An ever tougher task

As a CEO I find I am needing to say sorry – sorry to our staff for not having managed to fix all this and mostly sorry to patients when I know things are not working the way they should.

Chief executive, acute trust    

In March 2017, NHS Providers published Mission impossible? which set out how the task required of frontline NHS trusts in 2017/18 was impossible to deliver. As this financial year draws to a close, the substantial progress that NHS trusts have made over the past 12 months is striking. Despite having experienced the busiest year recorded, and emerging from the toughest winter, on many measures trusts have performed extremely well in 2017/18. The sector has:

• Treated more patients than ever before. In February, the NHS saw over 1.5 million attendances; a 2% rise on February 2017. Despite February’s performance against the four-hour standard dropping to the worst it has ever been since data collection began, the NHS still managed to treat, and then admit, discharge or transfer 1,547,784 patients within four hours in February; an increase of 28,500 patients in a year.
• Continued to outstrip UK levels of productivity. The provider sector is delivering productivity improvements of 1.8% (NHS Improvement, 2018), nine times that of the wider UK economy over the past five years (Nuffield Trust, Health Foundation and King’s Fund, 2017).
• Continued to deliver a level of efficiency savings higher than other western healthcare systems have been able to achieve. The sector is still on plan to deliver over £3bn savings this year, which would be over £194m (6%) more than last year.
• Seen their partnership working starting to bear fruit. The NHS and social care have made substantial efforts to reduce delayed transfers of care, freeing up around 1,500 less daily delayed transfers of care (DTOC) beds in January 2018 when compared to January 2017 due to system wide efforts to ensure patients are treated in the most appropriate settings.

Despite February’s performance against the four-hour standard dropping to the worst it has ever been since data collection began, the NHS still managed to treat, and then admit, discharge or transfer 1,547,784 patients within 4 hours in February; an increase of 28,500 patients in a year.

   

However, sadly, for the NHS, its staff and patients, even this level of effort was not enough. Our predictions that the 2017/18 task was impossible have proved all too accurate. Although we await the final data covering the entire year, it is already clear that, despite best efforts:

• Trusts will have missed the planned financial deficit of £496m by a significant margin – the forecast deficit at quarter three was just under £1bn, but that included an extra injection of around £240m winter funding in the Budget and it is likely quarter four will be further off plan given the winter pressures trusts have faced.
• Far from recovering, the A&E 95% four hour standard, performance has deteriorated further. Though, thanks to the focus and effort devoted to urgent and emergency care over the last 12 months, the speed of decline seen in the last few years has slowed down.
• Again, far from recovering the elective waiting 92% 18 week standard, performance has slipped significantly and we are yet to see the full impact of the operations that had to be cancelled to deal with emergency demand from January 2018 onwards. We expect this to show further slippage.

There are similar stories in cancer waiting time, ambulance targets and across the mental health and community sectors.

Setting NHS trusts an achievable task each year matters. Failing to do so has a number of impacts. It risks:

• the credibility and authority of NHS England, NHS Improvement and the Department of Health and Social Care (DHSC) and trusts losing confidence in the ability of these organisations to lead the service at national level
• trusts being portrayed as failing as they inevitably fall short of delivering an impossible task, however well they perform
• demotivating and disengaging staff as their trust cannot deliver what is asked of it, however hard they all work.

Setting an achievable task is particularly important in the current trust financial framework.

   

This creates a toxic culture, based on pretence, where trusts are pressurised to sign up to targets they know they can’t deliver and then miss those targets as the year progresses. Underlying all this, setting an impossible task weakens accountability and fails to maximise taxpayer value for money because the planning process is neither robust nor rigorous and in year performance and financial management becomes much more difficult.

Setting an achievable task is particularly important in the current trust financial framework. A crucial amount of trust funding (the £1.8bn in the sustainability and transformation fund (STF) in 2017/18, rising to £2.45bn in 2018/19) is allocated based on whether trusts hit their financial and performance targets or not. By the end of 2017/18, around £800m of that funding may not have  been earned by trusts, and will therefore be re-allocated to those providers which have hit their financial targets. This means that the funding will likely be concentrated in a smaller number of providers, further worsening the financial problems faced by trusts in most need.

All this risks public confidence in the NHS as the service is seen to consistently fail, year after year. This is already being felt in terms of the attitude of the population towards the NHS. Once one of the most resilient and most loved public services, the latest British Social Attitudes survey showed that satisfaction with the NHS was down to 57%, a 6% drop on last year (Robertson, Appleby and Evans, 2018). Dissatisfaction is now at 29%, nearly double the level recorded in 2014. Three of the main reasons that people gave for being dissatisfied with the NHS were: staff shortages, long waiting times, and lack of funding, which suggests that finally the pressures on the NHS have now entered the public’s consciousness.

 

The 2018/19 task

In February 2018, revised planning guidance, Refreshing NHS plans for 2018/19 (NHS England and NHS Improvement, 2018), set out the delivery requirements for NHS trusts for the coming year, reflecting the additional £1.6bn allocated to the NHS in the November 2017 budget and an additional £540m from the DHSC funds. The guidance contained a significant number of challenging financial and performance objectives for the NHS provider sector, including:

• aggregate financial breakeven position, including a pound for pound improvement in financial performance for the extra £650m added to the provider sustainability fund (PSF) (previously the STF)
• A&E target – 90% in September 2018 and the majority of providers meeting 95% by March 2019, as well as reducing delayed transfer of care days to 4000 and reducing inappropriate length of stay
• referral to treatment time (RTT) targets - hold at current number of people on the waiting list and halve the number of patients waiting over 52 weeks 
• requirements of Five year forward view for mental health 
• requirements of national cancer strategy
• requirements of Transforming care for people with learning Ddsability strategy
• requirements of national maternity strategy
• continue to implement provider efficiency programmes including Getting it Right First Time (GIRFT)
• further develop their sustainability and transformation plan or integrated care systems.

Three of the main reasons that people gave for being dissatisfied with the NHS were: staff shortages, long waiting times, and lack of funding, which suggests that finally the pressures on the NHS have now entered the public’s consciousness.

   

This list of 'must-dos' is long; and follows an extremely challenging year for trusts. As things stand, it seems very unrealistic that the sector will be able to achieve this in 2017/18.

As with last year’s Mission impossible?, this report seeks to assess how deliverable the 2018/19 provider task is. It sets out the consequences for patients and staff in section 2, the performance and financial detail in sections 3 and 4 and, in section 5, sets out how, in future, we avoid putting trusts in this impossible situation.

This year, we also draw on the results of a new survey of chief executives and finance directors from 97 NHS trusts and foundation trusts (42% of the sector), following the publication of the 2018/19 planning guidance.