QMR 14 | January 2015

How is the NHS performing?

  • “Services are stretched to the limit. With financial problems also endemic among hospitals and staff morale a significant cause for concern, the situation is now critical.”

    John Appleby, Chief Economist
  • 6 in 10 6 in 10 trusts are relying on financial support from the Department of Health or planning to draw down their reserves.

  • 49%
    For the second consecutive survey, nearly half of NHS trust finance directors identified staff morale as one of their top concerns.
  • 5.4% The proportion of outpatients waiting longer than 18 weeks for treatment was 5.4% in November – missing the target for the first time since 2008.

  • 47% In the most recent quarter, more than 414,000 patients spent longer than 4 hours in A&E – a 47% increase on the previous quarter.

  • 17k The numbers for all NHS staff groups are up by 3% since September 2009 – that's nearly 17,000 full-time equivalent posts.

Headlines

How is the NHS performing?

  • Our latest survey of finance directors shows a deepening pessimism about the current financial state of health organisations and worries about the coming financial year. Slightly more than 4 out of 10 trust finance directors forecast an overspend by the end of this year – the highest proportion since our survey began in March 2011 – and just over three-quarters say they are fairly or very concerned about staying within budget by the end of the next financial year.

Balancing the books this year: an increasingly difficult task?

  • As we reported in our previous quarterly report, the planned increase in overall funding for the English NHS this year amounted to a real rise of just 0.8 per cent. While additional money has been channelled to the front line within the year, this has mainly come from within existing NHS budgets at national level. Overall, funding remains extremely tight.

  • Forty-two per cent of trusts forecast a deficit by the end of this financial year. This is despite additional spending of nearly £1 billion directed at reducing waiting times and alleviating winter pressures and with 60 per cent of trusts in our survey drawing on their reserves and/or taking up loans or additional funding of one sort or another from the Department of Health to support their financial position this year. As Figure 1 shows, this represents a deterioration in trusts’ finances over the year since our survey in March last year and is evidence of a wider systemic financial problem.

NHS Trusts
What is your organisation’s forecast end-of-year financial situation? NHS trust finance directors

Respondent comments

  • “'Cash support has been agreed with the NHS Trust Development Authority and the Independent Trust Financing Facility.'”

    Acute trust
  • “'The surplus is only 0.4 per cent and is very dependent on driving down agency costs which is very difficult post-Francis.'”

    General acute and specialised
  • “'[Breaking even is] partly due to some non-recurrent actions so underlying position is into deficit.'”

    Acute teaching hospital

QMR 1-4 based on a panel of 50 trust finance directors

  • This proportion is similar to the financial position of trusts and foundation trusts reported half-way through the year by the NHS Trust Development Authority (TDA) and by Monitor last autumn. Then, the NHS TDA reported that around 27 per cent of trusts forecast a deficit this year while Monitor’s six-month report showed that 55 per cent of foundation trusts were overspent (Monitor 2014; NHS Trust Development Authority 2014).

  • Difficulties in balancing the books this year are reflected in finance directors’ views about their organisations’ cost improvement programmes (CIPs). On average trusts are planning CIPs of around 5 per cent of turnover (a cumulative total over the past four years of around 20 per cent). However, the trend over the past two years in the proportion of finance directors who say they are fairly or very concerned about achieving their CIP plans has increased; the latest survey shows that more than half are fairly or very concerned.

Increasing workloads: pressure on spending and longer waiting times?

  • The reason for increasing pressures on trusts’ spending is evident from trends in hospitals’ workloads. As Figure 2 shows, some quarterly seasonal trends aside, trends in referrals have been increasing over the past six years (at around 3.2 per cent per year), as are attendances at outpatients (3.2 per cent), accident and emergency (A&E) departments (1.8 per cent), and elective (2.8 per cent) and emergency admissions (1.8 per cent).
Quarterly referral and admission trends: English NHS 2008/9 quarter 1 – 2014/15 quarter 2

Data source: NHS England, Monthly hospital activity data (commissioner based time series) www.england.nhs.uk

  • While increasing demand – largely a reflection of increases in the population and its demographic structure – has an impact on spending, evidence of the general pressure on the secondary care system as a whole is also evident from trends in waiting times – in particular waiting times in A&E departments (which remain a top concern for finance directors).

  • As Figure 3 shows, the proportion of patients waiting more than 4 hours from arrival to discharge, admission or transfer in all A&E departments in the quarter from October to December last year was 7.4 per cent (ie, 414,000 patients) – a 47 per cent increase on the previous quarter and the poorest performance since quarter 3 in 2003/4. For major A&E departments, more than 14 per cent waited for more than 4 hours. Overall, for all types of A&E units, nearly 50 per cent of all hospitals missed the 4-hour target in the third quarter of 2014/15.

Percentage waiting more than four hours in A&E from arrival to admission, transfer or discharge

Data source: Weekly A&E SitReps 2014–15 www.england.nhs.uk.

  • While attendances at A&E departments have been higher in the third quarter of 2014/15 than in the third quarters of the previous two years, the much higher number of patients waiting to be admitted to a hospital bed from A&E (‘trolley waits’) than in previous years point to pressure on beds in other parts of hospitals, leading to disruption in the flow of patients though A&E.

  • Part of the pressure on beds in other parts of hospitals is due to problems with discharging patients – another top concern for finance directors, and reflecting the fact that since last summer there has been an acceleration in the number of delayed transfers. Numbers now stand at more than 5,000 patients per day. Two-thirds of all delays are related to NHS care and a third are related to social care. However, in terms of the reasons for delays, during the past year there has been a 50 per cent increase in waits for care packages, a 42 per cent increase attributable to waits for nursing home places and a 22 per cent increase in waits for assessments.

  • This suggests that capacity and workforce issues – particularly in nursing home and non-acute services – are becoming more important than social care funding issues per se. The overall pattern is not as straightforward as the ‘social care cuts = more delayed transfers’ narrative would suggest. With nearly a fifth of delays due to waits for non-acute NHS care, the need for better co-ordination between different parts of the NHS is just as significant as the hospital/social care interface.

  • Another indicator of pressure on beds is the number of cancelled operations as a proportion of elective admissions. Although (seasonal fluctuations aside) this has remained steady at between 0.8 per cent and 1.1 per cent for each quarter for the past decade and was 0.8 per cent for quarter 2 of 2014/15, year-on-year comparisons for the three-month period from November to January 2014/15 show an increase of around a third in the number of cancelled operations. Whether this will translate into a higher cancellation rate for the full 2014/15 quarter 3 compared to the equivalent quarter in 2013/14 depends on final admission and cancellation figures that will be published in February.

  • The combination of increasing elective referrals, pressure on beds, problems discharging patients and increasing emergency admissions into hospitals from A&E has also put increasing pressure on elective waiting times. As we have previously reported, since December 2012, there have been upward trends in all three stages of the 18-week referral-to-treatment path – for patients admitted to a bed in hospital, for those seen in outpatients and for those yet to be seen as either outpatients or inpatients. The latest figures (for November 2014), show that the proportion still waiting has stabilised at around 1 per cent within target. However, the outpatient target was breached (5.4 per cent versus a target maximum of 5 per cent) for the first time since the summer of 2008. The inpatient target was also missed (12.5 per cent versus a target maximum of 10 per cent) and is the highest proportion since this particular target was introduced in June 2010.

  • Breaches in the inpatient and outpatient stages of the 18-week referral-to-treatment target are to be expected given the ‘managed breach’ policy designed to reduce the growth in long waits for patients yet to be seen in outpatients or admitted as inpatients. However, while the number of patients still waiting more than 16 weeks has reduced by around 9,000 since last June, it seems unlikely that the government’s target reduction of 115,000 will have been met by December 2014. Whether the managed 18-week breaches for outpatients and inpatients return to target by December remains highly unlikely.

  • Seasonal fluctuations aside, given continued financial and demand pressures on hospitals, it is hard to see much improvement in overall elective waiting times over the next few months.

The outlook for next year: critical?

  • If this year looks gloomy, finance directors are even more pessimistic about next year. Aside from various promises from the three major political parties on NHS spending next year and beyond, current plans amount to a real increase of just 0.2 per cent over this year’s planned spending – equivalent to around £250 million. It is perhaps not surprising therefore that nearly 8 out of 10 trust finance directors are very or fairly concerned about their organisations’ ability to achieve financial balance by the end of 2015/16. A similar proportion are very or fairly pessimistic about the general state of their local health economy’s financial state next year too. However, CCG finance leads remain, by comparison, somewhat more confident about their financial position next year (31 per cent are fairly or very concerned) and slightly more than 7 out of 10 say they are pessimistic about the financial state of their local health economy next year.

  • Over and above the planned very small rise in overall funding, an important part of the financial context next year is the implementation of the Better Care Fund which will involve significant transfers of money from next year’s NHS budget to fund new services and initiatives in partnership with local authorities. So far, plans indicate possible commitments to the Better Care Fund of more than £5 billion.

  • Part of the planned benefit of the anticipated initiatives the Better Care Fund will facilitate is a reduction in emergency admissions. On average, trusts in our survey are planning a reduction in emergency admissions of 3.4 per cent next year (against a background of annual average increases of nearly 2 per cent per year over the past six years). However, neither trust nor CCG finance directors appear particularly confident of achieving these plans: 83 per cent of trust finance directors and 63 per cent of CCG finance leads are fairly or very concerned about the ability of trusts to achieve their planned emergency admissions reductions. This is in line with NHS England’s planning guidance for next year which has asked for revised plans and noted that ‘plans must be credible'. It is likely, in light of the rise in emergency admissions we have seen in recent months, that many of these ambitions will need to be revised downward.’ (NHS England 2015c)

  • Given the results from our latest survey of finance directors, the current overall financial position of the NHS and the outlook for next year, it is hard to escape the conclusion that the situation looks critical for NHS finances and services. While it is true that the majority of people using the NHS will continue to receive timely and high-quality care, increasing numbers of patients are having to wait longer and NHS organisations will find it harder to balance growing demands within budget.

References

  • Monitor (2014). Quarterly report on the performance of the NHS foundation trust sector: 6 months ended 30 September 2014. London: Monitor. Available at: www.gov.uk (accessed on 12 January 2015).

  • NHS England (2015a). Monthly hospital activity data 2014/15. London: NHS England. Available at: www.england.nhs.uk (accessed on 12 January 2015).

  • NHS England (2015b). Weekly A&E SitReps 2014–15. London: NHS England. Available at: www.england.nhs.uk (accessed on 12 January 2015).

  • NHS England (2015c). Information for commissioner planning, 2015/16. London: NHS England. Available at: www.england.nhs.uk (accessed on 12 January 2015).

  • NHS Trust Development Authority (2014). NHS trust service and financial performance report for the six month period ending 30 September 2014. Paper D for Board meeting 20 November 2014. Available at: www.ntda.nhs.uk (accessed on 12 January 2015).

1. Health care surveys

This quarter’s report is based on an online survey of the following groups.

73 NHS trust finance directors
51 clinical commissioning group (CCG) finance leads

This report details the results of an online survey of NHS trust finance directors carried out between 3 December 2014 and 17 December 2014. We contacted 252 NHS trust finance directors and 73 responded (29 per cent response rate). The sample included 38 (52 per cent) acute trusts; 23 (32 per cent) community and mental health trusts; 6 (8 per cent) specialist trusts; 1 (1 per cent) ambulance trust and 5 (7 per cent) unknown.

In addition, we contacted 203 clinical commissioning group (CCG) finance leads and 51 responded (25 per cent response rate). Between them these finance leads covered 59 CCGs (28 per cent of CCGs).

Respondents 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 £20 billion productivity challenge set for 2014/15 and beyond; the financial situation looking ahead to 2015/16; the key organisational challenges facing trusts and CCGs; and the impact of the Better Care Fund on stakeholder relationships between providers and commissioners in local areas.

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

Projected end-of-year financial balance: 2014/15

Slightly more than 4 out of 10 NHS trust finance directors forecast a deficit for the end of year (2014/15) (Figure 1). This is the highest proportion since we began surveying in 2011. Nationally, as at 30 September 2014, 27 per cent of all NHS trusts were forecasting a deficit for 2014/15 (NHS Trust Development Authority 2014). For foundation trusts, Monitor reports deficits at 81 foundation trusts (55 per cent of all foundation trusts) amounting to £254 million half-way through the year (Monitor 2014).

CCGs’ forecast position is not as bad as providers’: around 10 per cent of CCGs forecast ending 2014/15 in deficit (Figure 2). Nationally, the picture is similar, with NHS England reporting 18 CCGs in deficit in month 6 of 2014/15. NHS England is set to end the year with an overall deficit of £184 million, of which £120 million is for direct commissioning, and £21 million for CCGs (Wheeler 2014).

NHS Trusts
What is your organisation’s forecast end-of-year financial situation? NHS trust finance directors

Respondent comments

  • “'Cash support has been agreed with the NHS Trust Development Authority and the Independent Trust Financing Facility.'”

    Acute trust
  • “'The surplus is only 0.4 per cent and is very dependent on driving down agency costs which is very difficult post-Francis.'”

    General acute and specialised
  • “'[Breaking even is] partly due to some non-recurrent actions so underlying position is into deficit.'”

    Acute teaching hospital

QMR 1-4 based on a panel of 50 trust finance directors

CCG Leads
Figure 2: Trends: What is your organisation's forecast end-of-year financial situation?

Respondent comments

  • “'£3 million (in deficit) with no scope to cope with any increased activity over the winter.'”

  • “'In year roughly break-even but have brought forward surplus from previous years.'”

  • “'Our CCG sits within inner London, and is deemed to be "over capitation" according to the national funding formula. We are also forecasting substantial demographic growth over the next five years. As a result we are likely to see flat or even negative real-terms growth over this period, as our population grows faster than our allocation. Therefore our current surplus is very much non-recurrent and diminishing.'”

51 CCG finance leads answered this question for the 59 CCGs they cover collectively.
CCGs only surveyed since their establishment in April 2013.

In-year financial support

More than 60 per cent of finance directors reported that their forecast financial position depended upon additional financial support through loans and additional finance through Public Dividend Capital (PDC) from the Department of Health or drawing on their own reserves (Figure 3).

NHS Trusts
Figure 3: What does your forecast end-of-year outturn depend on?
18 Additional financial support (eg, additional Public Dividend Capital support, financing facility loans, etc)
22 Use of trust reserves
4 Both
29 Neither

Respondent comments

  • “'The deficit plan has worsened in the forecast figure which has required further cash loans due to CCG penalties, high non-elective activity and associated high agency costs.'”

    Integrated care organisation
  • “'Depends on CCGs giving us the much promised winter resilience funding.'”

    Acute teaching foundation trust
  • “'The trust will literally run out of cash in mid-March 2015 and will require on-going support for the next two to three years. We are joining the swollen ranks of bankrupt acute providers, but we are providing much improved quality of care and just about meeting demand.'”

    Acute foundation trust

Only foundation trusts are allowed to draw down on trust reserves

Cost improvement and QIPP programmes (2014/15)

The average cost improvement programme (CIP) target for trusts for 2014/15 is 4.9 per cent, ranging from 2.4 per cent to 8 per cent of turnover (Figure 4).

The average quality, innovation, productivity and prevention (QIPP) target for CCGs for 2014/15 is 2.7 per cent, ranging from 0.5 per cent to 4.8 per cent of allocation (Figure 4).

There has been a loss in confidence in achieving planned CIPs/QIPPs each year since we began these surveys. Around 53 per cent of all NHS trust finance directors now feel fairly or very concerned about achieving their CIP plans this year (Figure 5).

Similarly, around 42 per cent of all CCG finance leads were fairly or very concerned about achieving their QIPP plans this year (Figure 6).

NHS TrustsCCG Leads
Figure 4: What is your organisation's CIP/QIPP target for this financial year (2014/15) as a percentage of turnover/allocation?
NHS Trusts
Figure 5: Trends: How confident are you of achieving your cost improvement programme (CIP) target?

Respondent comments

  • “'Recruitment of staff, particularly nurses, is proving difficult and therefore high levels of agency premium are being required.'”

    Integrated care organisation
  • “'We'll get close but not quite there.'”

  • “'Delays in service developments from factors outside our control. Cost savings after five years of these are becoming extremely difficult to identify and put through.'”

    Specialist foundation trust

QMR 1-4 based on a panel of 50 finance directors. QMR1 and QMR5 excluded as wording of responses not compatible with other quarters' data.

CCG Leads
Figure 6: Trends: How confident are you of achieving your quality, innovation, productivity and prevention (QIPP) target?

Respondent comments

  • “'Very little of the QIPP target has been delivered in 2014/15.'”

  • “'No hope of achieving, schemes working but swamped by additional acute activity.'”

  • “'Currently forecasting to deliver 70 per cent but able to absorb.'”

51 CCG finance leads answered this question for the 59 CCGs they cover collectively.
CCGs only surveyed since their establishment in April 2013.

The outlook for 2015/16

Although additional funding over current plans for 2015/16 was announced in the Autumn Statement, NHS trust finance directors surveyed after this announcement are pessimistic about their trusts’ financial position next year. Slightly more than three-quarters were concerned about balancing their books next year (Figure 7).

Although more optimistic, just under a third of CCG finance leads felt fairly to very concerned about achieving financial balance in 2015/16 (Figure 8).

NHS Trusts
Figure 7: Looking ahead, how confident are you that your organisation will achieve financial balance in 2015/16?
2 Very confident
12 Fairly confident
3 Uncertain
12 Fairly concerned
44 Very concerned

Respondent comments

  • “'We won't, end of.'”

    Acute trust
  • “'3.8 per cent efficiency unachievable, 50 per cent marginal tariff on specialist growth is suicidal.'”

  • “'This year has been more difficult than we expected – which reflects the cumulative strain of year-after-year efficiency targets set at 4 per cent or higher in practice. Next year's tariff and wider payment system proposals from Monitor/NHS England ignore this cumulative strain completely and place an unsustainable burden of delivery and risk on hospitals generally and – with specific specialised commissioning contract proposals – providers of specialised services in particular.'”

    Multi-specialised large university teaching hospital
  • “'First time I've ticked that box (very concerned) in four years.'”

    Acute teaching foundation trust
  • “'We will be planning a deficit for the first time in 10 years. Cash will run out in 2016/17 if nothing changes re efficiency factors, demand pressures and lack of system change to support service sustainability.'”

    Mental health and community health foundation trust
CCG Leads
Figure 8: Looking ahead, how confident are you that your organisation will achieve financial balance in 2015/16?
6 Very confident
18 Fairly confident
11 Uncertain
7 Fairly concerned
9 Very concerned

Respondent comments

  • “'All hinges on whether the Better Care Fund investment delivers reduced non-elective admissions/or gets sucked into a local authority vortex!'”

  • “'Very confident for 2015/16, with confidence levels diminishing from 2016/17 onwards unless either the allocation formula more equitably reflects the health demand impact of deprivation and high levels of population churn or the NHS settlement is increased in line with costs.'”

  • “'We will have a planned deficit in 2015/16.'”

The £20 billion productivity challenge

With the £20 billion Nicholson Challenge approaching the end of its planned four-year period, views on the risk of achieving this value of productivity improvements are highly pessimistic.

Nearly 8 out of 10 trust finance directors felt there was a high or very high risk of failure to achieve the productivity challenge (Figure 9). CCG finance leads felt fairly pessimistic too – with the majority of respondents assessing the risk of failure as fairly or very high (Figure 10).

NHS Trusts
Figure 9: Trends: The NHS is now in its final year of 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?

Respondent comments

  • “'Under-achievement of demand management and lack of progress tackling underlying population health, are being masked by "sticking plaster" funding solutions in the short term.'”

    Multi-specialist large university teaching hospital
  • “'Much of the delivery to date has been through restrictions in pay. Limited evidence of productivity gains to this value. Foundation trusts generating real efficiencies of around 2 per cent on average.'”

    Mental health

Question not asked before QMR6 or in QMR7

CCG Leads
Figure 10: Trends: The NHS is now in its final year of 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?

Respondent comments

  • “'The financial savings have been made by not giving staff a pay award but genuine productivity gains - nowhere near £20 billion.'”

  • “'But even if we fail we will have achieved 95+ per cent of the target.'”

  • “'Hard to answer this - suspect will be close to £20 billion if include savings from pay restraint, pharmacy products and procurement - but this is not true productivity.'”

CCGs only surveyed since their establishment in April 2013

3. The state of patient care

Around 34 per cent of NHS trust finance directors felt that care in their local area had worsened over the past year (Figure 11).

Similarly, around 31 per cent of CCG finance leads felt that patient care had worsened in the past year; slightly more than a quarter thought it had got better (Figure 12).

NHS Trusts
Figure 11: 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?

Respondent comments

  • “'Acute pressures and staffing issues at an unprecedented low.'”

    Care trust (community and mental health)
  • “'I'm told that the CCGs still have cash, but we haven't seen it.'”

    Acute teaching foundation trust
  • “'The level of delayed transfers of care has increased, A&E activity is up, we are regularly in escalation and all this represents a poorer experience for the patients.'”

    General acute and specialised

Question not asked before QMR6

CCG Leads
Figure 12: 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?

Respondent comments

  • “'Referral-to-treatment and A&E targets are now being missed due to pressures in the system; not seeing additional activity, it's sicker patients, staying for longer and requiring packages/support to leave hospital.'”

  • “'Mainly access is worse. A&E targets suffering. Ambulance waits. Referral-to-treatment performance worse.'”

  • “'Some areas have deteriorated, particularly waiting times for children’s services, but would say the majority of services have remained the same and we are doing more elective procedures.'”

CCGs only surveyed since their establishment in April 2013

4. Organisational challenges

For trust finance directors, staff morale remains at the top of the list of concerns along with the A&E 4-hour wait target and delayed transfers of care (Figure 13).

CCG finance leads continue to be most concerned about A&E and 18-week referral-to-treatment (RTT) waiting time targets. Cancer treatment waiting time targets return to the top of their concerns – reflecting perhaps the continuing deterioration in performance against this target (Figure 14).

NHS Trusts
Figure 13: Trends: Which aspects of your organisation's performance are giving you most cause for concern at the moment? Please select top three

Respondents asked to choose their top three concerns. Figures expressed as a percentage of the total number of concerns in each survey.

CCG Leads
Figure 14: Trends: Which aspects of your organisation's performance are giving you most cause for concern at the moment? Please select top three

Respondents asked to choose their top concerns. Figures expressed as a percentage of the total number of concerns in each survey.

5. Nursing workforce

One result of various reports on the quality of care provided by the NHS (Keogh 2013; National Advisory Group on the Safety of Patients in England 2013; The Mid Staffordshire NHS Foundation Trust Public Inquiry 2013) appears to be a renewed growth in the number of nurses. Between August 2013 and March 2014, the nursing workforce was at its highest level ever (Appleby et al 2014). Yet despite this growth, difficulty with recruitment and retention of permanent staff means that many trusts are relying on temporary/agency staff to maintain these levels (Murray et al 2014).

Despite pressure on finances, just over three-quarters of all trust finance directors indicated a plan to increase the number of permanent nursing staff in the next six months (Figure 15).

NHS Trusts
Figure 15: Is your organisation planning to increase the number of permanent nursing staff in the next six months?
54 Yes
17 No

Respondent comments

  • “'The issue is are there any people to recruit?'”

    Integrated care organisation
  • “'In order to achieve financial balance need to lose 750 staff (mainly clinical) next year.'”

    Community and mental health foundation trust

71 respondents (for whom the question was applicable)

6. Better Care Fund

In relation to agreed Better Care Fund plans, the average target reduction in total emergency admissions for next year (2015/16) for NHS trusts is 3.4 per cent (ranging from 0 to 10 per cent) – similar to plans submitted to NHS England in September 2014. In addition to the 31 responses to this question, 24 finance directors either provided no answer, or stated that they did not know what the target was, and 18 respondents told us this question was not applicable to their organisation (Figure 16).

Slightly more than 8 out of 10 trust finance directors were either fairly or very concerned about achieving their organisation’s reduction target (Figure 17). Although slightly more optimistic, the majority of CCG finance leads (6 out of 10) were also concerned about the ability of their local providers to meet their reduction targets (Figure 18).

Overall trust finance directors felt that the impact of the Better Care Fund on relationships between various Better Care Fund stakeholders in their local areas had been negligible (Figure 19). On the other hand, CCG finance leads were more optimistic with nearly 4 in 10 stating that the relationships in their local areas had improved as a result of the Better Care Fund (Figure 20).

NHS Trusts
Figure 16: In relation to agreed Better Care Fund plans in your area, what is your organisation's target reduction of total emergency admissions for next year (2015/16) as a percentage?

31 respondents (for whom the question was applicable)

NHS Trusts
Figure 17: How confident are you that your organisation will be able to achieve this emergency admissions reduction target in 2015/16?
1 Very confident
3 Fairly confident
4 Uncertain
8 Fairly concerned
30 Very concerned

Respondent comments

  • “'Emergency admissions to our trust have risen by 10 per cent this year. Nobody knows why. Our "conversion rate" from A&E attendances is still among the lowest nationally, so it isn't changes in our clinical thresholds internally!'”

    Multi-specialist large university teaching hospital
  • “'There is no doubt it will not be achieved.'”

    Medium acute
  • “'10 per cent per annum increase seems to be about the norm for the past three years. Can't see this abating without some "BCF Pixie Dust" sprinkled in very large measure.'”

    Acute foundation trust

46 respondents (for whom the question was applicable)

CCG Leads
Figure 18: In relation to agreed Better Care Fund plans in your area, how confident are you that the providers in your area will achieve the total emergency admissions reduction target in 2015/16
0 Very confident
3 Fairly confident
16 Uncertain
17 Fairly concerned
15 Very concerned
NHS Trusts
Figure 19: Thinking about the impact of the Better Care Fund on relationships with other Better Care Fund stakeholders in your local area, do you think they have:
10 Improved
52 Stayed the same
11 Worsened

Respondent comments

  • “'Progress to-date has been through joint working and integration. I am fearful that the next steps will be through "competition and tendering" which may well damage progress so far.'”

    Teaching foundation trust
  • “'I am not sure that this has anything to do with the Better Care Fund but system relationships are better. I would assert that the fact that all organisations are financially challenged is forcing us to come together to find a system-wide solution.'”

    Acute foundation trust
CCG Leads
Figure 20: Thinking about the impact of the Better Care Fund on relationships with other Better Care Fund stakeholders in your local area, do you think they have:
20 Improved
25 Stayed the same
6 Worsened

Respondent comments

  • “'Good relationships and working but financial arrangements are unrealistic.'”

  • “'Better Care Fund (BCF) has been a catalyst in some ways to closer working. but the changing national rules and lack of clarity regarding the requirements eg, seven-day working, protection of social care, has often caused tensions locally.'”

  • “'Has provided more structure to our joint working with the local authority by requiring more detailed plans to be produced.'”

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

Ninety per cent of trust finance directors were fairly or very pessimistic about the financial state of their wider local health and care economy over the next year (Figure 21).

CCG finance leads are similarly more pessimistic about the coming year, with 75 per cent of respondents feeling fairly or very pessimistic (Figure 22).

NHS Trusts
Figure 21: Overall, what do you feel about the financial state of the wider health (and care) economy in your area over the next year?

Respondent comments

  • “'National context of anachronistic payment by results (PbR) regime, unreflective market forces factor (MFF), lack of understanding of rurality, marginal rate, lack of central understanding of the real costs of quality care and the misguided ignorance of stranded acute costs if activity is moved.'”

    Acute trust
  • “'The system is broken: the tariff doesn't work. Transformation by CCGs is non-existent. Social care has run out of cash and solutions. Better Care Fund is a three cups, one coin illusion.'”

    Acute foundation trust
  • “'The combined system is all well below plan and in a small deficit position overall year-to-date. The efficiency and other challenges for next year mean the system overall will have to deliver at least 50 per cent more CIP than this year to stay in breakeven - this is very unlikely to be achievable.'”

    Acute teaching hospital

Question not asked before QMR3. QMR 1-4 based on a panel of 50 trust finance directors

CCG Leads
Figure 22: Overall, what do you feel about the financial state of the wider health (and care) economy in your area over the next year?

Respondent comments

  • “'Impact of Better Care Fund transfer to prop up adult social care services.'”

  • “'Likely to require system wide financial recovery plan.'”

  • “'Biggest concern is related to the cuts in social care, and the resultant impact on the NHS.'”

8. References

  • Appleby J, Thompson J, Jabbal J (2014). How is the NHS performing? July 2014. London: The King's Fund. Available at: www.kingsfund.org.uk (accessed on 12 January 2015).

  • 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 12 January 2015).

  • Monitor (2014). Quarterly report on the performance of the NHS foundation trust sector: 6 months ended 30 September 2014. London: Monitor. Available at: www.gov.uk (accessed on 12 January 2015).

  • Murray R, Imison C, Jabbal J (2014). Financial failure in the NHS: what causes it and how best to manage it. London: The King's Fund. Available at: www.kingsfund.org.uk (accessed on 12 January 2015).

  • National Advisory Group on the Safety of Patients in England (Chair: 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 12 January 2015).

  • NHS Trust Development Authority (2014). NHS trust service and financial performance report for the six month period ending 30 September 2014. Paper D for Board meeting 20 November 2014. Available at: www.ntda.nhs.uk (accessed on 12 January 2015).

  • The Mid Staffordshire NHS Foundation Trust Public Inquiry (Chair: Francis R) (2013). Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. HC 898-I. London: The Stationery Office. Available at: www.midstaffspublicinquiry.com (accessed on 6 November 2014).

  • Wheeler K (2014). NHS performance report in the period to the end of September 2014. Paper NHSE111402 for Board meeting, 6 November 2014. Available at: www.england.nhs.uk (accessed on 12 January 2015).

1. Health care-acquired infections

Numbers of C difficile infections decreased over the latest quarter, from 443 in September 2014 to 415 in November (Figure 23).

There was a record low-number of MRSA infections in November 2014 of 15. This follows previous months of low counts for MRSA (Figure 23).

This quarter, levels of infection for MSSA, the strain of S aureus that is sensitive to methicillin, were higher than the same quarter last year, but the trend is relatively stable, and seasonal variance indicate this is an expected pattern (Figure 23).

The number of reported E coli infections continues to be subject to large seasonal variations. In the latest quarter numbers had once again dipped below 3,000 cases ahead of an anticipated drop in recorded infections over the winter period (Figure 23).

Figure 23: Monthly counts of selected health care-acquired infections

Data source: Clostridium difficile infection: monthly data by NHS acute trust http://www.gov.uk.

Monthly counts of methicillin resistant Staphylococcus aureus (MRSA) bacteraemia by post infection review (PIR) assignment http://www.gov.uk.

Monthly counts of trust apportioned methicillin susceptible Staphylococcus aureus (MSSA) bacteraemia by NHS acute trust http://www.gov.uk

Monthly counts of Escherichia coli (E coli) bacteraemia by NHS acute trust http://www.gov.uk

2. Workforce

The total full-time equivalent (FTE) number of NHS staff was just over 1.064 million in September 2014. This is higher than the previous month and the highest since this data was reported in September 2009.

Since September 2009, there has been an increase in all staff of more than 16,970 FTE posts (1.6 per cent). There has been growth in all staff groups except for managers. Consultant numbers have increased by more than 18 per cent; scientific, therapeutic and technical staff by 5.4 per cent; nurses, midwives and health visitors by 1.9 per cent; and others by 1 per cent. The number of managers has decreased by more than 17.5 per cent – although there has been a slow increase since April 2013 (Figure 24).

Figure 24: Index change in NHS full-time equivalent staff: September 2009 – September 2014

Data source: Monthly NHS Hospital and Community Health Service (HCHS) Workforce Statistics in England – September 2014, Provisional statistics www.hscic.gov.uk.

3. Waiting times

With the Secretary of State for Health having extended the deadline to carry out an additional £250 million worth of elective activity over the summer months to the end of the year (December 2014 data released in February 2015), we are still in a period of ‘managed breach’.

The latest figures reflect this with waiting times for both non-admitted (outpatient) and admitted (inpatient) patients breaching in November 2014 (Figure 25).

The proportion of admitted patients waiting longer than 18 weeks rose to 12.5 per cent, the highest since this target was introduced (Figure 25).

The proportion of non-admitted patients waiting more than 18 weeks rose to 5.4 per cent. This is the first breach in the non-admitted referral-to-treatment (RTT) target since the summer of 2008 (Figure 25).

The number of patients still waiting to begin their treatment (both admitted and non-admitted) reduced fractionally to 6.9 per cent. This suggests the managed breach is having some positive impact (Figure 25).

However, the targets of the managed breach were to have all RTT standards met by December 2014 and have 115,000 fewer patients waiting more than 16 weeks to begin treatment. While in November 2014 there were 9,000 fewer patients waiting 16 weeks or more to begin treatment, it seems very unlikely the remaining reduction will have been achieved or that breaches in other parts of the patient pathway will have returned to target in December (Figure 25).

The number of patients waiting more than 6 weeks for a diagnostic test is still declining following a recent peak in May 2014. The percentage of patients waiting more than 6 weeks has reduced to 1.2 per cent which, though still in breach of target (1 per cent), is heading in the right direction (Figure 25).

Figure 25: Percentage still waiting/having waited more than 18 weeks (more than 6 weeks for diagnostics)

Data source: Referral-to-treatment waiting times statistics www.england.nhs.uk.

Diagnostic waiting times statistics www.england.nhs.uk.

The total elective waiting list dipped below 3 million in November 2014 for only the second time since April last year. However, NHS England predicts the true waiting list in November 2014 to be around 3.2 million given that several trusts have not submitted data for several months (Figure 26).

Figure 26: Referral-to-treatment total waiting list size in millions, England

Data source: Referral-to-treatment waiting times statistics www.england.nhs.uk.

There are further waiting list targets for cancer care. The standard for a maximum 62-day wait from urgent GP referral through to first treatment is useful to monitor as it measures how well the whole cancer pathway is able to respond to the demands placed upon it.

The standard is that 85 per cent of patients receive treatment for their cancer within 62 days of urgent referral from their GP. This standard had been met since quarter 4 2008/9 (from when we have data) but since quarter 4 2013/14 performance has been below the target. In the latest quarter (quarter 2 2014/15 – from July to September 2014) performance has slipped further to 83.5 per cent, the lowest on record (Figure 27).

Figure 27: Maximum 62-day wait for first treatment: all cancers (urgent GP referral to treatment)

Data source: Provider-based cancer waiting times www.england.nhs.uk.

4. Accident and emergency

In quarter 3 2014/15 the proportion of patients waiting more than 4 hours from arrival to discharge, admission or transfer in all A&E departments was 7.4 per cent (more than 414,000 patients) – a 47 per cent increase on the previous quarter and the poorest performance since quarter 3 2003/4 (Figure 28).

Percentage waiting more than four hours in A&E from arrival to admission, transfer or discharge

Data source: Weekly A&E SitReps 2014–15 www.england.nhs.uk.

For major A&E departments more than 14 per cent of patients waited more than 4 hours and less than 10 per cent of providers achieved the target.

For all providers nearly 50 per cent missed the 4-hour target in the third quarter of 2014/15, the highest we’ve seen since we started recording the data.

Alongside attendances, much higher numbers of patients waiting to be admitted into a hospital bed from A&E (‘trolley waits’) were also seen in this quarter. Almost 9 per cent of patients (accounting for more than 90,500 patients) waited for more than 4 hours to be admitted into hospital, the highest for more than a decade (Figure 29).

Figure 29: Patients waiting more than four hours in A&E from decision to admit to admission

Data source: Weekly A&E SitReps 2014–15 www.england.nhs.uk.

The latest weekly data for all types of A&E departments show that performance continued above target into the first two weeks of 2015, with national performance for both weeks showing more than 10 per cent of patients waited more than 4 hours (figure 30). For major A&E departments (which treat about 65 per cent of all patients), the 4-hour target has now been missed for the past 78 weeks.

Figure 30: Percentage waiting more than four hours in A&E from arrival to admission, transfer or discharge; weekly data

Data source: Weekly A&E SitReps 2014–15 www.england.nhs.uk.

5. Delayed transfers of care

Over the past quarter the number of patient delayed transfers of care has increased by more than 300, increasing the total number of patient delays to more than 5,000 per day in November 2014, the highest number for more than four years (Figure 31).

The number of total days delayed passed 143,000 in October 2014, a level not reached since July 2008 (Figure 32).

Figure 31: Average number of patients delayed per day each month

Data source: Acute and non-acute delayed transfers of care, patient snapshot, 2014/15 www.england.nhs.uk.

Figure 32: Delayed transfers of care: Total number of days delayed each month

Data source: Acute and non-acute delayed transfers of care, total days delayed, 2014/15 www.england.nhs.uk.

About the QMR

What is The King’s Fund’s quarterly monitoring report?

Our quarterly monitoring report (QMR) reveals the views of NHS trust finance directors and clinical commissioning group finance leads on the productivity challenges they face, and examines some key performance data for the NHS in England.

It provides a regular update on how the NHS is coping as it grapples with the evolving reform agenda and the more significant challenge of making radical improvements in productivity.

What is different about the digital QMR?

Our first nine issues were produced as longer PDF documents and can be found on The King’s Fund website at kingsfund.org.uk/qmrproject. The new QMR features digital versions of the survey results and interactive performance data charts showing the key findings for this quarter.

Where does the data come from?

The quarterly monitoring report combines publicly available data on selected NHS performance measures with views from NHS trust finance directors and clinical commissioning group finance leads. These views are collated through a survey run by The King’s Fund data team.

Making the most of the digital QMR

  • Filtering the survey by respondents

    Filter the survey results by respondent group (financial directors of NHS trusts, financial directors of clinical commissioning groups, and financial directors in social care in applicable quarters) by clicking them on or off at the top of the survey page.

  • Comments from survey respondents

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  • Survey charts

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  • Sharing and saving charts

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    See the data in a different date range by moving the sliders on the x-axis.

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    Print the report by clicking on the print icon