Government claims last December that they were on track to save a colossal £17 billion from NHS “efficiencies” over the next three years seem to be more than slightly over-optimistic, according to the latest Lowdown survey of Integrated Care Boards (ICBs) and trusts in the North West of England.
Two of the three North West ICBs (Cheshire & Merseyside; Greater Manchester and Lancashire & South Cumbria) seem set to miss financial targets set last April by NHS England.
In Cheshire & Merseyside, trusts have relied on unplanned cash handouts of “Provider Distressed Cash” to prop up balance sheets. By Month 8 (November) providers had already received £82.6m (p8-9), and the January Board meeting of Cheshire & Merseyside ICB heard that by the end of February providers would have requested £260m, and received £151m. (p101)
But it’s touch and go for Greater Manchester ICB, which predicted at its meeting on March 18 that the giant Manchester University NHS Foundation Trust will scrape through to the end of the financial year with enough cash for just one day, while the Northern Care Alliance and Bolton NHS Foundation Trust would be left with just 2 days, and two trusts (Tameside And Glossop Integrated Care and Wrightington, Wigan and Leigh would each be left with cash to run for less than a week (6 days). (p237)
Greater Manchester is counting on receiving all of the £42.5m Deficit Support Funding (DSF) agreed with NHS England, and seems to be on track to slightly exceed its huge £656.0m targets for cost improvements (CIPs) – with £175.0m to be saved by the ICB itself and £481.0m by GM providers. On this basis they are still predicting, as of March 18, that the system as a whole will deliver its planned deficit, and thereby “break even”.
Lancashire & South Cumbria are also predicting a “break-even” in the sense that they will deliver a deficit no larger than the £164m agreed with NHS England, and which is supposed to be covered by an equivalent amount of DSF – assuming the system as a whole sticks to the plan, and the delivery of £394m of CIP savings.
However, by month 10, the system was £67.7m behind plan, with a deficit £81.9m worse than the year-to-date planned deficit of £14.2m, all of this down to the providers (Blackpool and University Hospitals Morecambe Bay each £10m adrift, East Lancashire Hospitals £25m and Lancashire Teaching Hospitals £24m adrift). Each of these trusts has a mountain to climb in two months to meet the target, with UH Morecambe Bay having to transform its £10m deficit into a £3.8m surplus to deliver the plan.
All of three ICBs are seeking to reduce their own staffing numbers, with providers attempting to do the same, to strict targets: but none seem to give any details on which staff are leaving, or give any details of the impact this is having on the continuity and quality of services to patients or the morale of the remaining staff.
Cheshire & Merseyside
Cheshire & Merseyside ICB initially proposed to end 2025/26 with a combined £255m deficit, consisting of £23.6m surplus on the commissioning side (ICB) partially offsetting an aggregate NHS Provider deficit position of £278.7m.
When this plan was rejected by NHS England, a revised plan of £178.3m deficit (requiring an increased £50.4m surplus for the ICB and a reduced £228.6m deficit for providers) was agreed and submitted on 30th April 2025.
As a result of NHS England accepting the revised deficit plan the ICS was allocated up to £178.3m deficit support funding from NHSE “to cover the deficit and allow the financial system plan to be adjusted to a balanced breakeven position.”
However, the support funding was conditional on the whole system sticking to the agreed plan, and as Cheshire & Merseyside fell behind, the support funding was withdrawn – leaving an even bigger deficit. Although support funding was paid in Quarter 1, it was not awarded from Quarter 2: “Therefore, the YTD system financial position is adversely affected due to £89m of DSF funding relating to Q2 & Q3 being withheld.” (p92)
In addition, NHS England has put several of the trusts, as well as the ICB, in special measures, awaiting a recovery plan that will demonstrate the steps required to move the system into a balanced financial position.
The most recent (January) ‘mid-case’ forecast is a £335m deficit – £156m off plan, while the ‘best-case ’ forecast is £244m – £66m adrift. Significantly, there are no projections for a “worst case” scenario. The ICB warns that “If the average level of underlying improvement continues the system would end up £113m off plan.”
To make matters worse, the ICB has had to bring in costly management consultants from Price Waterhouse Coopers (PWC) “until the end of the financial year,” to “work alongside NHSE and the ICB,” undertake monthly reviews with “High-risk organisations, including the ICB,” and conduct Rapid Baseline reviews for high-risk programmes within the ICB and Balance Sheet reviews across all ICS organisations. (p93)
C&M staffing (from trust board papers where available)
The ICB reports that the system as a whole was 889 WTE above plan at Month 8 (with 9 of the 16 trusts still above target staffing). However, the BMA has just issued a press release flagging up medical staff concerns and the impact of staffing cuts in C&M trusts, putting patient care at risk.
Trust Board papers show Liverpool University Hospitals having achieved a total reduction of 362 WTE by month 10, but a net reduction of 114 (plus 135 WTE funded from new income sources and another 113 transferred under TUPE.) The Trust’s recurrent pay CIP and WTE reductions were £34m behind plan at Month 10, with mid-case forecast deficits of £13.8m at Aintree and £17.3m at the Royal – despite recruitment freezes and overtime restrictions at the Royal and weekly vacancy control panels at all trust sites.
Liverpool Heart & Chest FT pay costs were £1.6m below plan at month 10, mainly through vacancies in healthcare support and non-clinical roles. Its substantive staff were 29 WTE below plan, and total WTE 32 below plan. The Trust had reduced overtime spending by 51%, agency by 8%, waiting list initiative by 35%.
Liverpool Women’s Hospital had exceeded its planned reduction of staff by 10 WTE in January, although this had been lower still (38 below plan) in December. Although the target for reduction of agency staff had not been met, the £12.7m CIP target has been exceeded.
Alder Hey Children’s FT has paused recruitment into corporate and managerial non-patient-facing roles until the end of March, and is restricting the number of new starters to half the number leaving. However, despite a vacancy panel, a recruitment freeze and MARS, the number of substantive staff has increased by 108, while the number of temporary staff has only been reduced by 5 Bank and 1.2 Agency.
Greater Manchester
Greater Manchester ICB meets monthly, and by February (Month 9 figures) seemed to be puzzlingly £10m adrift of plan despite exceeding CIP targets, which were £24m ahead of plan. (p10)
By Month 10, the Finance Committee (p220) discussed a paper reporting a worse system-wide deficit of £24.8 million against plan (£75.7m deficit, against a planned deficit of £50.9m) (p225), with NHS GM itself in line with its planned deficit of £6.3 million, but providers showing a larger variance.
By far the largest share of the increased deficit was down to Manchester University Foundation Trust (£13.2m out of £16.1m) “adverse performance against the in-month recovery plan”. (p227)
GM’s problems are substantially driven by the private sector, not least the costs of ADHD, Autism, and support under Section 117 of the Mental Health Act, which requires the NHS and local authorities to provide free, specialised aftercare to individuals in England and Wales who were detained under specific sections of the Act. It aims to prevent readmission, reduce deterioration in mental health, and support reintegration into the community through tailored care plans. It covers all support needed for the mental health condition, including social care, nursing care, and sometimes housing, aimed at reducing the risk of deterioration, and services must be provided free of charge.
GM ICB notes that these services were resulting in “the continuing issue of backdated invoices being submitted by new providers under Right to Choose.” (p227)
In addition, “All Age Continuing Care [financial performance] has deteriorated this month, due to new backdated high-cost complex cases,” as well as “pressures associated with Independent Sector elective activity and delays in delivery of savings”.
The recovery actions have reduced spend compared to earlier in the year, but they have not delivered the originally planned reductions.
And even though Month 9 data indicates a reduction in activity levels, “Independent Sector activity is still estimated as being slightly behind the recovery plan” (i.e. not falling as fast as NHS provided activity), with the Forecast Outturn increased to £15.0m this month. (p228)
GM ICS Staffing
The system’s risk score on staffing and staff costs has increased from 12 (amber) to 16 (red), specifically the risk that the requirement for financial savings and the impact of NHS reforms
“will result in recruitment challenges to key areas, reduced staff wellbeing, lower morale and inequality of opportunity. This will further impact on service delivery and leadership capacity to manage change.” (p84)
The pressures increasing these risks are spelt out clearly:
“Workforce cost pressures, with Trusts exceeding workforce cost plans by £51.3m at Month 6 and projections indicating a potential £100.3m year-end variance, despite progress in reducing bank and agency spend in line with national targets. […]
- Persistent workforce gaps, many of which are influenced by national supply issues and outside of local control.
- Increased reliance on migrant workers, combined with rising visa costs, tighter settlement and sponsorship rules, ethical recruitment requirements, and strong international competition, heightens recruitment and retention risks and may exacerbate workforce shortages. These pressures also carry delivery, skills dilution, and workforce wellbeing risks, particularly affecting a predominantly female and migrant workforce amid growing anti-migrant sentiment.
- Organisational change and turnover, particularly within NHS GM, following national VR announcement, resulting in loss of organisational memory, reduced continuity, and increased reliance on interim and agency staff.
- Financial constraints, including the requirement to reduce pay bills to achieve long-term sustainability, limiting flexibility to invest in workforce growth and development.” (p84)
ICB staff
The ICB’s Greater Manchester Transition Committee in February heard that “approximately 200 [ICB] staff left the organisation at the end of January 2026, with mitigations in place to address gaps, prioritise critical work, provide well-being support, including increased HR engagement and leadership briefings.” (p282)
GM NHS providers (from trust board papers where available):
The latest available data show Manchester UFT reduced whole time equivalent posts (WTE) by 202 in the 12 months to July, and has increased vacancies to 1,935 WTE, monitored by a Vacancy Control Panel. However by November 2025 temporary staff were 112 WTE (9%) above the reducing target (92 bank staff and 20 agency), although agency staff had been reduced to 0.17% of total WTE.
The Northern Care Alliance estimated last year it would save £10.4m through holding a high level of vacancies, and by June 2025 had reduced substantive staff numbers to just below target, with 581 staff applying to leave under Mutually Agreed Resignation Scheme. By January 2026 it had reduced substantive staff numbers by another 286 to 17,950 WTE, but this was 495 above plan. Bank staffing was also 8% (102 WTE) above plan, although Agency staff was 47% (36 WTE) below plan.
Greater Manchester Mental Health FT has been running weekly Vacancy Panels, and exceeded the target of reducing agency staff to 2%, delivering 1.8% – saving £9m.
Stockport FT, too, has exceeded the target for reducing agency staff, cutting to 1.2% of the pay bill, against a 1.5% target – an additional reduction of 79 WTE. Substantive staffing was 12 above plan at Month 9, down from 42 above plan in November.
The Christie FT planned to cut 70 WTE through CIP, and had cut 63.7 by the end of month 10, with £14.8m CIP fully delivered. Staff cuts delivered by over 20 individual schemes –involving increasing vacancies, cuts in bank and agency use, bed closures and skill mix reviews, along with a weekly Establishment Control Panel.
Lancashire & South Cumbria
The ICB heard at its March 19 meeting that the system was £67.7m behind plan at Month 10, with a reported £81.9m deficit against a year-to-date planned deficit of £14.2m. Nevertheless, the system is forecasting breakeven to plan for the full year, with a £10.1m surplus in the ICB to offset a £10.1m deficit in provider trusts and £164m of Deficit Support Funding.
To deliver the plan LSC needs to generate £394.2m savings, (£251.5m for provider trusts and £142.7m for the ICB). This follows last year’s LSC savings target of £530m.
ICB CEO Aaron Cummins told the Board in January that the ICB continued to face significant challenges in maintaining service and access standards within a severely constrained budget, alongside the voluntary redundancy process affecting nearly 200 colleagues.
In March he followed this with an even more open expression of concern at the consequences of the staffing cuts within the ICB itself:
“It’s fair to say that 2025/26 has been a year of turmoil. It has been almost twelve months since the reductions to ICB costs of commissioning were announced and colleagues have continued to work with professionalism, dedication and compassion whilst managing personal uncertainty.
… Operationally, our system remains incredibly challenged. Our organisations always plan for the post-Christmas spike in activity both through planned and urgent care pathways and in access to primary care and community services, but this year feels to be even more challenging.
… By 31 March, approximately 170 colleagues will have left the ICB after applying for voluntary redundancy (VR) through the scheme launched in November 2025.
… It is estimated that the combined NHS experience from those leaving will be more than 4,000 years across clinical and non-clinical roles.”
For the current financial year LSC faces serious problems: as at January 31 its provider trusts have a shortfall of £53.8m on the year-to-date delivery of efficiency savings, and the ICB has a shortfall of £32.7m.
As with Greater Manchester, the private sector is at the heart of the financial problems. The main areas of challenge are as reported in previous months: Acute (Independent Sector) Contracts – £14.1m; Mental Health & Learning Disability & Autism – £11.4m; Continuing Care – £39.6m (including £15.8m of prior year costs) and Prescribing – £9.9m.
The full year forecast for the system is showing delivery of £317.0m ‘efficiency’ savings, against a plan of £394.2m, a shortfall of £77.2m.
Future cuts proposed
LSC is one of the few ICBs to publish explicit proposals to save between £24m and £31m in the coming 2026/27 financial year by decommissioning services. (page 10)
- They hope to save £4m by ending a contract with private hospital chain Ramsay for pain management in December 2025 before deciding “the optimum model” to take its place.
- Also facing a financially driven axe is the use of private sector MRI facilities (£690,000).
- Another £900,000 is to be saved through “consistent” commissioning of Local Enhanced Services from GPs and “decommissioning of atypical services”.
- There are hopes of much larger savings (£3-£10m per year) from stopping or reducing “Integrated Urgent Care” services, and reducing the £16.5m capacity investment funding for Urgent and Emergency Care. There is a concern to avoid public consultation, and continuing cost pressures to fund, including private Non Emergency Patient Transports.
- The largest projected saving (a very precise £14.93m) would be from withdrawing funding for some contracts – but no details are given.
LSC staffing (from trust board papers where available):
Blackpool Teaching Hospitals FT has been seeking to reduce staffing levels, with Waste Reduction Programme (WRP) aiming to save £63m in 2024/25 and £44.7m in 2025/26. However total WTE wound up 258 above target in 2024/25, and new target set to cut another 279 substantive WTE posts in 2025/26, and drive headcount down to 2018/19 levels. By Month 8 the vacancy rate had risen to 10.6% (more double the 4.3% target) and the WRP £6m behind target, while agency staff costs remain above target at 3.6% (target 3.2%). Next year the pressure to cut jobs is set to further increase, targeting reduction of 376 WTE.
East Lancashire Hospitals have seen an increase in vacancy levels as numbers of substantive staff have been cut by 486 WTE in the 12 months to November 2025, driven by holding vacancies and MARS. Use of agency staff dramatically reduced from 1.9% to 0.55 of pay bill by month 8, but use of bank still significant.
Lancashire & South Cumbria FT needs to make £39m savings by end of March, with up to 200 jobs to go, and up to 46 of these requiring actual redundancy.
Lancashire Teaching Hospitals FT, in special measures, cut 690 WTE (6.5%) in 2024/25 and was £24m adrift from its planned £2m deficit by month 10 of 2025/26. The ICB expects the Trust somehow to reduce that deficit to £9.2m.
University Hospitals Morecambe Bay was running a vacancy rate of 21.4% in September 2025, but still facing a deficit £10m greater than plan by Month 10.
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