thought possible.” (p7)
In SSOT these general problems are made worse by the higher-than-average costs of services from local providers, and most especially acute services from UHNM:
“each unit of health care the ICB purchased cost, on average, substantially more than the national average, on which planning assumptions and funding flows are in part based. This was particularly the case for acute hospital care: NHS England analysis suggests unit costs in 2024/25 at UHNM were, overall, 3% higher than the national average.” (p12)
No explanation is offered for this variation in cost, but it’s likely that other trusts, given their geography and other local factors may face greater costs in recruiting and retaining staff, and of course many other acute hospitals, like University Hospitals North Midlands’ (UHNM’s) main centre, the Royal Stoke Hospital face inflated annual costs from repayments on Private Finance Initiative contracts running into the 2040s.
And in common with many acute trusts, UHNM has been unable to cut staff on the level required. Worse still, its costs of providing acute services are higher than the standard prices laid down in NHS guidelines: they effectively lose money on every patient they treat, so treating more patients is not a solution.
Reducing access
The third important point is that when staff cuts and other savings cannot be delivered on anything like the scale required, it becomes inevitable that a substantial share (in fact the largest portion) of the cash savings had to come from reducing access to health care:
“This report focuses predominantly on the ICB’s share of savings, and finds the largest portion (in the region of £60m) of these were planned to come from the ICB withdrawing from funding services and interventions it no longer views as legitimate health care expenditure.”
The bulk of these savings have fallen (as previous Lowdown reports on ICB cuts have suggested) on Continuing Health Care (CHC), which is mainly focused on elderly and disabled people.
Such cutbacks are a blow to councils – which face additional pressure on already stretched social care budgets – but because social care is means-tested, they are also a potential heavy blow to many patients and their families. If they have property or assets, they can wind up with hefty bills for nursing home or domiciliary care.
The device used by NHS bodies to escape financial responsibility for continuing care is to tighten eligibility criteria, redefining the boundaries of health and social care. But the report find SSOT has gone further still:
“both reducing the numbers of people found eligible for CHC as well as reducing the intensity of services and expenditure items included in the CHC packages.”
The report finds this tightening has already had a marked impact:
“By September 2025, SSOT ICB had reduced its eligibility rates for standard CHC care by 27% compared to September 2024. If the rate had been maintained at the September 2024 level, we estimate that an additional 293 adults would have been receiving CHC care packages in September 2025 across the ICB, of which 78 would have been residents of the Stoke-on-Trent City Council area. […] the savings stemming from the reduction in standard CHC care eligibility across the entire ICB between 2024/25 and 2025/26 would be in the region of £37.6m over a full year …. (p48)
The cutbacks have also sought to save another £4m by refusing to cover any elements of Personal Health Budgets that improve quality of life but are not specifically related to “assessed healthcare needs.”
Mental health care packages are also facing cutbacks, with plans projecting savings of £12m by the ICB no longer automatically funding 50% of such packages, but moving instead “towards a ‘fair share’ arrangement, where only elements of packages viewed as ‘health care’ would be funded by the NHS.” (p51)
Squeezing private sector
The fourth major point made by the report has been to focus on the £24m cut in SSOT-funded elective care activity in independent sector providers, although the likely final figure is in the region of £14m. This represents the vast bulk of the planned reduction in services by the ICB for 2025/26. (p18)
The report notes that
“While the plan, if successful, will help to preserve funding streams into the pressurised area of emergency hospital care […] it does so at the cost of a slower reduction in elective waiting times than would likely be achieved had funding levels been maintained.
“This trade-off is a consequence of the ICB lacking sufficient funds to grow activity levels in both elective and emergency care simultaneously.”
This will result in longer waits for some patients, and so this is further investigated by the report, which echoes many critiques of the use of private providers to deliver NHS-funded care. It notes that over-reliance on private sector provision “is problematic for three main reasons”:
“First, activity increases (and waiting time reductions) are skewed towards only those specialties and procedures where independent sector capacity is available. Second, independent sector facilities are unable to treat patients with complex or multiple health conditions, which risks exacerbating health care inequities; and third, when the commissioning budget is spent in the independent sector, the opportunity to retain funds within the NHS is lost.” (p20-21)
The skewing of activity (and funding) towards key private sector specialties is most glaringly exposed in the case of cataract operations:
“99% of patients referred to the largest independent sector provider of cataract procedures had a referral to treatment time of under 18 weeks, compared to an average for SSOT patients referred for all elective treatments of 57%” (p21-22)
Since 2019 the expansion of private sector cataract treatment in SSOT since 2019 has seen the transition from the NHS providing 2.5 times the private sector number of procedures to the private sector treating twice as many as the NHS. (p23)
The report shows how this raises serious issues of inequality in access:
“… patients living in SSOT’s most deprived neighbourhoods … within the most deprived decile (10%) of neighbourhoods nationally – were significantly less likely to receive the expected number of procedures (given their age profile) than those living in SSOT’s most affluent neighbourhoods. […] However, the gradient was much steeper for patients treated in independent sector providers, where activity levels for patients from the most deprived areas were 43% lower than expected, compared to activity levels just 6% below expected in SSOT’s most affluent areas.” (p24)
So in a strange way, SSOT’s reduction in the number of NHS patients treated by private providers, and lengthening waiting lists, turns out to be an overall progressive measure, reducing the extent to which the most deprived population, and the patients with the more complex needs for elective treatment, are left waiting while wealthier and more minor cases are treated ahead of them.
But the extent to which SSOT pulled back from its plan to cut private referrals by £24m suggests the ICB is, to say the least, half-hearted in its commitment to tackle inequalities in access.
Calling in expert opinion has given Stoke City Council more ammunition in its attempts to resist cost-dumping by the ICB, and helped throw a spotlight on these same issues in other ICBs.
But more work still needs to be done to discover which staff have been axed (or are still threatened) at ICB and trust level, which services have been restricted, how many patients may have been affected, and what the next steps are supposed to be in the effort to rein in spending even further in 2026/27.
Campaigners could help to drive forward more initiatives that help to uncover the reality of £4 billion of claimed “cost savings” across the rest of England by persuading local councils to:
- commission similar reports, from organisations that have a record of delivering evidence-based studies.
- holding their own investigations through Health Oversight and Scrutiny Committees,
- or working with local trade unions to commission research and reports.
Meanwhile, campaigners should make every effort to attend every Board meeting of their local ICB and trusts (almost all of which are now streamed online).
It may also be worth trying to get some response from largely dormant Health Watch bodies that ministers want to abolish – leaving little or no local public accountability.
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