The 2017 Budget on 8 March confirmed that, while there was extra money for social care and a small amount of extra capital funding for the NHS, there would be no extra revenue funding for the NHS in 2017/18, the new financial year which starts on 1 April 2017. Analysis by NHS Providers predicts that, without realism, flexibility and support, it will be impossible for the NHS hospital, ambulance, community and mental health trusts who account for more than 63% of NHS spend to deliver all that they are being asked for in 2017/18.
What NHS trusts need to deliver in 2017/18
2017/18 NHS trust delivery requirements are set out in the NHS 2017/19 planning guidance. They can be summarised as:
- absorb a forecast 5.2% demand and cost increase
- deliver the required NHS constitutional performance targets, for example the 95% A&E four hour standard, the 18 week elective surgery standard and the cancer targets
- eliminate the provider sector financial deficit and deliver a minimum zero aggregate provider sector financial balance
- all within the NHS funding allocation, which will increase in 2017/18 by a much lower amount than in 2016/17.
Why the 2017/18 delivery requirement is currently impossible to deliver
While individual NHS trusts may be able to meet all their delivery requirements, and individual requirements can be met at a sector level, the aggregate 2017/18 provider sector task is currently undeliverable for the following six reasons:
- NHS trusts will receive a smaller funding increase in 2017/18: provider NHS funding increases are dropping from 4% in 2016/17 to 2.6% in 2017/18 (clinical commissioning group and specialised commissioning funding. See chapter 2 for the difference between the NHS England 2017/18 real terms funding increase of 1.3% and the figure we use here of an actual 2.6% increase for NHS trust funding, which is due to the higher level of increase in clinical commissioning group (CCG) and specialised commissioning allocations).
- However, demand and cost is predicted to rise by 5.2% in 2017/18, double the 2017/18 NHS provider funding increase of 2.6%.
- Evidence from the last decade indicates it is impossible for NHS provider efficiency savings, which average between 1 and 2% per year, to close this gap, which would be required to just maintain existing performance.
- Key performance targets are already being missed and achievement of the performance targets in 2017/18 will require a significant improvement and extra investment. For example:
- Performance against the key 95% A&E standard in the 12 months to January 2017 was running, on average, at 88.9%. NHS Providers estimate it would cost an extra £400-600 million to recover performance to the required level across the year.
- Performance against the key 92% 18-week elective surgery target is running at 89.9%. NHS Providers estimate it would cost a minimum estimated £2.0-2.5bn to recover performance to the required level.
- The NHS provider sector will enter 2017/18 with a likely deficit of between £800-900m and therefore needs to improve its financial performance by this amount to eliminate the deficit and achieve the required balance.
- NHS trusts are required to deliver a new set of extra commitments from the recent cancer and mental health taskforces which NHS Providers estimates will cost between £150-200 million.
In short, the 2017/18 funding increase, together with best case scenario provider efficiencies, does not even cover the predicted cost and demand increases in 2017/18, which is required to just maintain existing performance levels. NHS Providers estimates it would cost a minimum further £2.4-3.1 billion, which the NHS cannot afford, to recover the performance standards to required levels.
There are two further £800-900 million and £150-200 million pressures to eliminate the provider sector deficit and meet extra new commitments. If NHS trusts could not deliver NHS performance standards on a 4% funding increase for trusts in 2016/17, there is no evidence to suggest they can deliver them on a 2.6% funding increase in 2017/18.
The 2017 budget announcements of £2 billion for extra social care, £100 million capital for extra GP front door triage in A&E Departments and £325 million capital for the most advanced sustainability and transformation plan (STP) footprints were welcome. However, they are unlikely to make a significant difference to this underlying position. The impact of extra social care support on NHS performance in 2017/18 is uncertain given that there are no “must benefit the NHS conditions” attached to the new funding. Extra capital of £425 million is marginal in the context of an estimated £2.4 billion a year required for STPs and a forecast maintenance backlog of £5.8 billion.
Impact on patients and staff
Patients will be impacted if NHS trusts are unable to meet all their delivery requirements. Depending on what is prioritised, this impact could, on current performance trajectory, mean an estimated 1.8 million patients having to wait more than 4 hours for A&E treatment and an estimated 100,000 patients waiting longer for elective surgery than they should do – 40% and 150% increases on the respective levels this year (NHS Providers estimates, see section on target and performance delivery).
Trying to meet performance targets on inadequate funding levels also places an unfair and unsustainable burden on NHS staff.
Trying to meet performance targets on inadequate funding levels also places an unfair and unsustainable burden on NHS staff
NHS Providers shares the recent judgement of the chief inspector of hospitals that “the scale of the challenge that hospitals are now facing is unprecedented – rising demand coupled with economic pressures are creating difficult-to-manage situations that are putting patient care at risk.” This applies to the entire provider sector, not just hospitals.
NHS Providers is particularly concerned by the impact on patient safety of current bed occupancy levels in both acute and mental health settings. Events in January 2017 showed that, in a number of local systems, we are now putting patient safety at unacceptable levels of risk. We argue that in the re-prioritisation the NHS must now undertake, addressing this risk should be a key priority.
What next – the options
NHS trust leaders are strongly committed to providing the best possible care for patients, meeting their NHS constitutional performance standards and achieving financial balance, including an appropriate degree of performance, productivity and financial stretch. Their strong and clear preference is for the NHS to be funded at a level that enables the average trust to deliver that aggregate task. However, in the absence of adequate funding to achieve this and with less than a fortnight till the start of the new financial year, NHS Providers believes that the NHS now has to make some rapid, difficult, choices.
There are two broad approaches. One is to act as though delivery of the requirements is still achievable. This risks setting an impossible task for trusts, misleading the public, preventing the NHS from planning to maximise patient benefit from the resource spent and placing an unsustainable burden on frontline staff.
NHS trusts will do everything they can to deliver what they are asked but they will need realism, support and flexibility from NHS political and system leaders
The second is to fully develop the emerging approach being adopted by the NHS arm’s length bodies, who have recently indicated that the 95% A&E standard will not be deliverable across the year. NHS leaders need to recognise that delivery of these requirements is no longer possible and they need to set more realistic targets, with appropriate flexibility:
- The NHS England mandate and the new NHS delivery plan, due at the end of March, need to set out what can be realistically delivered for 2017/18 in relation to each priority.
- Building on work already undertaken, the NHS should carry out an urgent exercise to examine whether, by the end of quarter 1, money could be reallocated from non-frontline care (commissioning costs, and further reductions to administration budgets from the Department of Health and its arm's length bodies; in 2015/16 their admin budgets totalled £5.65 billion), to frontline care.
- Frontline and central NHS leaders need to work together to identify what support and investment is required to enable trusts to make significant progress in reducing the unwarranted variation in performance between trusts that has been identified in several recent reviews.
NHS trusts will do everything they can to deliver what they are asked but they will need realism, support and flexibility from NHS political and system leaders.