Survey of 19 Integrated Care Boards (part 2 of 2), Key points:

(West Midlands, South East and South West of the country – 19 ICBs)

  1. Workforce pressure continues to push “trust leaders to the limit” with difficult choices.
  2. Pressure on leaders to avoid deficits is stalling progress and leading to discussions about cuts.
  3. ICBs are flagging up a “risk to life” and falling standards of patient care.

The second part of a Lowdown national survey of ICB papers highlights the problems that a lack of staff continues to cause for patients and staff, with only a minority of ICBs celebrating progress in the recruitment of new staff and in reducing the number of high-cost agency staff needed.

Every one of the 19 ICBs in the second part of our survey stated that they have ‘workforce challenges’, and reported efforts to fill vacancies, including with international recruitment, to maintain staff numbers and patient safety, while simultaneously reducing the use of agency and bank staff.

Urgent warnings

Despite these actions – taken largely by NHS providers, workforce shortages continue to impact upon patient safety and waiting times.

Herefordshire & Worcestershire ICB papers note  “there remain critical areas of workforce shortages in nursing, some medical specialities and social workers…Workforce shortages in some specialties have resulted in increased levels of service fragility, particularly in cancer and stroke pathways.” 

In Surrey ICB papers it notes that

“if the significant maternity and neonatal workforce shortages affecting all Trusts across the Surrey Heartlands system are not resolved then there could be risk to life, long-term, reduced place of birth choice and poor experience of clinical care for pregnant people and babies.” 

Hampshire & Isle of Wight ICB noted the “significant workforce gaps in mental health particularly in medical and nursing staff.”  The lack of staff, it notes “ is impacting on patient/client experience and the number of complaints received”.

Cornwall and Isles of Scilly ICB noted that it is constrained in its plan for maternity and neonatal services, including making progress towards the national safety ambition, due to workforce constraints.

This  ICB is also having problems recruiting sufficient staff to ensure the percentage of patients that receive a diagnostic test within six weeks is in line with the March 2025 ambition of 95%. 

In Dorset, the ICB papers note that the failure to “sustain a transformational focus on mental health services” is being hampered by a lack of sufficient workforce to deliver sustained changes. The high number of vacancies across CAMHS and adult mental health services and the difficulties in recruiting to vacant posts means that the waiting list for treatment remains high for children and adults, with a number of people waiting over a year.

Some Progress?

Coventry & Warwickshire ICB reported in March a 5.4% increase in nursing staff and a reduction in vacancy numbers, plus a growth in consultant workforce of 3.4%, although the vacancy rate remains high at 14.6%.

Frimley ICB noted that it has “hired 1,351 more permanent staff since the start of the financial year and in collaboration with the nursing team, the HCA team is actively working towards achieving the NHSE target of net zero vacancies.”

Surrey ICB reports “an increase of 3% in substantive workforce growth, a 29% reduction in bank and 31% reduction in agency.”

The context

The latest available figures are 121,000 full-time equivalent (FTE) vacancies and only 26% of the workforce state there are enough staff at their organisation. 

Between 2018/19 and 2021/22, spending on agency staff increased by £600 million (23%). 

Without adequate permanent staff, continuity of care suffers, and money is spent on agency staff that could be spent delivering other services to patients, so reducing this spend has been a major target for all ICB.

Efforts undermined

But all is not well, within the same sets of papers it becomes clear that the approach taken over much of 2023, to fill the vacancies to reduce the need for expensive agency staff, has come to a grinding halt. The requirements from NHS England for ICBs to tackle deficits and breakeven, means all the ICBs are now back-tracking.

Birmingham’s ICB noted that the ICS workforce had increased by nearly 3,500 since April 2022, but the ICB has realised that “challenges now exist in the ability of the system to recurrently fund this growth”.

So despite acknowledging the ‘benefits’ of such workforce growth, workforce constraint is being used as a key to controlling costs, with system partners being asked to “focus on workforce controls and temporary staffing ambitions.” The meeting papers noted that staff members have already raised concerns about the  ‘no workforce growth’. 

The Black Country ICB notes that all providers have been told that the 2024/25 operational plan will have “no growth in workforce” and Surrey ICB reported that recruitment had stopped across all posts from December 2023, with an exception process overseen by CPO and CFO. 

Most of the ICBs reported that they now have tighter control over vacancies, including the introduction of vacancy control panels, including in Bath and North East Somerset, Swindon and Wiltshire ICB, and Devon ICB.

Devon ICB, note though that “there should be caution with this approach as restricting staffing can impact on time to deliver practice, which will increase long-term care costs.” 

Since the vast majority of these ICB meetings, which took place in March/April, the situation for the ICBs has become much more difficult. Their plans based on no workforce growth may already be out of date.  In late March, The Times reported that NHS England has asked the ICBs for services to be reviewed and cuts made to the workforce in order to make savings of £4.5 billion. Already, ICBs were looking at no workforce growth for 2024/25, but now many will have to consider ways to reduce workforce costs to avoid a deficit.

Of the ICB papers surveyed, Staffordshire and Stoke-on-Trent ICB has already analysed what reducing the workforce headcount across its area would mean. It concluded that the scale of staffing cuts required to balance the books would put patients at risk.

The ICB’s analysis found its provider trusts would have to cut 10% of their workforce to break even. The report noted that it “would bring our teams below safe staffing levels” and have a “profound effect on our ability to deliver safe services”.

The ICB would have to terminate “a very high proportion of our third sector contracts for organisations such as hospices and our voluntary sector partners, who are key to our admissions avoidance and health inequalities work across the system.” 

Saffron Cordery, deputy chief executive of NHS Providers, told,The Times:

“Trust leaders are being pushed to the very limits of what is possible, and there will be a situation where they have to make difficult choices about keeping basic services going versus investing in quality and improvement for the future.”

An unnamed NHS chief told the Times

“We have been asked to ‘think the unthinkable’ to break even. That will be impossible without closing beds and significantly reducing staffing numbers, and NHS England has been clear that beds must not be closed. It’s a clusterf**k. Who is seriously going to propose closing and merging A&Es and maternity units in an election year?”

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