QMR 11 | April 2014

How is the NHS performing?

  • “The NHS has coped well this winter, but there is a growing recognition that the NHS will face a financial crisis in 2015/16, if not before.”

    Richard Murray, Director of Policy
  • 1 in 8 1 in 8 trusts and CCGs predict an overspend on their budgets in 2013/14

  • 16% Only 16 per cent of NHS trust finance directors are confident that they will achieve financial balance by 2015/16

  • 98%
    98 per cent of NHS trust finance directors think a 15 per cent reduction in emergency admissions in 2015/16 is unlikely
  • 4.8% The target that no more than 5 per cent of patients should wait more than four hours in A&E was met in the quarter 4 2013/14

  • 3m The number of people on hospital waiting lists is nearing 3 million – the highest for six years

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How is the NHS performing?

  • The 2013/14 financial year (that has just ended) is the fourth year of a difficult financial period for the NHS. While afforded a degree of relative protection in previous spending rounds, after taking account of various transfers to local authorities the NHS in England has effectively had no real rise in spending between 2010/11 and 2013/14.

  • Despite the challenge this has created, on key performance measures and based on our latest survey of finance directors, in broad terms the NHS has continued to provide services to a growing population and to maintain the quality of those services.

  • However, there is deepening pessimism about the ability of the NHS to make ends meet financially, particularly in 2015/16.

  • Helped in part by a relatively mild (if wet) winter, the NHS did not repeat the significant breaches of the A&E four-hour target that happened last year (see figure below). However, there are some signs of pressure building on the elective side, with the number of people on hospital waiting lists nearing three million – the highest for six years – and indications that workload is not keeping pace with the growth in lists.

A&E weekly performance against target that no more than 5 per cent of patients wait longer than four hours from arrival to admission, transfer or discharge

Data source: Weekly A&E SitReps 2013–14 www.england.nhs.uk.

  • On the finance side, the number of trusts and CCGs forecasting a deficit for the end of 2013/14 has fallen since the last survey in December, with one in eight CCGs and trusts predicting an overspend. To an extent this is to be expected as trusts forecasting deficits take action towards the end of the year to cut spending or rectify their deficit position through other means. For example, around 10 per cent of trusts reporting a surplus or breakeven position also note that this is as a consequence of actions such as additional financial support in one form or another, one-off activities such as asset sales and, for some, smaller surpluses than they had planned at the beginning of the year.

  • The slight improvement at the end of the year is reflected in, for example, a reduction reported by the NHS Trust Development Authority in the number of non-foundation trusts forecasting a deficit from 33 in November to 26 in January (NHS Trust Development Authority 2014, 2013). However, the gross deficit reported in March remained similar to the level in January at around £460 million, with the net deficit across all non-foundation trusts falling only marginally from around £250 million to £247 million.

  • And for foundation trusts, Monitor reported in January that 39 were in deficit (15 more than planned) with deficits running at £180 million (£12 million more than planned). Significantly, the size of the surplus across all foundation trusts has halved compared to the same time last year. As Monitor notes, this reflected foundation trusts' response to the '... tough financial climate' (Monitor 2014).

  • Trusts' financial situation depends on achieving savings through their cost improvement programmes (CIPs). As in previous quarters, trusts are aiming to make savings of around 4.8 per cent of turnover for 2013/14. There is a variation in how confident finance directors feel achieving plans. Compared with previous surveys, the proportion who are very or fairly concerned about their cost improvement programme plans now stands at just under 40 per cent – having improved slightly towards the end of the financial year as with forecasts of the overall position (see figure below).

NHS Trusts
How confident are you of achieving your CIP target?

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

  • However at an aggregate level, pessimism about quality, improvement, productivity and prevention (QIPP) programmes has deepened with more than 80 per cent of finance directors now thinking there is a high or very high risk of the NHS overall failing to achieve its £20 billion productivity target by the end of 2014/15.

  • Part of the pressure on savings programmes and finances more generally appears to be local decisions to increase staffing – particularly, nurses – as a result of recommendations of Robert Francis's report on Mid Staffordshire NHS Foundation Trust and against a general background of concern about service quality and patient safety raised in other reviews.

The outlook for 2014/15 and 2015/16

  • Looking forward, this quarter's survey found NHS trust finance directors and CCG finance leads pessimistic about 2014/15 – and particularly so for 2015/16. Asked how they felt about the financial state of their local health and care economy over the next 12 months, 83 per cent of trust finance directors and 72 per cent of CCG finance leads were fairly or very pessimistic.

  • Around one-third of trust finance directors were concerned about balancing the books by the end of 2014/15, with two-thirds concerned about 2015/16, and a further one-fifth being uncertain. CCG finance leads also expressed a growing concern about their financial position into 2015/16.

NHS Trusts
Looking ahead, how confident are you that your organisation will achieve financial balance in 2014/15 and 2015/16?

Respondent comments

  • “'As a community services organisation, we have seen activity growth but no further investment.'”

    Community trust on 2014/15
  • “'Unless the marginal rate baseline is amended then financial balance will not be achieved.'”

    Acute trust on 2014/15
  • “'Need to undertake radical change and merger appears difficult in the current legislative environment.'”

    Specialist acute trust on 2015/16
  • “'Without a change to the tariff balance is impossible. The number of organisations failing would suggest that there has to be a change.'”

    Acute trust on 2015/16
  • Apart from the financial exigencies of a fifth and sixth year of little or no real funding increases, a key concern for trust finance directors in particular is the implication of the Better Care Fund in 2015/16. While the NHS has provided local authorities with just under £1 billion from its budget each year from 2010/11, in 2015/16 this will total £3.8 billion, most of which will come from existing budgets – a significant increase and one that will have an opportunity cost for the NHS. NHS England has suggested that this cost could translate into a 15 per cent cut in emergency admissions. However, none of the NHS trust finance directors we polled from organisations that carried out emergency work (42 out of 74) thought such a cut was likely in 2015/16.

  • The question remains how the NHS will deal with a continued freeze in overall funding, compounded by the reallocation in funding implied by the Better Care Fund, a growing concern about the ability of trusts to extract savings, and productivity improvements.

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

References

  • Monitor (2014). NHS foundation trusts: review of nine months to 30 December 2013. London: Monitor. Available at: www.monitor.gov.uk/performance (accessed on 27 March 2014).

  • NHS Trust Development Authority (2014). NHS Trust Development Authority board meeting, 20 March 2014. Service and financial performance of the NHS trust sector for the period ending 31 January 2014. London: NHS TDA. Available at: www.ntda.nhs.uk (accessed on 27 March 2014).

  • NHS Trust Development Authority (2013). NHS Trust Development Authority board meeting, 23 January 2014. Service and financial performance of the NHS trust sector for the period ending 30 November 2013. London: NHS TDA. Available at: www.ntda.nhs.uk (accessed on 27 March 2014).

1. Health care surveys

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

74 NHS trust finance directors
47 clinical commissioning group (CCG) finance leads

This report details the results of an online survey of NHS trust finance directors carried out between 24 February 2013 and 10 March 2014. We contacted 230 NHS trust finance directors to take part and 74 responded (32 per cent response rate).

In addition, we contacted 195 clinical commissioning group (CCG) finance leads and 47 responded (24 per cent response rate). Between them these finance leads covered 58 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 likely achievement of a 15 per cent reduction in emergency admissions as part of the Better Care Fund costing; and their assessment of the key current concerns for their organisation.

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

Projected end-of-year financial balance: 2013/14

One in eight trusts forecast ending 2013/14 in deficit. This improvement on the one in five forecasting this position in December is to be expected as organisations take action to minimise or reverse deficits by cutting spending in the last few months of the year (figure 1).

One in ten trusts reporting either breakeven or surplus noted that their position was helped by one-off asset sales or otherwise non-recurring financial actions.

As Monitor and the NHS Trust Development Authority note, 2013/14 may be the first year since 2006/7 that the provider side of the NHS will end up in a net deficit position (Monitor 2014; NHS Trust Development Authority 2014).

While NHS England reported a net overspend of £366 million in the first nine months of the year for specialised commissioning (NHS England 2014), one in eight CCG finance leads forecast a deficit for the year as a whole (figure 2).

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

Respondent comments

  • “'Our surplus is heavily underpinned by asset sales; otherwise it would be around 1 per cent of turnover.'”

    Ambulance trust
  • “'Whilst we will deliver our target financial performance, this has been achieved through non-recurrent means.'”

    Acute trust

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?
45 In surplus
6 Breaking even (+/-0.25% of turnover)
7 In deficit

Respondent comments

  • “'Achieving this [a surplus] required CCGs in our patch to implement risk sharing arrangements.'”

Note: 47 CCG finance leads answered this question for the 58 CCGs they cover collectively.

NHS Trusts
Figure 3: Trends: What is your organisation’s likely end-of-year financial situation?
CCG Leads
Figure 4: Trends: What is your organisation’s likely end-of-year (2013/14) financial situation?

Cost improvement and quality, innovation, productivity and prevention programmes

The average cost improvement programme (CIP) target for trusts this financial year is again 4.8 per cent, representing between 3 per cent and 8 per cent of turnover (figure 5).

The average quality, innovation, productivity and prevention (QIPP) target for CCGs for this financial year is 2.8 per cent, ranging from 0.5 per cent to 7 per cent of allocation (figure 5).

Since the beginning of this financial year there has been a general increase in certainty as to the achievement (or not) of planned CIPs.

However, nearly four in ten NHS trust finance directors remain concerned about achieving their CIP plans (figure 6).

Generally, concern about savings plans appears more marked in 2013/14 than in the previous two years (figure 8).

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

Note: 47 CCG finance leads answered this question for the 58 CCGs they cover collectively.

NHS Trusts
Figure 6: How confident are you of achieving your CIP target in 2013/14?
19 Very confident
22 Fairly confident
5 Uncertain
12 Fairly concerned
16 Very concerned

Respondent comments

  • “'Taking costs out of clinical frontline services whilst addressing Francis and other quality issues is proving an impossible task.'”

    Very concerned – acute trust
  • “'We will be within about a £1m of the £29m target. The real issue is that this is about the fifth year of delivering 4-5 per cent CIP levels and it is becoming difficult to see how we will sustain this over the next couple of years, let alone the next 5 years. Possible solutions will involve cross-system working, which the current legal/competitive/regulatory environment does not support.'”

    Fairly confident – acute trust
  • “'It's starting to get very tricky... as a result of tariff deflator, 'CIP' is straying into 'service reduction' territory.'”

    Fairly confident – mental health trust
CCG Leads
Figure 7: How confident are you of achieving your QIPP target in 2013/14?
27 Very confident
12 Fairly confident
4 Uncertain
3 Fairly concerned
12 Very concerned

Respondent comments

  • “'We will hit around 90 per cent of QIPP with other underspends filling the difference (arguably defacto QIPP as demand suppressed in these areas).'”

    Uncertain
  • “'Reporting that we will deliver 96 per cent, but that is only because we negotiated a block contract for emergency activity that has mitigated QIPP under-delivery. Recurrently we have delivered circa 65 per cent.'”

    Fairly confident

Note: 47 CCG finance leads answered this question for the 58 CCGs they cover collectively.

NHS Trusts
How confident are you of achieving your CIP target?

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

CCG Leads
Figure 9: How confident are you of achieving your QIPP target in 2013/14?

Note: 47 CCG finance leads answered this question for the 58 CCGs they cover collectively.

The £20 billion productivity challenge

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

However, views about the risk of failure to meet the £20 billion productivity target by the end of 2014/15 have grown, with more than eight in ten NHS trust finance directors now stating there is a high or very high risk of failure (figures 10 and 12).

On the other hand, CCG finance leads are slightly more optimistic – though most assess the risk of failure as greater than 50/50 (figure 11).

NHS Trusts
Figure 10: The NHS is now more than 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
1 Little risk of failure
12 50/50 risk of failure or success
35 High risk of failure
26 Very high risk of failure

Respondent comments

  • “'Progress to date has been underwritten by pay restraint at national level, but the reliance on deflating tariffs and providers delivering 4 per cent year after year has reached the point of unsustainability.'”

    University teaching hospital
CCG Leads
Figure 11: The NHS is now more than 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
4 Little risk of failure
20 50/50 risk of failure or success
16 High risk of failure
7 Very high risk of failure

Respondent comments

  • “'The increased focus on Francis/Keogh and staffing ratios will mean that trusts will have to reverse efficiencies previously delivered by reducing numbers/skill-mix of frontline staff.'”

    Very high risk of failure
  • “'Might be achieved, but 2015/16 and beyond will really be the test.'”

    50/50 risk of failure or success
  • “'This added to the Better Care Fund challenge means at some point providers need to work as networks and engage in a shared challenge with commissioners.'”

    50/50 risk of failure or success
NHS Trusts
Figure 12: Trends: The NHS is now more than 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.

CCG Leads
Figure 13: Trends: The NHS is now more than 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?

3. The state of patient care

The focus on not just maintaining the quality of services but improving them has been sharpened since the publication of major reports in 2013 such as the Francis, Keogh and Berwick reviews (Francis 2013; Keogh 2013; Berwick 2013).

Although around one in five NHS finance directors and CCG finance leads felt care in their local area had got worse over the past year, this has reduced over time, and there has been some improvement over the past year in the number thinking care had got better (figure 16).

NHS Trusts
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?
22 Better
37 The same
15 Worse

Respondent comments

  • “'Rising expectations re investment in seven-day working and nursing staff have had an impact. Financially though this has proved difficult to manage and presents a challenge for the trust.'”

    Acute and community trust
  • “'Fragmented and conflicted commissioning structures [has led to worse patient care].'”

    Acute and community trust
  • “'Performance has improved as a result of increased focus although this has been at the expense of delivering the CIP.'”

    Acute trust
CCG Leads
Figure 15: 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
19 The same
10 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.

CCG Leads
Figure 17: 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?

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.

Top of the list of current concerns for CCG finance leads continue to be waiting times targets for A&E, referral to treatment (RTT) and cancer (figure 19).

For trusts however, staff morale remains a chief concern ahead of waiting times targets (figure 18).

NHS Trusts
Figure 18: Which aspects of your organisation's performance are giving you most cause for concern at the moment? Please select top three
6 Health care-acquired infections
14 Cancer treatment waiting time targets
16 Emergency readmission on threshold
17 Patients’ care experience
17 Level of engagement in performance issues by senior clinicians
21 A&E four-hour wait target
21 18-week RTT
23 Delayed transfers of care
23 Staff morale
CCG Leads
Figure 19: Which aspects of your organisation's performance are giving you most cause for concern at the moment? Please select top three
6 Patients’ care experience
6 Level of engagement in performance issues by senior clinicians
6 Emergency readmission on threshold
7 Health care-acquired infections
10 Delayed transfers of care
10 Staff morale
17 Cancer treatment waiting time targets
27 18-week RTT
31 A&E four-hour wait target

Respondent comments

  • “'Targets are important but if staff morale is an issue then the likely impact will be in the care experienced by patients may reduce leading to the failure to achieve the targets!'”

  • “'Financial prospects of the health and social care system locally beyond next year.'”

5. The Better Care Fund/emergency hospital admissions

While the Better Care Fund should offer an opportunity to pool resources to address immediate pressures on services and lay foundations for a more integrated system of health, there are risks too (Bennett and Humphries 2014).

As most of the £3.8 billion funding for the Better Care Fund is drawn from existing NHS budgets this necessarily represents an opportunity cost for the NHS. NHS England has suggested that part of this cost – the additional transfer of £1.9 billion in 2015/16 – in effect represents a reduction in emergency activity for hospitals of around 15 per cent (NHS England 2013).

However, when asked how likely it was that their hospital would be able to achieve such a cut, 98 per cent of NHS trust finance directors and 80 per cent of CCG finance leads felt that it was quite or very unlikely that this reduction would be achieved (figures 20 and 21).

NHS Trusts
Figure 20: How likely is it that your hospital will be able to achieve a cut in emergency admissions of 15 per cent in 2015/16 as suggested by NHS England as part of the opportunity cost of the Better Care Fund?
0 Very likely
0 Quite likely
1 Don’t know
12 Quite unlikely
29 Very unlikely

Respondent comments

  • “'We have worked well with community partners and redesign of acute pathways to reduce emergency admissions by 9 per cent this year, so concern that there is relatively little incremental improvement possible. That having been said, there are still at any time c60 beds occupied by patients who do not need acute care, so in theory, if all these patients were accommodated out of hospital this could deliver 15 per cent further improvement.'”

    Acute trust
  • “'The CCG has invested in community services and hence the trust is looking to reduce admissions by 5 per cent over the next 12 months. This will be a real challenge and a test to see if specific and targeted community investment can make real headway in terms of emergency admissions reductions.'”

    Acute and community trust
  • “'There are currently no commissioner plans to achieve any reduction in unplanned care - all QIPP is targeted at elective care. Our trust's schemes are only like to achieve a levelling of emergency activity.'”

    Acute, community and social care trust
  • “'It's a system challenge – not just a hospital challenge'”

Note: 42 respondents (for whom the question was applicable).

CCG Leads
Figure 21: How likely is it, that working with your local authority partners, you can achieve a 15 per cent reduction in emergency admissions in 2015/16 as suggested by NHS England as part of the opportunity cost of the Better Care Fund?
1 Very likely
6 Quite likely
3 Don’t know
15 Quite unlikely
22 Very unlikely

Respondent comments

  • “'Emergency admissions are rising and the demographic changes are such that they are adding to this, therefore seeing a reduction at that scale is very unlikely.'”

  • “'Feel we are doing many of the right things already and still activity is going up. Need to close beds (if they are there, they will be admitted to) but we have a fairly new private finance initiative hospital and don't have a way of forcing this to happen.'”

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

When asked how they felt about the financial state of their local health and care economy, not just their own organisations, over the next year, eight out of ten (84 per cent) NHS trust finance directors were fairly or very pessimistic (figure 22).

In general, views about the financial future have become gloomier since our survey began in 2011 (figure 23).

CCG finance leads are similarly pessimistic about the coming year (figures 24 and 25).

NHS Trusts
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?
0 Very optimistic
4 Fairly optimistic
8 Neutral
37 Fairly pessimistic
25 Very pessimistic

Respondent comments

  • “'The rise in emergency admissions in 2013/14 has left a financially unsustainable position with the trust. Despite considerable communication and evidence-based reports the CCGs refuse to recognise the need for change – this will lead to arbitration on the 2014/15 contract negotiations unless there is some flexibility from commissioners.'”

    Acute trust
  • “'There is a lack of a collective vision across the health and social care economy about how services need to be delivered in the future which stifles progress.'”

    Mental health and community trust
  • “'The acute sector cannot continue to face cost reduction demands implied by the tariff.'”

    Acute trust
CCG Leads
Figure 23: Overall, what do you feel about the financial state of the wider health (and care) economy in your area over the next year?
1 Very optimistic
8 Fairly optimistic
4 Neutral
26 Fairly pessimistic
8 Very pessimistic

Respondent comments

  • “'The position in CCGs is okay, but for providers, especially DGHs without specialist services, the position is dire. Cash could become a major issue for such foundation trusts in 2014/15.'”

  • “'The financial position is manageable this year, however, if we do not see real delivery of the majority of the QIPP savings in 2014/15 then we are unlikely to be able to deliver in 2015/16, especially with the impact of the Better Care Fund. The savings for social care in 2014/15 and 2015/16 are also very challenging.'”

NHS Trusts
Figure 24: Trends: Overall, what do you feel about the financial state of the wider health (and care) economy in your area over the next year?

Note: Question not asked before QMR3.

CCG Leads
Figure 25: Trends: Overall, what do you feel about the financial state of the wider health (and care) economy in your area over the next year?

7. The outlook for 2014/15 and 2015/16

Looking ahead to 2015/16, NHS trust finance directors become increasingly pessimistic. While slightly more than a third were concerned about balancing their books in 2014/15, nearly two-thirds were very or fairly concerned about 2015/16 (figure 26).

Although more optimistic, around a quarter of CCG finance leads felt fairly to very concerned about achieving financial balance in 2014/15. This rose to 40 per cent for 2015/16 (figure 27).

NHS Trusts
Looking ahead, how confident are you that your organisation will achieve financial balance in 2014/15 and 2015/16?

Respondent comments

  • “'As a community services organisation, we have seen activity growth but no further investment.'”

    Community trust on 2014/15
  • “'Unless the marginal rate baseline is amended then financial balance will not be achieved.'”

    Acute trust on 2014/15
  • “'Need to undertake radical change and merger appears difficult in the current legislative environment.'”

    Specialist acute trust on 2015/16
  • “'Without a change to the tariff balance is impossible. The number of organisations failing would suggest that there has to be a change.'”

    Acute trust on 2015/16
CCG Leads
Figure 27: Looking ahead, how confident are you that your organisation will achieve financial balance in 2014/15 and 2015/16?

Respondent comments

  • “'We have built up a war chest, (which will get us through the next two years) and will be one of the last CCGs standing. I also cover another CCG who have less of a war chest!'”

    CCG finance lead on 2014/15
  • “'The big issue is the Better Care Fund. So long as plans to deliver large reductions in [emergency] admissions during 2014/15 are delivered, the Better Care Fund is possible. If not, there will be devastating failure.'”

    CCG finance lead on 2015/16

8. References

  • Appleby J, Humphries R, Thompson J, Galea A, Jabbal J (2013). Quarterly monitoring report, September 2013. London: The King’s Fund. Available at: www.kingsfund.org.uk (accessed in 4 April 2014).

  • Appleby J, Thompson J, Galea A (2012). Quarterly monitoring report, September 2012. London: The King’s Fund. Available at: www.kingsfund.org.uk (accessed on 1 April 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 2 April 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 2 April 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 on 2 April 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 2 April 2014).

  • Monitor (2014). NHS foundation trusts: review of nine months to 30 December 2013. London: Monitor. Available at: www.monitor.gov.uk (accessed on 27 March 2014).

  • NHS England (2014). NHS England Board meeting, 6 March 2014. Performance report. London: NHS England. Available at: www.england.nhs.uk (accessed on 2 April 2014).

  • NHS England (2013). Everyone counts: planning for patients 2014/15 to 2018/19. London: NHS England. Available at: www.england.nhs.uk (accessed on 2 April 2014).

  • NHS Trust Development Authority (2014). NHS Trust Development Authority board meeting, 20 March 2014. Service and financial performance of the NHS trust sector for the period ending 31 January 2014. London: NHS TDA. Available at: www.ntda.nhs.uk (accessed on 27 March 2014).

1. Health care–acquired infections

The lowest monthly total of C difficile (382) for more than five years was achieved in January 2014. However, while the total number of cases over the year to date (4,216) represents a 22.4 per cent decrease on the previous year, with only two months left before the end of 2013/14 it will be very difficult to meet this year’s target reduction of 29.6 per cent (figure 28).

There were 36 cases of MRSA in January 2014, an increase on the previous month but a decrease on the same month last year. Annual counts for 2013/14 look likely to be very similar to 2012/13; the count for the year to date shows that the numbers for this year are only 1 per cent below levels last year (figure 28).

Figure 28: Monthly counts of C difficile and MRSA

Data source: Trust-apportioned monthly counts of C difficile infection http://www.hpa.org.uk.

Post-infection review assigned monthly counts of methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia www.hpa.org.uk.

2. Workforce

Staff numbers increased for the sixth month in a row in December 2013, there are now 18,500 more full-time equivalent staff compared to June 2013 (figure 29).

This increase is equivalent to a 2 per cent increase across all staff groups except managers, which saw a 5 per cent reduction in ‘senior managers’ and a 5 per cent increase in ‘managers’.

Following calls from Robert Francis to revisit the idea of minimum staffing levels on hospital wards, staff numbers for all groups – but particularly for nurses – increased markedly in September 2013 (figure 30).

Since this initial surge numbers have abated slightly, indeed numbers for qualified nurses, midwives and health visitors decreased this month, although remain at their highest level for more than four years.

Figure 29: Index change in NHS full-time equivalent staff: September 2009 – December 2013

Data source: Monthly NHS Hospital and Community Health Service (HCHS) Workforce Statistics in England – December 2013, Provisional statistics www.hscic.gov.uk.

Figure 30: Absolute monthly increase/decrease and total numbers of full-time equivalent qualified nurses, midwives and health visitors

Data source: Monthly NHS Hospital and Community Health Service (HCHS) Workforce Statistics in England – December 2013, Provisional statistics www.hscic.gov.uk.

3. Waiting times

Referral-to-treatment waiting times have increased for all lists (figure 31).

At 9.6 per cent, the proportion of patients waiting longer than 18 weeks on inpatient waiting lists is close to its 10 per cent target, the highest it has been for 2½ years.

The proportion of outpatients waiting longer than 18 weeks for treatment rose to 3.8 per cent in January, the highest proportion for 5½ years (though still within the 5 per cent target).

The proportion of patients still waiting after 18 weeks has increased to 6.7 per cent, the highest proportion for two years, but is still within its target (8 per cent).

For diagnostics the proportion of patients waiting longer than 6 weeks has increased to 1.8 per cent, above its target of 1 per cent. This follows seasonal variation for this month, but it is the highest proportion of patients waiting more than 6 weeks for 2½ years.

Compared to January 2013, there were an additional 362,000 people on waiting lists in January 2014. January is traditionally a month where the waiting list decreases compared to December; however the waiting list increased by more than 20,000 people from December 2013 to January 2014 (figure 32).

Growth in the length of the waiting list would not be a problem if the flow off the list kept pace. However, the ‘time to clear the waiting list’ – a measure of flows onto and off the waiting list – has been increasing since June 2011. The clearance time of more than 11 weeks in December 2013 was the highest since May 2008.

Everyone counts (NHS England 2013) introduced a zero-tolerance approach to patients waiting more than a year on referral-to-treatment waiting lists. By November 2013 the number of patients waiting longer than a year for treatment had reduced to an all-time low of 218. However, in January 2014 this crept back up to 430.

Figure 31: 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.

Figure 32: Referral-to-treatment total waiting list size in millions, England

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

4. Accident and emergency

In quarter 4 2013/14 the percentage of people waiting longer than four hours from arrival to admission, transfer or discharge was 4.8 per cent. This is an increase on quarter 3 2013/14 but below the performance target of 5 per cent (figure 33).

The latest quarter’s figure is also down on quarter 4 2012/13 where more than 5.9 per cent of patients waited longer than four hours.

Figure 33: Waiting times: Percentage waiting more than four hours in A&E from arrival to admission, transfer or discharge

Data source: Weekly A&E SitReps 2013–14 www.england.nhs.uk.

Weekly data shows that the national average breached the 5 per cent target in five out of the thirteen weeks that made up the final quarter of 2013/14 (figure 34).

This is much improved over quarter 4 2012/13 where the target was breached in twelve out of thirteen weeks.

A&E weekly performance against target that no more than 5 per cent of patients wait longer than four hours from arrival to admission, transfer or discharge

Data source: Weekly A&E SitReps 2013–14 www.england.nhs.uk.

More than a quarter (27 per cent) of providers breached the four-hour standard in quarter 4 of 2013/14 (figure 35).

This is fractionally higher than in quarter 3 of the same year but a reduction on the quarter 4 figures from 2012/13.

The composition of providers masks high variation, however. More than 60 per cent of type 1 departments (major consultant-led departments) missed the 5 per cent target in quarter 4.

Figure 35: Waiting times: Percentage of providers reporting more than 5 per cent of patients waiting longer than four hours in A&E departments from arrival to admission, transfer or discharge

Data source: Weekly A&E SitReps 2013–14 www.england.nhs.uk.

‘Trolley waits’ (those patients delayed for more than four hours in type 1 (major) A&E departments from decision to admit to admission) were up to 5.5 per cent in quarter 4 2013/14 (figure 36).

This is the highest percentage this year but is down from quarter 4 2012/13 (when it was 6.8 per cent).

Figure 36: ‘Trolley waits’: The proportion of patients spending more than four hours in major A&E departments from decision to admit to admission into hospital

Data source: Weekly A&E SitReps 2013–14 www.england.nhs.uk.

5. Delayed transfers of care

Following seasonal reductions in December 2013, recent trends in both patients and days delayed were maintained in January and February 2014 (figures 37 and 38).

A running 12-month count of patients and days delayed shows that current rates of delayed transfers are higher than they were a year ago.

Acute and non-acute refers to the treatment these patients were receiving when the delay occurred, acute being more intensive. Acute delays now account for 65 per cent of patients delayed and 64 per cent of days delayed.

Splitting the data by the organisation responsible for the delay shows that 61 per cent of patient delays and 71 per cent of days delayed in February 2014 were due to the NHS, rather than social care.

We have previously commented on the disparity between the measurement of delayed transfers and NHS concerns about them (Thompson 2014) – once again this quarter they were the second top concern for NHS trusts.

The latest Care Quality Commission survey of inpatients (2013) shows a large number – 41 per cent – of patients self-reporting a delay in discharge of some kind. Though many of these delays are small (48 per cent under 2 hours), this still roughly equates to 2.3 million patient delays per year. This compares to the current delayed discharge methodology, which is capturing around 1.5 million delayed patients per year, highlighting again how much work is still needed to fully understand the extent of delayed discharges.

Figure 37: Delayed transfers: Average number of patients delayed per day each month

Data source: Acute and non-acute delayed transfers of care, patient snapshot, 2013/14 www.england.nhs.uk.

Figure 38: Delayed transfers: Total number of days delayed each month

Data source: Acute and non-acute delayed transfers of care, patient snapshot, 2013/14 www.england.nhs.uk.

6. References

  • NHS England (2013). Everyone counts: planning for patients 2013/14. London: NHS England. Available at: www.england.nhs.uk (accessed on 2 April 2014).

  • Thompson J (2014). 'Delayed transfers: beyond the headlines'. Blog. The King's Fund website. Available at: www.kingsfund.org.uk (accessed on 14 April 2014).

  • Care Quality Commission (2013). National findings from the 2013 national inpatients survey [online]. Care Quality Commission website. Available at: www.cqc.org.uk (accessed on 14 April 2014).

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

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