Our Quarterly Monitoring Report examines the views of finance directors on the productivity challenge they face, as well as some key NHS performance data to see how the NHS is performing.
QMR 12 | July 2014
How is the NHS performing?
About this report
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“Our latest quarterly report paints a picture of a service under huge pressure, with cracks beginning to appear in NHS performance.”
John Appleby, Chief Economist -
1 in 4 1 in 4 trusts forecast ending 2014/15 in deficit.
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9k The number of nurses, midwives and health visitors has increased by almost 9,000 in the last 6 months to nearly 315,000 – the highest on record.
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55%55% of CCGs are planning for emergency activity to decrease this year. Only 8% of trusts are planning for a decrease.
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4.9% 4.9% of patients waited more than 4 hours in A&E during the quarter. That's the highest in this quarter since 2004/5.
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3m The number of people on waiting lists for treatment in hospital is now at its highest level for 6 years at more than 3 million.
Headlines
Download the QMR 12 July 2014 headlines PDF
Download PDFHow is the NHS performing?
- As the NHS starts its fourth year with effectively no real increase in funding and faced with undiminished urgency to generate more care to meet growing demands, it is of little surprise that our latest survey of finance directors reveals continuing pessimism about the financial position of health organisations and local health economies.
Money remains the fundamental issue
The 2013/14 financial year ended with around a quarter of trusts and foundation trusts in deficit and almost a tenth of commissioning groups also in deficit (Dorsett 2014; NHS Trust Development Authority 2014; Baumann 2014). The use of previous years’ surpluses by many trusts and the draw-down of money carried over from 2012/13 at national level to offset higher than planned spending in some areas helped to keep budgets more or less in balance across the NHS as a whole. However, funding gaps in spending from surpluses and carry-overs from previous years is an inherently short-term fix for underlying deficit positions.
Looking ahead, nearly 25 per cent of trust finance directors in our survey forecast a deficit by the end of this financial year (2014/15). And there is a distinct lack of optimism about the general state of the finances of local health economies over the next year, with around 85 per cent of trust finance directors saying they were fairly or very pessimistic. This continues the negative trend of the past three surveys (see figure below).
NHS Trusts
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
There is also deepening pessimism among local authority directors of adult social services about the next 12 months, with more financial reductions to come and the new Care Act to implement. Despite the Better Care Fund, half of directors thought there would be greater pressure on the NHS as a result of the budget savings this year (Association of Directors of Adult Social Services 2014). More directors agreed than disagreed that fewer people would access support, the risk of provider failure would increase and councils would face more legal challenges.
In recognition of the difficult financial circumstances the NHS in England is facing, up to £650 million of funding from central budgets and reserves has been announced by the Department of Health and NHS England. £250 million will be released as part of the ‘system resilience’ funding programme focused in part on urgent care services – similar to the amount put in last year. This will be topped up this year with an additional £150 million as well as a further £250 million to be distributed to NHS England area teams to improve performance on the 18-week referral-to-treatment waiting time targets. While extra money at the front line is welcome, whether health services can effectively and efficiently deploy these resources at short notice remains to be seen.
Waiting times and lists are growing
- The additional money to improve waiting times comes when performance on the accident and emergency (A&E) four-hour waiting time target was breached during May and June – an unusual situation for this time of year (see figure below). While these waiting time targets cover all types of A&E units – including walk-in centres and minor injury units – the performance of major A&E departments (which treat around 65 per cent of all A&E patients) remains particularly challenged; in aggregate, major A&E departments have now breached the four-hour target for 51 weeks in a row.
Proportion of A&E patients waiting longer than four hours from arrival to admission, transfer or discharge: comparison of winter and summer 2013 and 2014
Data source: Weekly A&E SitReps 2014–15 www.england.nhs.uk.
- Other waiting times targets are also under pressure.
- In February and March this year the 18-week inpatient (‘admitted care’) referral-to-treatment target was breached for the first time in three years.
- The diagnostic waiting time target of no more than 1 per cent waiting more than six weeks has now been breached each month from December 2013 to May 2014.
- Although still within its target, outpatient (‘non-admitted care’) waiting times remain on an upward trend.
- The target that 85 per cent of patients should wait no longer than 62 days from an urgent GP referral to first definitive treatment for cancer was missed for the last three months of 2013/14 – the first time since the target was established four years ago.
- Overall, the number of people on waiting lists for treatment in hospital is now at its highest level for six years at more than 3 million – around 5 per cent of the population of England.
- This performance on waiting times is reflected in our survey findings this quarter which show that concerns about the 18-week referral-to-treatment and A&E waiting time targets top the list of worries for NHS trust finance directors and clinical commissioning groups finance leads.
Pressures to spend more continue
While it remains to be seen whether the additional funding proves timely and large enough to adequately deal with growing waiting times and lists, evidence of pressure to carry out more work and improve quality is clear.
We found a significant disparity between the expectations of providers and those of commissioners. Almost 50 per cent of the NHS trust finance directors we surveyed are planning for an increase in emergency activity this year (and just 8 per cent a decrease), and almost 70 per cent expect an increase in elective work compared to last year (with none planning for a decrease). How this will be reconciled with the fact that 55 per cent of clinical commissioning group finance leads are planning for a reduction in emergency work and only 32 per cent an increase in elective activity remains to be seen.
This is a significant and worrying difference in plans and expectations; provider plans are flattered by the income they expect from commissioners as a result of increased work, but commissioner plans are flattered by the reduced expenditure they plan to give to providers. These inconsistencies are reflected in the fact that three months into the year, 30 per cent of contracts between providers and commissioners still remain unsigned. Problems with planning also prompted NHS England to ask commissioners to revise and resubmit their 2014/15 plans by the end of June.
With emergency admissions from the beginning of the financial year to the fourth week of June 6 per cent higher than over the same period last year, and accident and emergency activity 4 per cent higher over the same period, currently it looks as though providers are more accurate in their forecasts. If the scale of these increases continues it will have severe implications for the finances of local health economies as they will struggle to match funding with workload. If hospital workload continues to increase through 2015/16 this will also jeopardise the basis on which the Better Care Fund is predicated – in part to build alternative services and care pathways to substitute for some hospital care. An additional risk is that increased activity combined with pressures on commissioning budgets could see a deterioration in waiting times.
On the prospects for the effective use of the Better Care Fund next year, the Association of Directors of Adult Social Services (ADASS) found that nearly half of the money transferred to local authorities from the NHS budget this year is being used to protect existing services rather than to expand provision in response to rising needs (ADASS 2014). How the Better Care Fund will operate next year is still being developed. The latest development suggests that up to £1 billion of the £3.8 billion fund will be contingent on achieving a locally agreed and nationally endorsed reduction in emergency admissions. This announcement is a sign of growing anxieties within government as the NHS heads towards a financial crunch in 2015/16.
Apart from the pressure on finances arising from growing workloads, the impact of various reports on the quality of care provided by the NHS – from the Francis Report on Mid Staffordshire hospital (Francis 2013), to Sir Bruce Keogh’s inquiries (Keogh 2013) and Don Berwick’s review (Berwick 2013) – is evident from the unprecedented growth in the number of nurses, midwives and health visitors recently. Between August last year and March this year, the number of nurses, midwives and health visitors employed by the NHS grew by nearly 9,000 (2.9 per cent), bucking seasonal trends and boosting the nursing workforce to its highest level ever (see figure below). While this increase will hopefully help to deliver better services, there is a difficult trade-off with budgets as hospitals face continued pressure on their finances.
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 – March 2014, Provisional statistics www.hscic.gov.uk.
- More detailed results of the survey and the performance dashboard results are set out in the next two parts of this report.
References
Association of Directors of Adult Social Services (2014). Annual budget survey report 2014: final. London: ADASS. Available at: www.adass.org.uk (accessed on 7 July 2014).
Baumann P (2014). Consolidated 2013/14 finance report. Board paper, no 1505143. London: NHS England. Available at: www.england.nhs.uk (accessed on 7 July 2014).
Berwick D (2013). A promise to learn – a commitment to act: improving the safety of patients in England. London: Department of Health. Available at: www.gov.uk (accessed on 17 June 2014).
Dorsett J (2014).Performance of the foundation trust sector: year ended 31 March 2014. London: Monitor. Available at: www.gov.uk (accessed on 7 July 2014).
Francis R (2013).Report of the Mid Staffordshire NHS Foundation Trust public inquiry. London: The Stationery Office. Available at: www.midstaffspublicinquiry.com (accessed on 17 June 2014).
Keogh B (2013).Review into the quality of care and treatment provided by 14 hospital trusts in England: overview report. Available at: www.nhs.uk (accessed on 12 May 2014).
NHS Trust Development Authority (2014).Service and financial outturn report for the period ending 31 March 2014. Paper F for Board meeting 15 May 2014. Available at: www.ntda.nhs.uk (accessed on 7 July 2014).
1. Health care surveys
This quarter’s report is based on an online survey of the following groups:
73
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 23 May 2014 and 6 June 2014. We contacted 248 NHS trust finance directors to take part and 73 responded (29 per cent response rate).
In addition, we contacted 206 clinical commissioning group (CCG) finance leads and 47 responded (23 per cent response rate). Between them these finance leads covered 61 CCGs (30 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 likely achievement of maintaining the 18-week referral-to-treatment waiting time target throughout the year; and their plans for both elective and non-elective activity in 2014/15.
2. End-of-year financial situation and cost improvement/quality, innovation, productivity and prevention programmes
End-of-year financial position: 2013/14
One in ten trusts ended the year in deficit. This is a slight improvement from the one in eight trusts forecasting this position in April, and seems to have been helped by organisations taking action to minimise or reverse deficits by one-off asset sales or otherwise non-recurring financial actions (figure 1).
These results are somewhat better than those reported for trusts and foundation trusts. End-of-year reports from Monitor and the NHS Trust Development Authority show that around a quarter of all trusts ended 2013/14 in deficit (Dorsett 2014, NHS TDA 2014).
The year-end position for CCGs was healthier, with only 3 per cent ending the year in deficit (figure 2). Overall, NHS England reported 19 CCGs ending the year with a deficit, accounting for 9 per cent of all CCGs (Baumann 2014).
The difference between the results of the NHS England survey (Baumann 2014) and those by Monitor (Dorsett 2014) and the NHS Trust Development Authority (2014) in part reflect the wording of our survey question (which allows organisations that expect a deficit of up to 0.25 per cent of turnover to report this as a break-even position but which would be reported by Monitor/NHS Trust Development Authority as a deficit) and the possibility that the survey has a slight bias towards better performing trusts.
NHS Trusts
Figure 1: Looking back on 2013/14, what was your organisation’s end-of-year financial situation?
50
In surplus
15
Breaking even (+/-0.25% of turnover)
8
In deficit
Note: The area of the bubble in the survey charts represents the value shown. The sizes of the bubbles are comparable between the charts.
CCG Leads
Figure 2: Looking back on 2013/14, what was your organisation’s end-of-year financial situation?
55
In surplus
4
Breaking even (+/-0.25% of turnover)
2
In deficit
Note: 47 CCG finance leads answered this question for the 61 CCGs they cover collectively
Projected end-of-year financial balance: 2014/15
One in four trusts forecast a deficit for 2014/15 – the highest proportion since we began surveying in 2011. This suggests a worsening of trusts’ financial position compared to 2013/14 when 11 per cent reported a deficit (figures 3 and 5).
Around one in ten CCGs forecast ending 2014/15 in deficit (figure 4). Nationally, NHS England is struggling to present a balanced financial plan (Baumann 2014).
NHS Trusts
Figure 3: What is your organisation’s forecast end-of-year financial situation for 2014/15?
41
In surplus
14
Breaking even (+/-0.25% of turnover)
18
In deficit
Respondent comments
-
“'Plan is for a small surplus, but forecast already suggests deficit.'”
Acute trust
CCG Leads
Figure 4: What is your organisation’s forecast end-of-year financial situation for 2014/15?
52
In surplus
4
Breaking even (+/-0.25% of turnover)
5
In deficit
Respondent comments
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“'Plan to drop surplus from 1.5 per cent in 13/14 to 1 per cent in 14/15. This has been the CCG's plan all along and was the plan through authorisation. However, we are concerned that NHS England will require the CCG to change this planned surplus to a higher level.'”
Note: 47 CCG finance leads answered this question for the 61 CCGs they cover collectively
NHS Trusts
Figure 5: Trends: What is your organisation's forecast end-of-year financial position?
CCG Leads
Figure 6: Trends: What is your organisation's forecast end-of-year financial position?
Cost improvement and QIPP programmes
The average cost improvement programme (CIP) target for trusts in the 2014/15 financial year is 4.7 per cent, ranging between 2.4 per cent and 8 per cent of turnover (figure 7).
The average quality, innovation, productivity and prevention (QIPP) target for CCGs for the 2014/15 financial year is 2.8 per cent, ranging from 0.5 per cent and 5.5 per cent of allocation (figure 7).
Since the end of 2013/14 there has been a marked loss in confidence in achieving planned CIPs/QIPPs (figures 10 and 11). Around four in ten NHS trust finance directors were fairly or very concerned about achieving their CIP plans this year (figure 8).
NHS TrustsCCG Leads
Figure 7: What is your organisation’s CIP/QIPP target for this financial year (2014/15) as a percentage of turnover/allocation?
NHS Trusts
Figure 8: How confident are you of achieving your cost improvement programme (CIP) target in 2014/15?
6
Very confident
23
Fairly confident
17
Uncertain
14
Fairly concerned
13
Very concerned
Respondent comments
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“'It's definitely getting tougher to take cost out – we are on to major transformation plans which are complex and take a long time to execute. Patients are attending our A&E at rates higher than any of us have ever seen, which makes it harder to create capacity to make change.'”
Large teaching acute foundation trust
CCG Leads
Figure 9: How confident are you of achieving your quality, innovation, productivity and prevention (QIPP) target in 2014/15?
8
Very confident
26
Fairly confident
14
Uncertain
10
Fairly concerned
3
Very concerned
Respondent comments
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“'Fairly confident with current plan. But if NHS England remove more funding in an unplanned way after we've reached contract settlements with our providers, as was the case in 13/14 for specialised commissioning, then this confidence level will change.'”
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“'So much effort now on creating the Better Care Fund, QIPP energy has been diverted.'”
Note: 47 CCG finance leads answered this question for the 61 CCGs they cover collectively
NHS Trusts
Figure 10: Trends: How confident are you of achieving your cost improvement programme (CIP) target?
Note: QMR1 and QMR5 excluded as wording of responses not compatible with other quarters' data
CCG Leads
Figure 11: Trends: How confident are you of achieving your quality, innovation, productivity and prevention (QIPP) target?
Note: 47 CCG finance leads answered this question for the 61 CCGs they cover collectively
The £20 billion productivity challenge
As the £20 billion ‘Nicholson Challenge’ reaches its final year, views on the risk of achieving this value of productivity improvements are the most pessimistic to date (figures 14 and 15).
Around eight in ten NHS trust finance directors felt the risk of failure to achieve the productivity challenge was high or very high (figure 12). CCG finance leads felt fairly pessimistic too – with the majority of respondents assessing the risk of failure as fairly or very high (figure 13).
NHS Trusts
Figure 12: 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?
1
Very little risk of failure
1
Little risk of failure
12
50/50 risk of failure or success
32
High risk of failure
27
Very high risk of failure
Respondent comments
-
“'Cost restraint (especially pay bill) has been a key part of apparent delivery, but underlying productivity has not improved by any more than half this rate or magnitude. Evident from surrounding organisations that the scale and pace of productivity improvement has become significantly less sustainable over the last 12 months.'”
Major tertiary and specialist university hospital
CCG Leads
Figure 13: 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?
0
Very little risk of failure
7
Little risk of failure
12
50/50 risk of failure or success
20
High risk of failure
8
Very high risk of failure
Respondent comments
-
“'Year-on-year efficiency savings at scale are very difficult to deliver whilst maintaining quality and safe patient care. Impact of local authority cuts and its knock-on to health care is difficult to quantify.'”
NHS Trusts
Figure 14: 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?
Note: Question not asked before QMR6 or in QMR7
CCG Leads
Figure 15: 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?
3. The state of patient care
Although around 20 per cent of NHS trust finance directors felt care in their local area had got better over the past year, 27 per cent thought it had got worse (figure 16).
On the other hand, while a fifth of CCG finance leads felt patient care had worsened in the last year, more than a third thought it had got better (figure 17).
NHS Trusts
Figure 16: 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?
15
Better
38
The same
20
Worse
Respondent comments
-
“'Growing waiting times and a relentless reduction of cash to the acute sector. The NHS may be protected at a national level but what feeds its way down to acute trusts is extreme cuts.'”
Acute trust
CCG Leads
Figure 17: 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?
17
Better
20
The same
10
Worse
Respondent comments
-
“'This is one of the best performing areas of the country, and we've just about managed to keep our heads above water.'”
NHS Trusts
Figure 18: 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 19: 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
CCG finance leads continue to be most concerned about A&E and 18-week referral-to-treatment waiting time targets. For the first time since we started asking the question they are also very concerned about patients’ care experience (figure 20).
For trusts, staff morale drops down the list of concerns and waiting time targets and delayed transfers of care return to the top of their worries (figure 21).
NHS Trusts
Figure 20: Which aspects of your organisation's performance are giving you most cause for concern at the moment? Please select top three
4
Health care-acquired infections
11
Patients’ care experience
12
Cancer treatment waiting time targets
12
Emergency readmission on threshold
17
Level of engagement in performance issues by senior clinicians
19
Staff morale
26
A&E four-hour wait target
27
Delayed transfers of care
29
18-week RTT
Respondent comments
-
“'Feels like winter throughout the year.'”
Acute trust
CCG Leads
Figure 21: Which aspects of your organisation's performance are giving you most cause for concern at the moment? Please select top three
2
Emergency readmission on threshold
3
Health care-acquired infections
7
Level of engagement in performance issues by senior clinicians
8
Delayed transfers of care
10
Staff morale
12
Cancer treatment waiting time targets
20
Patients’ care experience
32
18-week RTT
34
A&E four-hour wait target
5. Waiting time targets
Unusually for this time of year, a number of key waiting time targets and the A&E four-hour waiting time standard have been breached.
Around one in five NHS trust finance directors felt that their organisation would have a poorer performance for the A&E four-hour waiting time standard compared to last year (figure 22).
Worryingly, around one in three NHS trust finance directors felt fairly or very concerned that their organisation would not be able to maintain the 18-week referral-to-treatment standards throughout 2014/15 (figure 23).
NHS Trusts
Figure 22: Compared to last year, how do you think your organisation will perform on the A&E four-hour waiting time standard?
6
Better
27
The same
8
Worse
1
Don't know
Respondent comments
-
“'Inflowing demand and increased acuity mix, as surrounding hospitals struggle and patients vote with their feet, is outstripping our capacity and redesign solutions.'”
Major tertiary and specialist university hospital
Note: 42 respondents (for whom the question was applicable)
NHS Trusts
Figure 23: How confident are you that your organisation will be able to maintain the 18-week RTT standards throughout 2014/15?
7
Very confident
26
Fairly confident
6
Uncertain
9
Fairly concerned
8
Very concerned
Respondent comments
-
“'If urgent care activity (funded at 30 per cent of tariff price) continues to rise how can we possibly keep elective activity on course?'”
Acute trust
Note: 56 respondents (for whom the question was applicable)
6. Elective and non-elective activity in 2014/15
Around one in three CCGs expect an increase in elective activity in 2014/15 (figure 27). However, more than two in three trusts are planning for an increase in elective activity in 2014/15 (figure 26).
The scale of the dissonance in planning assumptions widens considerably for emergency admissions; nearly 50 per cent of trusts expect an increase this year (figure 24), but more concerning is that while around 50 per cent of all trusts plan for an increase, 60 per cent of all commissioners plan for a reduction (figure 25).
The risk is that providers will be buoyed up by the level of income they expect from commissioners, and commissioners’ plans will be similarly balanced by the expected reduced expenditure. Both cannot be right; activity figures for the first few months of the year suggest higher, not lower, emergency activity, for example.
NHS Trusts
Figure 24: What are your plans for non-elective activity in 2014/15 compared to last year?
23
An increase
21
Little or no change
4
A reduction
Respondent comments
-
“'Our plan is for no change from last year’s outturn, but the actual at the moment is 5 per cent higher than this time last year, and we have escalation beds open.'”
Acute and community trust -
“'Commissioners wish to plan for reductions but no confidence in the plans and no precedent for reductions.'”
Teaching hospital foundation trust
Note: 48 respondents (for whom the question was applicable)
CCG Leads
Figure 25: What are your plans for non-elective activity in 2014/15 compared to last year?
6
An increase
15
Little or no change
26
A reduction
Respondent comments
-
“'The three CCGs are planning to reduce emergency admissions by between 2 and 3 per cent to deliver the 15 per cent reduction over 5 years of the Strategic Plan period.'”
NHS Trusts
Figure 26: What are your plans for elective activity in 2014/15 compared to last year?
32
An increase
15
Little or no change
0
A reduction
Note: 47 respondents (for whom the question was applicable)
CCG Leads
Figure 27: What are your plans for elective activity in 2014/15 compared to last year?
15
An increase
25
Little or no change
7
A reduction
7. 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, 86 per cent of trust finance directors were fairly or very pessimistic (figure 28).
In general, views about the financial future have become gloomier since our survey began in 2011 (figure 29).
CCG finance leads are similarly more pessimistic about the coming year (figure 30).
NHS Trusts
Figure 28: 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
6
Neutral
46
Fairly pessimistic
17
Very pessimistic
Respondent comments
-
“'On the provider side the NHS is beginning to unravel from a financial perspective. Regardless of the starting point, years of tariff deflation combined with increasing inflationary pressures on costs are not sustainable. We are now at the tipping point... something has to change.'”
Anonymous -
“'Surrounded almost entirely by hospitals which are in deficit positions and getting progressively worse. Impact of Better Care Fund on CCG affordability of secondary activity in 2015/16 likely to be severe as no evidence that significant shifts in demand will be achieved within this timescale. Specialised Commissioning financial outlook is irreconcilable with continuing underlying treatment and demand challenges.'”
Major tertiary and specialist university hospital
NHS Trusts
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 30: 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
11
Fairly optimistic
7
Neutral
21
Fairly pessimistic
8
Very pessimistic
Respondent comments
-
“'The financial positions are challenging, but manageable during 2014/15. However 2015/16 really concerns me. Local authority cuts begin to cause pain, at the same time Better Care Fund transfers will only be possible with heroic reductions in non-elective care...which is the challenge of the Better Care Fund...but quite honestly the prospect of this really happening is not good.'”
CCG Leads
Figure 31: Trends: Overall, what do you feel about the financial state of the wider health (and care) economy in your area over the next year?
8. References
Baumann P (2014). Consolidated 2013/14 Finance Report. Board paper, no 1505143. London: NHS England. Available at: www.england.nhs.uk (accessed on 7 July 2014).
Dorsett J (2014).Performance of the foundation trust sector: year ended 31 March 2014. London: Monitor. Available at: www.gov.uk (accessed on 7 July 2014).
NHS Trust Development Authority (2014).Service and financial outturn report for the period ending 31 March 2014. Paper F for Board meeting 15 May 2014. Available at: www.ntda.nhs.uk (accessed on 7 July 2014).
1. Health care-acquired infections
Monthly counts of C difficile continue to be low, though NHS England acknowledge the historic rates of reduction achieved appear to be slowing (NHSE 2014). Targets for this year reflect this, with national reductions set at around 13 per cent, compared to 29 per cent last year (figure 32).
In May 2014 there were 23 cases of MRSA, the second lowest number on record. Monthly counts are low for MRSA compared to other infections – good news for the NHS as it tries to eradicate MRSA from hospitals altogether (figure 32).
Figure 32: 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
Total staff numbers increased for the ninth month in a row in March 2014, with total full-time equivalent roles increasing to more than 1.059 million (figure 33).
There were increases for all staff groups apart from scientific, therapeutic and technical staff who were fractionally down on the previous month but still up compared to the same time last year (figure 33).
The total number of full-time equivalent nurses, midwives and health visitors continues to increase and was up by almost 630 posts in March and more than 5,900 posts compared with the same month last year. It is the highest number of nurses, midwives and health visitors on record (figure 34).
Figure 33: Index change in NHS full-time equivalent staff: September 2009 – March 2014
Data source: Monthly NHS Hospital and Community Health Service (HCHS) Workforce Statistics in England – March 2014, Provisional statistics www.hscic.gov.uk.
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 – March 2014, Provisional statistics www.hscic.gov.uk.
3. Waiting times
The proportion of inpatients waiting more than 18 weeks from referral to treatment breached the 10 per cent target for the first time in almost three years in February and March 2014. In April and May 2014 the target was met (figure 35).
The proportion of patients waiting more than six weeks for a diagnostic test has now missed its performance target (no more than 1 per cent to wait longer than six weeks) for the past six months in a row. In May 2014 more than 18,600 patients waited longer than six weeks for a diagnostic test, more than double the number compared to a year ago (figure 35).
For all other waiting lists the operational standards were met throughout the last quarter of 2013/14 and the opening months of 2014/15 (figure 35).
The total waiting list in England breached 3 million patients for the first time in six years in April and May 2014. The reported size of the waiting list is now 3,090,000, more than 5 per cent of the population of England (figure 36).
Figure 35: 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 36: Referral-to-treatment total waiting list size in millions, England
Data source: Referral-to-treatment waiting times statistics www.england.nhs.uk.
The target that 85 per cent of patients should wait no longer than 62 days from an urgent GP referral to first definitive treatment for cancer was missed for the first time since its introduction in quarter 4 2013/14 (figure 37).
Figure 37: 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
The proportion of patients waiting more than four hours from arrival to admission, transfer or discharge in the first quarter of 2014/15 was 4.9 per cent – within the 5 per cent target, but the highest first quarter level since the introduction of the revised 5 per cent target (figure 38).
The latest weekly A&E waiting times data (for the week ending 6 July) shows that across all types of departments 4.8 per cent of patients waited more than four hours. However, for major A&E departments which treat around 65 per cent of all patients, the four-hour target has now been missed for the past 51 weeks (figure 39).
Figure 38: Waiting times: 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.
Figure 39: 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. Weekly data: November 2010-July 2014
Data source: Weekly A&E SitReps 2014–15 www.england.nhs.uk.
The first quarter of data for A&E has shown a shift away from previous trends over the same period for previous years. Though there was a long winter in 2012/13 the picture for spring was much the same as previous years, with weekly A&E data showing the proportion of patients waiting longer than four hours in A&E to be well below the 5 per cent target (figure 40).
But figures for spring 2014 are stark in that they are much higher than previous years. In fact for the first quarter of 2014/15 there were breaches in 7 of the 13 weeks (figure 40).
Proportion of A&E patients waiting longer than four hours from arrival to admission, transfer or discharge: comparison of winter and summer 2013 and 2014
Data source: Weekly A&E SitReps 2014–15 www.england.nhs.uk.
5. Delayed transfers of care
Seasonal increases in delayed transfers of care were observed in May 2014 for both the number of patients delayed and the total number of delayed days (figures 41 and 42).
Delayed transfers for acute patients, those receiving the most intense care, now account for 64 per cent of all delays. This has increased from 54 per cent four years ago, showing that the patients who are being delayed are increasingly likely to be in need of higher intensity follow-on care (figures 41 and 42).
This perhaps in part explains why a number of finance directors in our survey reported that delayed transfers were a particular issue for their organisation.
Figure 41: Delayed transfers: 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 42: Delayed transfers: Total number of days delayed each month
Data source: Acute and non-acute delayed transfers of care, total delayed days, 2014/15 www.england.nhs.uk.
6. References
- NHS England (2014). Clostridium difficile infection objectives for NHS organisations in 2014/15 and guidance on sanction implementation. Available at: www.england.nhs.uk (accessed on 8 July 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
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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Changing the date range of the NHS performance data charts
See the data in a different date range by moving the sliders on the x-axis.
Printing the QMR
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Respondent comments