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How is the health and social care system performing?

  • Our latest survey of NHS trust finance directors, clinical commissioning group (CCG) finance leads, and directors of adult social services contains some good news, but also a worrying rise in pessimism.

  • Despite the ongoing financial squeeze, to date most NHS finance directors and directors of adult social services believe quality of care in the NHS has stayed stable or improved and indeed trusts are more confident about quality of care in December 2013 than they were a year previously. This suggests a service holding up well, which official data generally confirms. However, equally striking is the rapid growth in concern about staff morale and a wave of pessimism about delivering further savings and productivity gains in the future, as well as concern about the overall financial health of the wider health and social care system over the next year. If this growing pessimism proves correct, then the feasibility of achieving a balancing act between quality and finance may finally be coming to an end.

  • Optimistically, and especially given the problems with accident and emergency (A&E) waiting times experienced early last year, official data suggests that up to the end of December, A&E waiting times were generally within target. The number of health care-acquired infections has also remained at historically low levels.

  • More importantly perhaps, for those at the front line in hospitals, the four-hour A&E waiting time target is no longer trust finance directors’ main concern (see figure below). In our last three reports this target had topped the list of worries. Management focus, hard work by clinical and other staff, the media spotlight, a great deal of political pressure (plus relatively benign weather) has – so far – combined to ensure better performance this quarter.

  • As to whether the additional winter pressure monies have or will make a difference there were some mixed views. Nearly 30 per cent of NHS trust finance directors thought the impact of the extra money would be marginal. According to trust finance directors, improved care outside hospital in order to reduce preventable attendances at A&E, and reductions in delayed transfers elsewhere in their hospitals would make the most difference to pressures faced by A&E departments.

  • Past experience shows that the emergency care system will be under more pressure over January through to March. And, for CCG finance leads, the A&E target remains a top concern. It is also worth bearing in mind that while the target was met in aggregate in the quarter to December, slightly more than one in four trusts breached the target over this period.

NHS Trusts
Figure 1 Which aspects of your organisation’s performance are giving you most cause for concern at the moment? NHS trust finance directors
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
  • More pessimistically, as this figure shows, for the first time the most important worry for trust finance directors is the morale of staff. As NHS England has recently noted, staff satisfaction is an important indicator of quality; as the latest planning framework for 2014/15 to 2018/19 states, ‘... happy, well-motivated staff deliver better care and … their patients have better outcomes’ (NHS England 2013a). The Point of Care Foundation has recently emphasised the importance of staff morale and patient care in: Staff care: how to engage staff in the NHS and why it matters (Point of Care Foundation 2014). While it is hard to see the pressure on staff from organisational and service change and general financial exigencies abating, addressing morale problems needs to be a priority.

  • Despite generally continuing good performance on the 18-week referral-to-treatment time (RTT) target, this continues to be a concern for trusts – perhaps reflecting that maintaining relatively good performance has not been easy and could become increasingly difficult.

  • On the question of financial pressures, evidence of a deteriorating position is clear: more than one in five trusts and one in eight CCGs report a possible overspend by the end of this financial year. The NHS Trust Development Authority has reported that around 30 per cent (of 102) non-foundation trusts are planning a deficit for this financial year (NHS Trust Development Authority 2013) and Monitor reports that around 11 per cent (of 147) foundation trusts are forecasting a similar position (Monitor 2013). Taken together the total proportion of provider organisations forecasting a deficit is around 19 per cent – very similar to the results of our survey.

  • Monitor’s second quarter performance report suggests some deterioration in foundation trusts’ financial position, with a number of organisations reporting deficits for the first time (Monitor 2013).

  • For directors of adult social services the position is even worse: a third forecast an overspend of more than 1 per cent of their budgets. This suggests that the tough financial settlement for local government is beginning to bite and reflect the mounting pressures on social care reported in the ADASS 2013 Budget Survey. The forecast end-of-year financial positions for CCGs and trusts are the worst since March 2011, when we began monitoring performance.

  • Trusts’ financial situation depends on achieving savings through their cost improvement programmes. As in previous quarters, trusts are aiming to make savings of around 4.8 per cent of turnover by the end of this financial year. How confident finance directors feel in achieving plans varies, and compared with previous surveys the proportion who are very or fairly concerned about their CIP plans now stands at more than 44 per cent – slightly higher than our last survey in July 2013 and the highest proportion recorded in our surveys to date (see figure below).

NHS Trusts
Figure 2 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.

  • Looking forward – in time, if not in anticipation – this quarter’s survey found finance directors more depressed than ever about the financial state of their local health and care economies. Eighty-six per cent of trust directors were fairly or very pessimistic about the next year financially, as were 65 per cent of CCG finance leads and 63 per cent of directors of adult social services. Nearly a third of trust finance directors say they are very pessimistic – the highest proportion since we began monitoring (see figure below).
NHS Trusts
Figure 3 Overall, what do you feel about the financial state of the wider health (and care) economy in your area over the next 12 months? NHS trust finance directors

Note: Question not asked before QMR3.

  • Beyond the next financial year and into 2015/16, the financial situation for the NHS looks even more difficult. While overall real allocations remain flat, the NHS will increase the amount of money to local authorities via the jointly managed Better Care Fund (formerly the Integration Transformation Fund) – bringing the total transfer to nearly £4 billion.

  • A summary from our own work and other research about which approaches are likely to achieve maximum impact for the Better Care Fund in a way that will benefit both the NHS and social care has recently been published by The King’s Fund (Bennett and Humphries 2014). However, NHS and local authority views on whether this fund will help or hinder work to maintain or indeed improve performance in areas such as the four-hour A&E target or delayed transfers are mixed. While many do not know what will happen, only 12 per cent of trust finance directors thought the Better Care Fund would be a help and nearly half thought it would be a hindrance. Views from directors of adult social services on the other hand were directly reversed, with 55 per cent saying the fund would help and only 9 per cent saying that it would be a hindrance.

  • It is hard not to feel the relevance today of Enver Hoxha’s New Year message to the Albanian people in 1967: ‘This year will be harder than last year. On the other hand, it will be easier than next year.’

  • More detailed results of the surveys and the performance dashboard results are set out in the next two sections of this report.


  • NHS England (2013a) Everyone counts: planning for patients 2014/15-2018/19. London: NHS England. Available at: www.england.nhs.uk (accessed on 13 January 2014).

  • Point of Care Foundation (2014). Staff care: how to engage staff in the NHS and why it matters. London: Point of Care Foundation. Available at: www.pointofcarefoundation.org (accessed on 17 January 2014).

  • NHS Trust Development Authority (2013). Summer report for the period 1 April to 31 July 2013. London: NHS TDA. Available at: www.ntda.nhs.uk (accessed on 13 January 2014).

  • Monitor (2013). NHS foundation trusts: review of six months to 30 September 2013. London: Monitor. Available at: www.monitor-nhsft.gov.uk (accessed on 13 January 2014).

  • Association of Directors of Adult Social Services (2013). 'ADASS budget survey 2013'. ADASS website. Available at: www.adass.org.uk (accessed on 14 January 2014).

  • Bennett L, Humphries R (2014). Making best use of the Better Care Fund: Spending to save? London: The King's Fund. Available at: www.kingsfund.org.uk (accessed on 13 January 2014).