Financial performance

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1 Financial performance In our first NHS Financial Temperature Check briefing 2 we noted the number of organisations that were overspending or reporting a deficit has increased since the 2012/13 financial year and more organisations reported a deficit than had planned to at the start of the 2013/14 financial year. The most recently available financial data shows that NHS finances are deteriorating in all sectors. Financial context NHS England reported on its financial performance at its November 2014 Board meeting, forecasting overspend against plan. The NHS Performance Report 3 notes that as at 30 September 2014 across all 211 CCGs there is a small forecast overspend of 21m (0.). Whilst 179 CCGs are forecasting in line with plan and 11 will slightly exceed their plans, 21 CCGs () are forecasting overspends against plan. Expenditure (for NHS England as a whole) is 23m (0.) and 184m (0.2%) above plan in the year to date and full year forecast outturn position respectively. This results in a cumulative surplus of 283m against a plan of 467m, representing a 584m reduction in the cumulative surplus of 867m brought forward from 2013/14. The CCG sector can currently rely on 400 million of cumulative surpluses carried forward from primary care trusts but the overspend forecast for 2014/15 includes the use of surpluses drawn down from previous years underspending. CCGs will not have access to this surplus once spent, which is likely to be within the next two to three years. In 2014/15 the most recent data available shows that the financial challenges are increasing. Monitor s publication on the Performance of the foundation trust sector: 6 months ended 30 September notes the FT sector as a whole reported a deficit of 254m at quarter 2, against a planned deficit of 59m. In FTs, financial performance is deteriorating against plan, with 55% of all FTs being in deficit at quarter 2. However, acute trusts represent the majority of the deficit, being overall 326m in net deficit, with 77% of acute FTs in deficit at the end of quarter /15, contributing over 9 of the total gross deficit. For non-fts the position is similar, according to the latest 2014/15 information available 5. The NHS Trust Development Authority (TDA) Board report on the financial performance of NHS trusts showed a 376m deficit at 30 September 2014, compared with a planned deficit of 317m ( 59m worse than plan). 26 NHS trusts (27%) are forecasting a year-end deficit, 24 are acute trusts. 39% of commissioner finance directors and 74% of trust finance directors are forecasting a worse 2014/15 year-end financial position than in 2013/14. 38% of commissioner and trust finance directors are also forecasting a worse 2014/15 year-end position than was originally Report-for-September-2014.pdf

2 planned at the start of the financial year. This indicates a rapid deterioration in the finances of nearly 2 out of 5 NHS organisations in our sample /15 year-end forecast position compared with 2013/14 year-end and the planned year-end position for 2014/15 Commissioner Trust Commissioner Trust 14/15 forecast compared with 13/14 14/15 forecast compared with 14/15 plan Better Same Worse 62% of commissioners finance directors and 5 of trust finance directors are quite confident in the accuracy of their organisation s year-end financial forecasting. 18% and 26% respectively are very confident and 15% and 22% respectively told us it is too early to say. 5% and 2% respectively are not very confident. 1 in 5 trust finance directors told us they had been asked to submit a revised forecast by their regulator (either Monitor for FTs or the TDA for NHS trusts). Cost pressures Further analysis of the data shows there is no single factor leading to the deterioration in NHS finances. 45% 35% 25% 15% 5% What are the main drivers for the change in the forecast 2014/15 year-end financial position in trusts? Increase in pay costs Under-achievement of CIPs Increase in non-pay costs Decrease in revenue

3 What are the main drivers for the change in the forecast 2014/15 year-end financial position in commissioners? 45% 35% 25% 15% 5% Under-achievement of QIPP Increase in programme costs on acute contracts Increase in prescribing costs Decrease in allocation Over of provider trust finance directors reported the main drivers of the worsening yearend financial forecast are unforeseen increases in pay costs, allied with lower than expected savings from cost improvement plans. Between 35% and of commissioner CFOs and finance directors reported under-achievement of quality, innovation, productivity and prevention (QIPP) savings plans and an increase in acute trust programme costs as the main driver of their worsening financial position, closely followed by prescribing costs at 28%. A more general question about the main cost pressures in 2014/15 (rather than those that had increased unexpectedly, affecting the year-end forecast) revealed more detail. In trusts the pressure on pay costs is through increasing the number of nursing staff (reported by 65% of our sample of finance directors) and agency staff costs (82%). CCGs main cost pressures are continuing healthcare costs (72%) and the combined effect of increasing demand (61%), particularly in emergency care (7) and slippage on QIPP savings, which are often associated with reducing demand (63%). Compared with our June 2014 NHS Financial Temperature Check the results are similar. In June we found, for provider trusts, the top two cost pressures were the costs of increasing demand for services (72%) and the costs of increasing the numbers of nursing staff employed (71%). CCG CFOs named three cost pressures as being particularly significant: emergency care (86%), continuing healthcare (79%) and increasing demand (71%). Another significant cost pressure is increasing premia for the Clinical Negligence Scheme for Trusts.

4 9 What are your main cost pressures in 2014/15? Area team CCG Trust Pay costs Trusts pay costs and workforce decisions are being driven largely by their response to improving quality and the availability of medical and nursing staff.

5 Reliance on bank, agency and locum staff What are the main drivers of pay costs in trusts? Response to quality concerns (including Keogh and Francis reviews) Staff turnover CQC reports Local market forces factors Redesign of jobs Trust finance directors (82%) report that one of the main drivers of their pay costs has been reliance on bank, agency and locum staff. 69% report their organisations response to quality concerns, such as those raised by the Keogh and Francis reviews, have also driven pay costs. Finance directors report a wide range of factors driving their reliance on bank, agency and locum staff in addition to increasing demand including staff sickness absence, the increasing acuity of patients requiring higher staffing levels than in the past, challenges in recruiting staff in some areas or specialties and a lack of trainee medical staff available to fill training places. 7 of finance directors told us the cost of agency medical staff had increased in the last 12 months and 76% said the same about nursing staff and health care assistants. Only 7% said the cost had decreased. Compounding these increases, 43% of finance directors reported medical staff vacancies had increased over the last 12 months, 56% reported an increase in nursing staff vacancies and 35% reported an increase in healthcare assistants. Finance directors face numerous difficulties in maintaining their workforce, varying in different parts of country and different sectors. For some there are problems with recruitment and retention that can relate to organisational reputation, career opportunities or local pay and conditions. London trusts, for instance, can often offer higher pay, via London weighting, to those living in the outskirts or a more desirable location to live in than some rural areas where overseas nursing staff may have been recruited to originally. Finance directors noted that some staff choose to work as agency and locum staff because they believe they will be paid more. Others noted that NHS pay scales do not provide flexibility and that in some cases, where trusts are bidding to provide services, they are being undercut by non-nhs organisations with lower pay costs.

6 Many trust finance directors identified specific specialties that are difficult to recruit to in certain areas of the country, namely mental health nurses, midwives, trainee doctors in A&E, elderly care and gastroenterology and allied healthcare professionals such as sonographers and therapists. The ageing workforce in some areas and specialities may lead to greater shortages of key medical staff and further cost pressures on pay budgets where temporary staff are used. One finance director felt there was an overall lack of cohesive national manpower planning. Mechanisms to address the financial challenges Finance directors intend to use a mixture of mechanisms to address the financial challenges they face. What are the main mechanisms commissioners are planning to use to meet the financial challenges ahead? Area team CCG

7 What are the main mechanisms trusts are planning to use to meet the financial challenges ahead? Reducing agency staff costs Procurement cost savings Estates rationalisation Reducing clinical variation Redesigning care pathways Redesigning jobs to reduce the cost of headcount The majority of CCG chief financial officers (75%) intend to invest in community services and primary care (63%), with the intention of reducing costs in the secondary sector. They plan to do this in conjunction with integrating or redesigning community care pathways (73%), acute pathways (63%) or through Better Care Fund schemes (61%). Area team finance directors intend to meet the challenges through redesign of their major service contacts (10) and through the changes to primary care commissioning (63%), which are expected to see CCGs taking a more active role in area team decision making. Trust finance directors intend to make agency staff cost savings (87%) and procurement costs savings (83%) along with rationalising their estates (67%). They also expect to meet the financial challenges through changes to clinical services, such as reducing clinical variation in the services being provided (61%), redesigning pathways (61%) and reducing staff costs through the redesign (55%). Trust finance directors responses are broadly similar to those in our June 2014 survey. Commissioners responses are generally not as strongly focused on specific areas as they were in June For instance, in June % of CCG CFOs intended to invest in community services compared with 75% in December % reported integrating or redesigning community care pathways (73% in December 2014) and 67% acute pathways (63% in December 2014). Main concerns across health economies Across health economies there are a number of concerns about the financial position that are largely shared by commissioners and providers, indicating broad acceptance of the causes of the financial challenges.

8 What are the main concerns about the financial health of your health economy? Commissioner - June Commissioner - December Trust - June Trust - December Finance directors main concerns are system management across the health economy (82% of commissioners and 78% of trusts), in other words, understanding who the people and organisations are in an area that have the influence to get consensus about the way forward and support change. Other shared concerns are about CCGs achieving QIPP savings plans (72%, 79%) and trusts achieving cost improvement savings (72%, 79%). Many of these issues have become a concern to more health economies since our June 2014 survey. For trusts, only system management has decreased as a concern, although it is still very high at 78%. For commissioners, only the achievability of trust savings plans decreased as a concern, from 76% to 72%.

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