There is much to be proud of within our NHS and within the NHS provider sector specifically. The NHS provides free care at the point of need for 56 million citizens and employs 1.2 million people. The NHS is the largest employer in the country and trusts act as anchor institutions in local communities, with a reach spanning far beyond healthcare in terms of the economic and social value they add for their population. The Commonwealth Fund ranks the NHS favourably relative to other countries on measures including quality of care, efficiency and equity. Given the right resources, trusts have long shown how they can make huge gains in improving care quality including improving outcomes for heart conditions, improvements in cancer survival rates, reducing infection, introducing talking therapies across the country and increasing access to perinatal mental health services. In fact, the provider sector has driven up Care Quality Commission (CQC) ratings over the last few years despite the significant challenges it faces.

Yet we all agree there is much more to do. As our population changes and ages, demand for health and care services is increasing year-on-year with patients often presenting with greater acuity and more complex needs. Patients, service users and the public now expect different things of their health services, including more personalised care, effective use of the latest innovations and technologies, and access to more integrated services in convenient locations. There is a general consensus across the sector of the benefits of embracing population health management, of addressing the wider determinants of health and of moving to a more preventative model of delivery.


The long term plan sets out a welcome vision to deliver these future aspirations through a renewed focus on integrated care systems (ICSs) and sustainability and transformation partnerships (STPs), accompanied by a real terms funding uplift of £20.5bn a year over a five-year period, with a commitment to see the provider sector return to financial balance by 2023/24. However, questions remain as to how far this will stretch, as the NHS seeks to absorb additional demand in existing models of delivery, and simultaneously transform to offer more modern, integrated and personalised care.


Although the NHS settlement was generous relative to other public services, the size of the increase is smaller than the long run average and the average annual increase across the period between the establishment of the NHS in 1948 and 2010 (when 'austerity' began). NHS frontline care has been impacted by budget cuts in other areas of public expenditure in recent years, most notably in public health and social care, and remains dependent on those services receiving sufficient funding to operate effectively. Repeated NHS capital to revenue switches have left a maintenance backlog of £6bn in trusts across the country. There is a clear need for a doubling of the NHS' capital budget, a multi-year capital settlement and a more streamlined and transparent process by which trusts can access capital. Finally, a multi-year settlement for the education and training budget has yet to be confirmed, leaving trusts unclear as to how workforce planning will operate and be funded in coming years.


The long term plan contains over 300 commitments for providers and their partners to deliver as part of an ambitious vision to move to system working. While the vast majority of these have been individually welcomed by providers, in the current context, our survey this year indicates that greater prioritisation will be needed to enable the sector to deliver a realistic 'ask' within the resources available.


In fact, the question of how far NHS funding will stretch becomes all the more pertinent when we evaluate the backdrop of transformative change currently facing the NHS. This includes: the cultural shift required to support a new collaboration between NHS England and NHS Improvement at the national level and the potential for a targeted NHS Bill to support the delivery of more integrated care, the establishment of new joint NHS England and NHS Improvement regional teams with responsibilities for regulation, improvement and relationship management, the evolution of ICSs as they seek to take on more collective responsibilities, the fast paced consolidation of the commissioning landscape as clinical commissioning groups (CCGs) reduce dramatically in number, opportunities for trusts to work together in new ways, in alliances, groups and by consolidating and the formation of primary care networks (PCNs) and other collaborations with primary care, social care and other partners, at the neighbourhood level. The scale of this transformation, and the leadership capacity and resource required to deliver it successfully at all levels of the system, must not be under estimated.


This cocktail of constrained finances, coupled with over 100,000 vacancies across the NHS workforce (and more across primary care and social care) means there are signs that parts of the country remain under considerable strain as they seek to absorb additional demands for care. The mismatch between demand and available resources is putting the NHS delivery model under demonstrable strain, most evident perhaps in the fact that trusts and the wider health and care sector, can no longer deliver the constitutional standards around access to care set out in the NHS constitution. CQC has commented on the 'integration' lottery presented by the current system and this year public satisfaction with the NHS overall fell to 53% – a 3% point drop from the previous year and the lowest level since 2007.


Equally concerning are aspects of the NHS staff survey results which show a rise in bullying and harassment and a need to support staff wellbeing and address stress in the workplace. The interim people plan rightly places priority on ensuring the NHS is 'a great place to work' by embedding a transparent culture of engagement at all levels of the system. However supporting and developing the NHS' talented and dedicated workforce will remain a central priority as we enter a period of change.


In this report we have sought to set out the scale of the challenge and opportunity facing trusts, and the wider health and care sector, as they seek to deliver the worthy aspirations of the long term plan.


We know that the NHS is a vital and caring institution with huge strengths on which to build for the future. Shoring up its success will mean answering questions which go to the core of the quality of care we all wish to deliver for the public, the investment of tax payer funds required to ensure sustainable services and the delivery model trusts and their partners will be adopting as the NHS moves forwards with system working.