Keeping on track for better health in a financially challenging year
At the start of what will be a ‘uniquely challenging’ year financially for the NHS, our Chief executive, Professor Tim Orchard, explains why the NHS is expected to do things differently and summarises what this means for our Trust and how we are responding.
You will have seen much in the news about NHS funding pressures and reforms, including NHS England being merged into the Department of Health and Social Care and a further slimming down of integrated care boards. We have also been working through how we best respond to the financially challenging year ahead while not just maintaining safety but also continuing to improve and help shape and deliver more transformational change.
We have now finalised our operational plan for 2025/26, which sets out what the national requirements and funding for NHS trusts mean for us locally. We have also refreshed our strategic plan to reflect current challenges and opportunities as well as the progress we have made towards our goals.
I want to highlight a few key points about 2025/26 – what is expected of us and how we are responding – for our patients and local communities, as well as for our staff.
This is part of a major, post-pandemic reset
Everything changed with the Covid-19 pandemic and, though we are back to normality in many ways, its legacy continues to shape how we work. Waiting times – for planned and urgent and emergency care – are still much longer than before and need is growing. The NHS workforce – and costs – increased rapidly in some areas, and many roles were re-focused.
Clinical pathways and relationships with partners adapted quickly too, and there wasn’t always time to work that through in terms of changes to commissioning contracts and payment arrangements.
We want to build on the changes that are delivering improvements while getting back on top of waiting times and cost control, and ensuring we are doing the right things, in the right way, so that we can be as effective, efficient and productive as possible. This is a major aspect of what we are being asked to deliver in the coming year.
We are starting from a strong position
I am proud of what we have achieved over the past few years – of the expertise and innovation that helped us care for thousands of people and improve treatment through the pandemic and, since then, to respond to the changing and growing needs of our patients and local communities.
The year just ended saw our fifth consecutive set of improved scores in the annual NHS staff survey, with responses to workforce race equality standards above average for the first time. It was the consecutive sixth year we met our annual financial plan. We delivered a whole range of projects, including rolling out Martha’s Rule and achieving Pathway to Excellence accreditation at Charing Cross, and launched major improvement programmes for outpatient services and cancer care. We were also part of some amazing clinical breakthroughs.
What we are required to do this year
The additional £22 billion allocated to the NHS nationally has been absorbed by pay awards and the full impact of inflation. To meet the financial gap, NHS trusts are required to spend one per cent less and deliver a four per cent increase in productivity overall. We have also been set targets for reducing our substantive workforce by one per cent, bank staff (our internal staff agency) by 15 per cent, (external) agency staff by a third and spending on corporate and other 'non-patient facing' roles equivalent to half the growth since 2018/19.
For our Trust, this means delivering a breakeven plan for 2025/26 (with £46m of support from North West London Integrated Care Board), including £80.1m of cost improvements.
It also means reducing our workforce by at least 450 whole time equivalent posts, mostly through a reduction in the use of bank and agency staff but also by reviewing vacancies, primarily in non-patient facing roles. This is also in the context of an establishment that has grown significantly since the pandemic, to over 16,000 currently.
And we need to meet a core set of operational performance improvement targets, spanning A&E, referral to treatment, cancer care and diagnostics waits.
Alongside these requirements, it’s important to note that, unlike in previous years, we will not be able to ‘earn’ our way to financial balance as there is a limit on the amount of income we can bring in from planned care activity, and that limit is currently set at a lower level than the amount of planned activity we carried out last year. On top of that, in previous years, we have benefitted from one-off financial measures (such as being able to release money that had been set aside to help manage a specific risk) but we are unlikely to have any of these measures available to help us this year.
How we are responding
We are focusing on making changes across all our services that will improve care and make us more productive. For example, we have seen a big increase in follow-up outpatient appointments since the pandemic, while waiting times for first outpatient appointments are growing. Our clinicians are exploring how to avoid unnecessary follow-ups by getting the most out of first appointments, for example by arranging diagnostic tests to be carried out beforehand, as well as giving patients control over when they want to be seen as part of ongoing care for long-term conditions rather than having standard intervals between appointments. We will also be working closely with our health and care partners to explore whether there are things we do that we are not commissioned to do, or where others may be better placed to do them.
We’re also reviewing non-patient-facing roles, including those in our corporate services, like finance and human resources. Our corporate and support services remain vitally important functions – and we don’t want to simply shift responsibility for essential work into clinical teams – but we do need to be clear on what we all expect these teams to provide and what resource that requires.
And our private care services, now back to their pre-pandemic capacity, are looking at how we can increase our share of the private care market, with all income coming back into the Trust.
Across all these actions, we have agreed a set of principles to help ensure our focus remains on quality and the health and wellbeing of our workforce. And we have processes in place to check that we are sticking to these principles and to monitor the impact of changes. This includes making sure we do not worsen health inequalities nor present any risks to safety, being open and transparent about what is happening and why, and considering the impact of proposed changes on patients, staff, GPs and other stakeholders and involving them directly wherever we can in the change process.
Temporary measures to ensure cost control
As we began the new financial year on 1 April, we had only been able to identify half of our cost improvement plans and we hadn’t yet brought our spending into line with this year’s budget. We therefore took the decision to put further controls on recruitment and use of bank and agency staff, essentially pausing activity except for where it was necessary to ensure safety, for two months.
Last year, we overspent at the start of the year and, while we worked hard to get back on track, we only met our breakeven target through one-off financial benefits which will not be available to us this year. Therefore, the additional controls are necessary measures to keep us on track while we make more sustainable changes in line with our overall direction of travel.
Listening and learning
We have put quality safeguards in place – for the temporary cost control measures as well as the longer-term changes – but we know we won’t always get things right. We will be monitoring impacts through our regular analyses of data and feedback, but we are being clear with our staff - and I want to be clear with our patients and local communities and our partners - that we want to know if you are concerned about safety or wellbeing. You can feed in concerns via our patient advice and liaison service or directly to any of our senior clinicians or managers, including to me and members of the executive management team. We will also be working closely with our lay partners, health and care partners and - for staff - our staff networks, freedom to speak up guardians and union representatives.
Looking ahead
The Government expects reform. Its Ten-Year Health Plan is due to be published later this year, aiming to deliver three key shifts – hospital to community, analogue to digital, treatment to prevention.
Our strategy – and that of the wider acute provide collaborative - is well aligned with this ambition. By improving our productivity and cost control, while staying true to our goals, we will be well placed to help and support the change that is needed. Ultimately, we will be on track to deliver our long-standing promise of ‘better health, for life’.
