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Toxic culture threatens unless NHS targets are more realistic and achievable

Plans for the NHS in the coming year look impossible to deliver despite recent comments from the Prime Minister on long term NHS funding, according to a detailed analysis by NHS Providers.


The report ‘Tough Task: The NHS delivering for patients and staff in 2018/19’ presents a stark and worrying assessment of the challenges facing NHS Trusts this coming financial year.

Based on a meticulous analysis of the most recent official data and a survey of NHS Trust leaders, the report reveals widespread scepticism about the ability of the service to meet performance and financial targets in 2018/19.


It says patients’ experience of care will continue to fall below the standards Trusts consider acceptable, with growing risks to quality and safety, adding to the burden on an already hard-pressed workforce.


Furthermore, it warns that failing to set an achievable task for NHS Trusts risks creating a toxic culture, based on pretence: weakening accountability, damaging morale and eroding public confidence in the NHS.  


The report focuses on the tasks set out in the recent revised planning guidance: a long list of ‘must-dos’ for the NHS. It points to the lack of capacity in terms of beds and staff affecting hospitals, mental health, community and ambulance Trusts, as health and social care services struggle to meet a steep and relentless rise in demand for treatment.


Although the Prime Minister’s remarks this week on health funding were welcome, the report makes clear that we are still in the midst of the longest squeeze in the history of the health service, though this will hopefully end soon. The NHS also faces growing workforce shortages.

In particular, the report highlights concerns in three key areas: A & E, planned hospital treatment and Trust finances.


Accident and Emergency


A & E performance is the worst it has been since data collection started in August 2010, with 85% of patients being seen and treated, admitted or discharged within four hours. Trusts have been told to raise overall performance to 90% by September 2018, with the majority reaching 95% by March 2019, even as demand continues to grow.


The report concludes that this looks impossible:


* Based on realistic projections of increased demand, the NHS would need to treat an extra 2.4 million people within four hours to meet the constitutional target of 95%.


* Given that A & E performance has fallen significantly in each of the last three years, the report shows why the ambition for March 2019 looks too optimistic.


* In our survey of Trust leaders just 5% were confident that their local area would be able to improve A & E performance to the level required.


Similar performance pressures are being experienced across other NHS services including mental health, community Trusts and ambulance services.


Planned hospital treatment


The waiting list for routine hospital treatment has risen to around four million - back to the highest levels since reporting began in 2007. Trusts have been told the list must not grow in the coming financial year, and the number of very long waits (over 52 weeks) must be halved. 


Here too, the report concludes that without radical changes it is inevitable that Trusts will struggle to meet expected levels of demand in 2018/19:


* A lack of beds and staff combined with the pressures of emergency care and winter cancellations mean admissions per working day have dropped.


* Based on realistic projections of increased demand, the waiting list will rise above four million.


* Trajectories suggest performance against the 18 week target for planned treatment will fall to 86.2%, so by March 2019 the number of people breaching the constitutional standard will reach 560,000 – a rise of nearly 80,000.


* In our survey of Trust leaders just 14% were confident that services in their area would be able to avoid lengthening waiting lists.


Trust finances


Trusts are going into 2018/19 in a much more difficult financial position than was predicted 12 months ago. In December the sector was forecast to end the year £930 million in deficit (compared with £496 million projected at the start of the financial year). And this was after a special cash injection in the Budget. Yet Trusts have been told to achieve a financial breakeven position next year.


The report concludes that this is unrealistic and could compromise patient care:


* Achieving financial balance will require the great majority of Trusts to sign up to and deliver on their control totals (financial targets) set by NHS Improvement.


* The average cost improvement plan would need to be 5.7% of relevant turnover – equivalent to overall savings in excess of £4 billion. This is 20% more than Trusts are on track to deliver this year.


* In our survey only about half of Trusts (54%) indicated they would sign up to their control total, and of these only a third (35%) were confident they could meet this.


* The main reasons for rejecting control totals were that they were too ambitious, the quality of care would be compromised and staff morale would be hit by a culture of failure.


* Trusts that do not sign up for control totals and meet performance targets will miss out on ‘sustainability funding’ which will make their situation even worse.


* Half of mental health Trusts are not confident their local commissioners will meet the ‘investment standard’ requiring them to increase mental health funding at least in line with the growth in their overall allocation.


Commenting on the findings, the Chief Executive of NHS Providers, Chris Hopson, says: “The NHS is a can-do organisation.It has shown great resilience in treating more patients than ever before while working to protect standards of care.


“It also has improved productivity at nine times the rate of the wider economy and delivered greater efficiency savings than other western healthcare systems. But our analysis shows the levels of performance expected and the savings demanded for next year are beyond reach.


“The new financial year begins this week. Whilst we strongly welcome the Prime Minister’s commitment to increase long-term funding for the NHS, it makes no immediate difference to the tough task facing Trusts for next year.


“It is vital that the government addresses the difficulties facing social care, which impact directly on the NHS. This report also shows - as the Prime Minister argued - that this is not just about funding. Trusts are struggling with major workforce shortages and they need help from the government here too.”


Following the publication of the 2018/19 planning guidance we surveyed Finance Directors and Chief Executives at NHS trusts in England. 


The online survey was open for a week at the end of February 2018. 97 NHS Trusts and Foundation Trusts responded to the survey, representing 42% of the sector.


Read the full report here.