The 2019/20 financial settlement is now set, with the available funding now allocated. It is important that, in the first year of increased NHS funding and a shift in the financial architecture, the NHS frontline delivers the financial improvement being targeted. It is also important that 2019/20 becomes the first year of a multi year sustained improvement in NHS finances and performance. Set out below are seven suggested actions that will help support the required improvement in both 2019/20 and beyond.


  1. Fully funding the Agenda for Change pay rise for community service providers
    The government committed in parliament to fully funding the Agenda for Change pay rise but community service providers holding local authority contracts have not been appropriately funded. As our survey shows, this is driving avoidable financial deficits. The government and national NHS system leaders need to meet the commitment that has been made.

  2. Reviewing the impact of specialist tariff changes
    Our survey suggests that 2019/20 tariff changes have particularly adversely affected some specialist trusts and others with high volumes of activity in the areas where the tariff has changed. Before setting the tariff for 2020/21, the impact of these changes should be reviewed.

  3. Understanding the reasons for unexpected 2019/20 variability
    Our survey, and wider feedback from our members, suggests that while many members have welcomed the 2019/20 financial settlement and the more realistic financial task it has set, there are larger numbers of trusts than expected arguing their 2019/20 financial task will be very difficult to deliver. We think it significant that trusts of a similar type and profile are reporting greater variability in the difficulty of achieving their 2019/20 financial task than in previous years. A quick, collaborative, deep-dive exercise in an appropriate number of relevant trusts, to understand why those trusts are finding their 2019/20 financial task more difficult than expected, would be very useful.

  4. Assuring oversight given the change in NHSE/I structure and processes
    Recent changes in the NHS England and NHS Improvement structure, particularly the creation of new regional directors, will mean significant changes in the way NHS finances and performance are managed. This transition brings added risk for 2019/20 financial and performance management. Appropriate NHS England/NHS Improvement national level assurance that this is being managed and supported effectively is important. Effective performance and financial management in the NHS depends on an appropriate collaborative partnership between trust level and arms length body leaders. The new regional directors need to collaboratively and openly co-create the new financial and performance management processes with trust leaders.

  5. Quick, collaborative, co-creation of the rules for the FRF
    Access to the FRF will represent an important element of trusts’ plans where they are in deficit, so they need rapid clarity on how the fund will actually work. There is a significant amount of complex work to do here but no clarity on how, when or at what level it will be done (for example, a single national approach, or one that varies between regions). It is important this work is done collaboratively with trust leaders. Trusts accessing the FRF remain concerned about their ability to deliver an additional 0.5% of efficiencies, and a quick light touch collaborative review exercise on this deliverability, at an appropriate point in 2019/20 and before the 2020/21 framework is set, would be helpful.

  6. Collaborative development of the journey to system control totals
    Trusts, and their local partners, are on a journey towards system level financial management (in complement to organisational financial management). The experience of the early integrated care systems (ICSs) suggests that this journey is difficult and complex. It would help, as with the wider sustainability and transformation partnership/ICS development journey, if more national level resource could be devoted co-creating these policy developments, and the mechanisms to support their implementation, with the sector.

  7. A clear, funded, performance recovery trajectory underpinned by appropriate workforce skills and capacity
    As this briefing has set out, setting a recovery trajectory for core NHS constitutional standards is currently on hold while those standards are reviewed. Once that review is complete, trusts will need clarity on the expectations to be set via the introduction of new standards and the desired recovery trajectory, including appropriate time to operationalise any changes. This is a critical piece of work to align the ‘ask’ of the service, and the access standards the public rightly expects for timely, high quality care, with the available funding. It needs to be developed collaboratively, fully funded and aligned with a realistic view of the available workforce.