Since July 2014, the Nuffield Trust has regularly surveyed a panel of 100 health and social care leaders in England for their views on a range of issues including: finance, general practice and rationing.
Below we present the views of health and care leaders on the pressures facing the NHS and social care, focusing on place-based commissioning, finances and staff morale.
Our sixth poll was conducted between 11 April and 15 May 2016, via an online survey.
In total, 67 of our 100 panellists responded. Of the 67 respondents, 29 are senior managers, 23 are clinicians or clinical leaders, eight are from local Healthwatch bodies and seven are from the social care sector. Of the health service managers and clinicians, 23 are from acute hospitals, 15 from clinical commissioning groups, five from private or voluntary sector providers, five from mental health providers, two from NHS ambulance trusts and two from NHS community trusts.
The panel members are named on our website, but their individual responses to the survey are anonymised.
- Staff engagement and morale are vital prerequisites for successful change in the NHS and for recruiting and retaining enough staff. However, a clear majority (57%) of our respondents told us that morale in their organisation had fallen in the past six months – and several noted that it had been poor to start with.
- Workload was the main reason given for this (77%), though financial pressures on both the sector and the panellists’ organisations were also noted. Many mentioned that the way that NHS governing bodies handled their role and the pressures on GPs were also important drivers.
- We asked our respondents about Sustainability and Transformation Plan (STP) areas, into which NHS bodies have been grouped for crucial five-year plans. They believed that these made sense as areas, and would create new chances to work together across divides in the service. However, many were concerned that the survival instincts of previously independent bodies, and the fragmented system of NHS governance, would continue to get in the way.
- Returning to financial balance and eliminating overspending is both a legal requirement for the NHS and a central plank of NHS England’s instructions for planning. Yet just 6% of our respondents agreed that they would be able to deliver this in the current financial year.
- With an ageing population and shrinking coverage since cuts to council budgets began, fixing the social care system so that it works for the public and the NHS should be a priority. Yet 60% of our respondents disagreed that new spending measures in last year’s Spending Review would make it possible to help more people.
- Two vital contributors to the current drive for savings are the hospital savings opportunities identified in the Carter review, and the aim of using cost caps to drive down spending on agency staff. Our respondents were unsure about the feasibility of the Carter review, although many saw it as having real value. They were equally unsure about whether the complex impact of agency caps would ultimately be positive or negative.
NHS England recently published a map of 44 Sustainability and Transformation ‘footprints’ – geographical areas under which local health and social care organisations are expected to come together to draw up regionally specific plans for developing efficient and co-ordinated plans for improving services and finances for the coming five years. We asked our panellists whether this development represented a workable solution for improving the state of care.
Q1. Thinking about your area, do you agree that your local ‘footprint’ adequately captures the ‘natural communities, patient flows and local working relationships’ aspired to in NHS England’s planning guidance?
The Sustainability and Transformation planning process is supposed to be the local mechanism for delivering the Five Year Forward View vision for a financially stable, high-quality health service.
A core aim is that planning will be done jointly across all NHS bodies in areas that typically combine about five clinical commissioning groups. The ambition is that local NHS bodies will collaborate rather than defend their own turf, and do so at a scale that allows strategic decisions to be made.
For this to work, it is important that the Sustainability and Transformation Plan (STP) ‘footprint’ captures all of the services used by the local people, so that, for example, GPs can work with the hospitals who treat their patients in order to improve connections between services. Equally, it is important that they bring together local institutions that are well placed to work together, or that have a history of actually doing so. Both factors are highlighted in NHS England’s guidance. The allocation of organisations to these 44 ’footprint’ areas was decided by a combination of local areas coming forward, and NHS England directing and signing off proposals. We asked our respondents – who hold senior posts across all the various bodies falling under STPs – whether they thought they had succeeded in bringing together organisations in a sensible way.
A majority of respondents (53%) agreed that the footprint did fully reflect these crucial factors – although a significant minority (31%) disagreed. One respondent, an NHS trust chief executive, said that it “builds on an already established economy”.
One CCG leader seemed to disagree, arguing that:
“All the STPs really form Venn diagrams and there will be many overlaps. The size and shape have been determined centrally, rather than by local intelligence and relationships.”
Comments made by health leaders showed that some were pleased with the new scale and definition of planning areas. However, many suggested that while the definition of their area might reflect historical or institutional arrangements, which was in some cases a real advantage, it did not reflect the way that patients themselves flowed through the local NHS.
Q2. Thinking about your area, do you agree that the creation of ‘place-based’ planning envisaged in the STP will enable new opportunities for collaboration between local organisations compared to previous planning arrangements?
‘Place-based’ planning is a governing principle of STPs. The idea is that organisations will pool their resources and decision-making powers, in order to try to meet shared goals and patient needs. In some respects this conflicts with earlier visions for planning and decision-making in the NHS, which emphasised the freedom of provider organisations to make decisions for their own institutions and for commissioners to use contractual and competitive mechanisms to get the best services for their patients.
Our respondents were generally optimistic that this change of tone and structure would create new opportunities to work together. Well over two-thirds agreed that the planning approach for STPs would create opportunities for better working together than was the case with earlier systems. In comments, many expressed the view that more co-operative relationships were already possible – and local areas had, or should have, made some progress in developing them. Some also pointed to elements of the law and wider system that they felt were not supportive of a collaborative way of working. One respondent, an NHS trust chief executive, said:
“This is the case in theory but while accountable officers are responsible to their boards and regulators for the bottom line and their local populations for providing services on a comprehensive footing, this can only go so far.”
A CCG leader agreed, pointing out that:
“Our FTs compete with each other and concentrate only on money. They need to begin to work together and we need to move away from PBR and block contracts and concentrate on high quality cost effective services.”
Q3. In your view, what might be the principal barriers to successful place based planning?
Despite the majority believing that the place-based planning process would create new opportunities to work together, our respondents also foresaw several powerful potential barriers. A concern that institutions would cling to or revert to a self-interested way of working was common, particularly in the case of foundation trusts, and particularly where organisational ‘survival’ was at stake. Many also pointed to fragmentation and division higher up in the NHS hierarchy, not designed for a system of coherent planning. One voluntary/private sector leader noted the problem of “trust and the baggage of competition”. A trust chief executive agreed:
“The system architecture is still working in traditional siloes. We are at risk of being reviewed to death by the 5/6 national bodies.”
The health service entered a new fiscal year in April and is still undergoing what is widely thought to be its biggest ever squeeze on finances. Although the 2015 Spending Review appeared to provide a generous settlement for the NHS, with a significant increase in spending over the current financial year, this may conceal cuts in other areas of health spending as well as large funding gaps in social care. We asked our panel what effect the current state of service finances was having on the ground.
Q4. The measures announced in the spending review (additional funding and new council tax freedoms) will enable local authorities in your area to meet the social care needs of more people.
There are signs that cuts to council funding over the past five years have resulted in many older people not receiving local authority-funded social care when they would previously have been eligible, and squeezed spending has put enormous pressure on companies providing social care. Ahead of the 2015 Spending Review, the Nuffield Trust and organisations representing providers and users of social care warned about the risk that a further five years of cuts would pose to social care services and the ability of the NHS to cope with the pressures it faces – for example, by contributing to high levels of delays in transferring patients.
In response, the Spending Review, while announcing further large cuts to core council grants, also announced new sources of funding for social care. Councils were allowed to raise council tax by an additional 2% as long as it went to these services – and later on in the Parliament, an additional £1.5 billion would be put in.
A critical question is whether these funding streams will enable care to be provided to more people – so that councils can return to providing for the same proportion of people they did five years ago, or at least keep up to some extent with the rising numbers of older people. Some 60% of our respondents disagreed with this proposition, with over a quarter strongly disagreeing. One CCG leader respondent felt that:
“Year on year decimation of council budgets will not be addressed by tiny increases now. Much too little, much too late.”
In comments, some felt that the new funding would do something to alleviate pressure on adult social care. However, many doubted whether councils would be politically willing to raise council tax at 2%. Others felt that even if they did, the money raised would be inadequate to address the existing and upcoming need for services.
Q5. It will be possible for my local health system to return to aggregate financial balance within 2016/17, as required in the Operational Plan by NHS England.
In recent years NHS trusts have accumulated large deficits as the cost of the care they provide exceeds the money they receive. The Department of Health and other central bodies have then had to bail out these organisations. The financial year 2015/16 saw overspends by trusts reach £2.45 billion in total, even after considerable accounting adjustments.
NHS Improvement has aimed to make 2016/17 a ‘firebreak’ year when this will end. This means stopping the growth of underlying deficits, and then using a Sustainability and Transformation Fund to top up funding so that they are effectively eliminated. To do so, a system of ‘control totals’ for trusts has been introduced, and the STP plans agreed across the system are supposed to guarantee overall balance in each local area.
Just 6% of our respondents agreed that this would be possible in their local area: 67% disagreed. A trust chief executive said:
“We are making good progress and have improved beyond recognition from previous years but we can't deliver a 5 year recovery programme in 12 months.”
Comments often highlighted the sheer scale of inherited problems and the short time-frame, as well as wider difficulties in the NHS – such as staffing shortages and disillusion, and the trend of rapidly rising activity.
Q6. The potential efficiencies identified in the Carter Review are feasible and achievable in my local acute trust(s).
In February 2016, Lord Carter’s review of hospital productivity identified £5 billion in potential savings to form a crucial component of the efficiencies the NHS is required to find by 2020. Many of these were picked out by measuring how much could be saved if hospitals with higher staffing and costs brought their spending down to match those who spent less on the same activity.
Our respondents had mixed views on the feasibility and achievability of the opportunities Lord Carter claimed existed: 27% agreed that they could be attained, 24% disagreed, and almost half neither agreed nor disagreed.
One trust chief executive respondent explained it as follows:
“They are but they are not sufficient – Carter estimates we can save about 50% of the amount we need to save in order to tackle our financial deficit.”
Comments often agreed that the work did identify some real and valuable opportunities, but many also raised doubts about its deliverability by the current system.
Q7. The cap on agency spending overall and agency staff rates per hour is having a positive impact on my local NHS trust.
Recent financial years have seen a steep rise in the use of agency staff by the NHS, repeatedly exceeding the amount providers planned to spend at the start of each year. This has been identified as a significant driver of deficits – although the Nuffield Trust warned about exaggerations of the role it plays.
In response, in 2015 NHS central bodies announced cost caps that limit the amount spent on agency staff, and the rate paid to staff who are employed in this way. The policy is an attempt to use the health service’s massive market power to drive down costs. However, policymakers acknowledge that one effect of the limit will be to drive away some staff who are unwilling to work at lower rates. They also anticipate that some trusts will be unable to stick to the limits. We asked our respondents whether they believed the caps would have a positive impact on their local trust.
A voluntary/private sector leader commented that:
“The position is very mixed. From the perspective of patients whose service continuity has been affected by the imposition of agency caps, the impact is anything but positive. Financially, the overall national impact is probably (just) beneficial.”
16% agreed that the impact would be positive, while more (29%) disagreed. A 55% majority, however, expressed no view either way, with comments suggesting that it was too soon to be sure and that the multiple factors at play created real uncertainty.
“We are in relatively good position and this challenge is going to be very hard even for us.”
While financial difficulties in the NHS are undoubtedly serious, problems with the workforce may be even more difficult to fix. The Nuffield Trust is concerned that signs of poor morale and engagement in the NHS in recent years are emerging, leading to staff shortages and difficulties in recruiting. We asked our panel whether they felt morale had worsened, and if so, why.
Q8. Thinking about your organisation over the past six months, has staff morale:
Our evaluations, research and briefings on change in the NHS have repeatedly highlighted that good staff engagement is vital to successfully changing how NHS organisations work and how technology is deployed. An open, positive culture is also an important part of addressing failures of care and improving quality. Yet the Nuffield Trust and other organisations are concerned about signs of poor morale and engagement in the NHS in recent years – with symptoms including unprecedented vacancy rates for GP training places and trust chief executives. As one respondent from our panel (a director of nursing) put it, “Everyone is tired.”
A clear majority of our respondents, drawn from across all sectors of the NHS and social care, agreed that staff morale had deteriorated in their organisation in the last six months. Many comments underlined this by emphasising that it had already been poor at the start of this period. Poor morale among GPs was especially highlighted by those respondents exposed to primary care.
Q9. If you believe staff morale has deteriorated, which if any of the following factors do you think have contributed to this?
We asked those respondents who thought morale had deteriorated to choose one or more factors they thought had caused this. A clear majority (77%) pointed to workload. Around half pointed to the financial position of individual organisations, and around half to the financial position of the sector as a whole. Despite their high political profile, pay and the dispute between the government and the British Medical Association (BMA) over junior doctor contracts were only selected by around a quarter of respondents.
One CCG leader felt that:
“It feels increasingly like we are asked to manage decline of the NHS.”
In addition to these factors, many comments also highlighted negative aspects of the health service’s culture, and regulators and central bodies creating pressure in the way that they govern and monitor the system.
Q10. The dispute between the government and the BMA over the junior doctor contract will damage the future supply of this segment of the workforce in my area:
A dispute between the Government and the BMA over terms for new junior doctors culminated in strikes in the first months of 2016, including the first all-out medical strike in NHS history in April. Key issues included the rates at which doctors would be paid for weekend and night working; which days and times counted towards this; and safeguards against doctors being worked excessive hours. The Government claimed an electoral mandate to meet standards of seven-day working in certain services, while representatives of the BMA argued that the contract would impose more demanding working patterns without the resources to make this fair and safe.
Agreement between NHS Employers and the BMA junior doctor committee has now been reached, subject to a vote by BMA members. However, the media and senior medics have expressed concerns that the intensely felt dispute will discourage junior doctors taking up places under a new contract.
On the dispute, a trust chief executive respondent on our panel, argued that:
“There is so much negative press it is bound to have a negative impact – [we] need to think what will attract the younger generation to commit to the NHS.”
A clear majority of our respondents, polled shortly before the negotiations that led to agreement, agreed that the dispute was likely to damage the future supply of junior doctors in their local area.
Our sixth survey of health and social care leaders shows a conflicted view of the system's prospects over the next five years and beyond. Some recent developments – such as the ‘footprints’ proposed for delivering STPs and the potential hospital savings identified by Lord Carter – are seen as providing real chances for improvement. However, respondents remain concerned about the clear continuing decline in staff morale, and pessimistic about the state of finances within individual trusts and the health service in general. It is noticeable that these concerns seem to be leading to a more general erosion of confidence in the ability of new systems or structures to deliver what they were set up to achieve.
Nuffield Trust (2015) Health leaders' panel survey 6: footprints, financing and staff morale. Nuffield Trust.