1. Health and social care surveys

This QMR issue is based on an online survey of the following groups:

79 NHS trusts finance directors
58 clinical commissioning group (CCG) finance leads
47 adult social services directors

This report details the results of an online survey of NHS trust finance directors carried out between 22 November 2013 and 6 December 2013. We contacted 230 trust finance directors to take part and 79 responded 34 per cent response rate).

In addition, 195 clinical commissioning group (CCG) finance leads were contacted and 58 responded (30 per cent response rate). Between them these finance leads covered 72 CCGs.

The online survey of directors of adult social services was carried out over the same period. Of the 152 directors contacted, 47 responded (31 per cent response rate).

The panel were asked about the financial situation of their organisation and local health economies over the past financial year; the state of patient care in their area; the likely impact of the Better Care Fund (formerly the Integration Transformation Fund) on performance of key areas (such as the four-hour A&E standard and delayed transfers of care); and their assessment of the key current concerns for their organisation.

Given the level of interest and importance of winter pressures, we took the opportunity to ask trust finance directors about the likely impact of the additional winter funding and about changes required to reduce pressures on A&E departments.

2. End-of-year financial situation and cost improvement/quality, innovation, productivity and prevention programmes

Projected end-of-year financial balance (2013/14)

The NHS is more than two-and-a-half years through the most significant period of financial constraint in its history, with the prospects beyond 2015 looking even more challenging.

At the aggregate level, the NHS seems to be managing reasonably well, in large part due to continued pay restraint and reductions in the tariff. However, this masks growing pressures within the system, with 22 per cent of trusts now predicting a deficit in 2013/14. This is the highest since we began reporting on the financial state of the NHS in 2011.

NHS Trusts
Figure 1: What is your organisation’s likely end-of-year (2013/14) financial situation?
45 In surplus
17 Break even (+/-0.25% of turnover)
17 In deficit

Note: The area of the bubble in the survey charts represents the value shown. The sizes of the bubbles are comparable between the charts.

CCG Leads
Figure 2: What is your organisation’s likely end-of-year (2013/14) financial situation?
57 In surplus
6 Break even (+/-0.25% of turnover)
9 In deficit

Note: 58 CCG finance leads answered this question for the 72 CCGs they cover collectively.

NHS Trusts
Figure 4: Trends: What is your organisation’s likely end-of-year financial situation?

Cost improvement programmes

2012/13 was the second full year of the four-year £20 billion productivity challenge. Now, part way into the third year of the productivity challenge, how are NHS organisations faring?

The average cost improvement programme (CIP) target for trusts this financial year is again 4.8 per cent, representing between 3 per cent and 7.5 per cent of turnover.

Since the beginning of this financial year there has been a reduction in uncertainty regarding the achievement of planned CIPs expressed by trust finance directors and now around 45 per cent are very or fairly confident of achieving their plans.

NHS Trusts
Figure 5: What is your organisation’s CIP target for this financial year (2013/14) as a percentage of turnover/allocation?
CCG Leads
Figure 6: What is your organisation’s QIPP target for this financial year (2013/14) as a percentage of turnover/allocation?

Note: 58 CCG finance leads answered this question for the 72 CCGs they cover collectively.

However, a similar proportion (45 per cent) are either fairly or very concerned about the achievement of their organisation’s CIP plans – the largest proportion since the summer of 2011 (figure 7 and figure 9).

CCG finance leads are slightly more optimistic about achieving their Quality, Innovation, Productivity and Prevention (QIPP) plans, with more than 61 per cent fairly or very confident (figure 8).

NHS Trusts
Figure 7: How confident are you of achieving your CIP target in 2013/14?
9 Very confident
28 Fairly confident
7 Uncertain
18 Fairly concerned
17 Very concerned
CCG Leads
Figure 8: How confident are you of achieving your QIPP target in 2013/14?
15 Very confident
29 Fairly confident
6 Uncertain
7 Fairly concerned
15 Very concerned

Note: 58 CCG finance leads answered this question for the 72 CCGs they cover collectively

NHS Trusts
Figure 9: Trends: How confident are you of achieving your CIP target?

Note: QMR1 and QMR5 excluded as wording of responses not compatible with other quarters’ data.

The £20 billion productivity challenge

Our previous reports show that NHS organisations appear to have made good progress in meeting productivity targets during the first two years of the Nicholson Challenge (Appleby et al 2013, 2012).

However, as we approach 2014/15, just under two-thirds of trust finance directors rated the risk of failure to meet the challenge as high or very high (figure 10).

CCG finance leads were again slightly more optimistic, but still six out of ten thought there was a high or very high risk of failure (figure 11).

NHS Trusts
Figure 10: The NHS is now halfway through the so-called Nicholson Challenge. What is your estimate of the risk involved in achieving productivity gains of the value of £20 billion by 2014/15?
1 Very little risk of failure
5 Little risk of failure
22 50/50 risk of failure or success
24 High risk of failure
27 Very high risk of failure
CCG Leads
Figure 11: The NHS is now halfway through the so-called Nicholson Challenge. What is your estimate of the risk involved in achieving productivity gains of the value of £20 billion by 2014/15?
0 Very little risk of failure
3 Little risk of failure
20 50/50 risk of failure or success
29 High risk of failure
6 Very high risk of failure
NHS Trusts
Figure 12: Trends: The NHS is now halfway through the so-called Nicholson Challenge. What is your estimate of the risk involved in achieving productivity gains of the value of £20 billion by 2014/15?

Note: Question not asked before QMR6 or in QMR7.

3. The state of patient care

The driving ambition underlying the challenge to deliver greater productivity and a stable financial position is not only to maintain the quality of services to patients, but to improve it. This emphasis on improving quality of care was underlined in three high-profile reports in 2013 (Francis 2013, Berwick 2013, Keogh 2013).

When asked about the state of patient care in the past 12 months, the majority of respondents felt that patient care had stayed the same (figures 13,14 and 15).

Nevertheless, around one in five trust finance directors and CCG finance leads felt care in their local area had got worse over the past year – an improvement on previous survey results, but of concern nonetheless (figure 16).

NHS Trusts
Figure 13: Thinking about the NHS in your local area, in the past 12 months, do you think it has got better, worse, or stayed the same in terms of patient care?
20 Better
41 The same
18 Worse
CCG Leads
Figure 14: Thinking about the NHS in your local area, in the past 12 months, do you think it has got better, worse, or stayed the same in terms of patient care?
18 Better
29 The same
11 Worse
NHS Trusts
Figure 16: Trends: Thinking about the NHS in your local area, in the past 12 months, do you think it has got better, worse, or stayed the same in terms of patient care?

Note: Question not asked before QMR6.

4. Organisational challenges

The scale of the current system reform, overlaid on an unprecedentedly tough financial settlement and the associated and equally unprecedented productivity target, continue to present a challenging environment for NHS organisations. This is exacerbated by a tough financial settlement for local government and evidence that local authority spending on adult social care continues to fall.

To understand how this was affecting them, trust finance directors and CCG finance leads were asked to state the three aspects of their organisation’s (or organisations they contract with) performance that were giving them most concern at the moment.

CCG finance leads continue to be concerned about A&E four-hour wait targets, while the level of staff morale is the top concern for trust finance directors. This is the first time since we began asking this question that levels of staff morale has been listed as a top concern (figures 17 and 18).

NHS Trusts
Figure 17: Which aspects of your organisation’s performance are giving you most cause for concern at the moment? Please select top three
9 Health care-acquired infections
10 Cancer treatment waiting time targets
14 Emergency readmission threshold
14 Patients’ care experience
21 A&E four-hour wait target
21 Level of engagement in performance issues by senior clinicians
24 18-week RTT
29 Delayed transfers of care
31 Staff morale
CCG Leads
Figure 18: Which aspects of your organisation’s performance are giving you most cause for concern at the moment? Please select top three
9 Staff morale
10 Level of engagement in performance issues by senior clinicians
11 Emergency readmission threshold
11 Patients’ care experience
15 Delayed transfers of care
16 Cancer treatment waiting time targets
20 Health care-acquired infections
28 18-week RTT
40 A&E four-hour wait target

5. Winter pressures on A&E departments

Analysis of data for the final quarter of 2012/13 showed that nearly 6 per cent of patients waited four hours or longer in A&E departments, the highest level since 2004.

Since then, there has been sustained pressure on the system to prepare and plan for winter 2013/14. Part of the planning was the distribution of £250 million to help A&E departments prepare for winter 2013/14, announced in June 2013 (Prime Minister’s Office 2013), and a further £150 million announced in November 2013 (NHS England 2013b).

Only 13 per cent of respondents felt this additional funding would have a significant impact on the pressures their organisations were likely to face over the winter months (figure 19).

As for the top three actions that would help with pressures on A&E departments, finance directors noted improvements in care outside hospital to reduce preventable admissions to A&E, reductions in delayed transfers of care elsewhere in the hospital to help with patient flow out of emergency departments and front-door triaging by senior doctors to direct patients to the most appropriate care for their condition (figure 20).

NHS Trusts
Figure 19: If you have received, or plan to apply for, any additional winter pressure funding, what impact will this have on the pressures your organisation is facing this winter?
8 Significant impact
35 Some impact
18 Marginal impact

Note: Question only applicable to those organisations that applied for additional funding (61).

NHS Trusts
Figure 20: Which of the following would have the most impact in reducing the pressures on your A&E department?
6 More beds and associated resources in other parts of the hospital
12 More senior clinical staff available in A&E
16 Front-door triaging by senior hospital clinicians/GPs
25 Reduction in delayed transfers of care elsewhere in the hospital
30 Improved out-of-hospital care to reduce preventable attendances

Note: Respondents asked to choose top two actions.

6. The Better Care Fund

Preventing unnecessary use of A&E services and ensuring delays in discharge from hospital are minimised will, of course, be two priorities for the Better Care Fund, which will be established mainly from top-sliced NHS funding in 2015/16 and administered jointly by the NHS and local authorities.

When asked if the Better Care Fund is likely help or hinder work to maintain performance in key priority areas such as delayed transfers of care, slightly more than half of directors of adult social services thought it would, but more than a third did not know (figure 23), perhaps reflecting that discussions about the fund were at an early stage.

CCGs’ views about the Better Care Fund were more mixed – 38 per cent thought it would help (figure 22), and trust finance directors were the least optimistic with only 12 per cent saying it would help (figure 21).

NHS Trusts
Figure 21: On balance, do you think the Integration Transformation Fund, will help or hinder your work maintaining/improving performance in key areas such as the four-hour A&E target and delayed transfers of care?
10 Help
32 Don’t know
37 Hinder
CCG Leads
Figure 22: On balance, do you think the Integration Transformation Fund, will help or hinder your work maintaining/improving performance in key areas such as the four-hour A&E target and delayed transfers of care?
22 Help
16 Don’t know
20 Hinder

7. The financial state of local health and care economies over the next 12 months

When asked how they felt about the financial state of their local health and care economy – not just their own organisations – over the next 12 months, nearly 9 out of 10 trust finance directors were fairly or very pessimistic. These are the most pessimistic views of the future since we began our surveys (figures 24 and 27).

Around two-thirds of CCG finance leads and directors of adult social services were also very or fairly pessimistic about the future financial state of their local health economies (figures 25 and 26).

NHS Trusts
Figure 24: Overall, what do you feel about the financial state of the wider health (and care) economy in your area over the next 12 months?
0 Very optimistic
2 Fairly optimistic
9 Neutral
42 Fairly pessimistic
26 Very pessimistic
CCG Leads
Figure 25: Overall, what do you feel about the financial state of the wider health (and care) economy in your area over the next 12 months?
0 Very optimistic
10 Fairly optimistic
10 Neutral
25 Fairly pessimistic
13 Very pessimistic
NHS Trusts
Figure 27: Trends: Overall, what do you feel about the financial state of the wider health (and care) economy in your area over the next 12 months?

Note: Question not asked before QMR3.

References

  • Appleby J, Thompson J, Humphries R, Jabbal J, Galea A (2013). Quarterly monitoring report, September 2013. London: The King’s Fund. Available at: www.kingsfund.org.uk (accessed on 13 January 2014).

  • Appleby J, Thompson J, Humphries R, Jabbal J, Galea A (2012). Quarterly monitoring report, September 2012. London: The King’s Fund. Available at: www.kingsfund.org.uk (accessed on 13 January 2014).

  • Prime Minister’s Office (2013). ‘Prime Minister announces £500 million to relieve pressures on A&E’. London: 10 Downing Street/Department of Health. Available at: www.gov.uk (accessed on 13 January 2014).

  • NHS England (2013b). 'Extra £150 million to ease winter pressures'. News article. NHS England website. Available at: www.england.nhs.uk (accessed on 13 January 2014).

  • Berwick D (2013). A promise to learn – a commitment to act: improving the safety of patients in England. London: The Stationery Office. Available at: www.gov.uk (accessed on 14 January 2014).

  • Francis R (2013). Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. Chaired by Robert Francis QC. London: The Stationery Office. Available at: www.midstaffspublicinquiry.com (accessed 14 January 2014).

  • Keogh B (2013). Review into the quality of care and treatment provided by 14 hospital trusts in England: overview report. London: NHS England. Available at: www.nhs.uk (accessed on 14 January 2014).