Creating a sustainable culture NHS financial resilience review 2015 - Efficiency Demand

Page created by Gary Armstrong
 
CONTINUE READING
Creating a sustainable culture
NHS financial resilience review 2015
Summary findings from our financial health checks of English NHS trusts, foundation trusts and CCGs
March 2015

                                                                    Efficiency

                                 Demand

                                                                                            Funding
Contents

Introduction                              1
Executive summary                         2
Key indicators of financial performance   6
Strategic financial planning              9
Financial governance                      11
Financial control                         13
Clinical commissioning groups             15
Appendix – Four year analysis             20
About us                                  23
Introduction

Purpose of this report                           Table 1 Themes and categories for analysis for trusts

In increasingly financially challenged            Theme		                       Category
times, it is vital for NHS organisations to
                                                  Key indicators of             •   Strategic financial targets
gain the best possible understanding of the       financial performance         •   Monitor financial risk ratings
challenges and potential solutions, and to                                      •   Public Sector Payment Policy/Better Payments Practice Code
benchmark against their peers. This report                                      •   Workforce
sets out our insight into how resilient NHS
                                                  Strategic financial           •   Focus of the medium-term financial strategy
finances are and provides a summary of            planning                      •   Adequacy of planning assumptions
the key themes and best practice that have
                                                                                •   Links to other plans
emerged from our national programme of
                                                                                •   Review processes
financial health reviews.                                                       •   Responsiveness of the plan

Our approach                                      Financial governance          •   Understanding
Our analysis is based on a review of the                                        •   Director and non-executive director (NED) engagement
delivery of 2013/14 (FY14) budgets and                                          •   Overview of key cost categories

planning for 2014/15 (FY15) and beyond                                          •   Risk management reporting
                                                                                •   Cost Improvement programme reporting (CIP)
at 63 foundation trusts (FTs) and non-FTs,
                                                                                •   Budget reporting – revenue and capital
collectively referred to as trusts throughout
                                                                                •   Internal audit recommendations
this report. Our analysis also covers 69
                                                                                •   Self-assessment
clinical commissioning groups (CCGs).
    Our bespoke methodology for                   Financial control             •   Budget setting/monitoring – revenue and capital
trusts assesses financial resilience across                                     •   CIP programme setting/monitoring
26 categories, drawn together in four                                           •   Accounting systems
key themes: key indicators of financial                                         •   Finance department resourcing
performance; strategic financial planning;                                      •   Internal audit arrangements
financial governance; and financial control                                     •   External audit arrangements
                                                                                •   Assurance framework/risk management
(Table 1). For each category a risk rating
was given (Table 2), and combined to
provide an overall rating for each theme.
                                                 Strategic financial targets (Table 2)
Sections two to five of this report set out
our findings for NHS providers.
    The methodology for CCGs differed
as these were in their first year and we
therefore assessed and risk-rated seven
categories designed to assess that first year.
                                                  Arrangements meet                         Potential risks and/or                         High risk
Detailed findings for CCGs are set out on
                                                  or exceed adequate                            weaknesses                          The trust’s arrangements
page 15.                                                                                                                            are generally inadequate
                                                       standards                             Adequate arrangements and
    Summary ratings over time are provided                                                    characteristics are in place
                                                                                                                                     or may have a high risk
                                                    Adequate arrangements                                                               of not succeeding
in the appendix. Figures and trends quoted             identified and key                      in some respects, but not
are based on our sample unless otherwise            characteristics of good                  all. Evidence that the trust is
                                                 practice appear to be in place              taking forward areas where
indicated. A year on year comparison can                                                       arrangements need to be
be found in the appendix.                                                                             strengthened

                                                                                                                     NHS FINANCIAL RESILIENCE REVIEW 2015   1
Executive summary

The NHS is at a financial impasse, arising from the ever increasing demands of an elderly population
and long-term complex conditions. Encouragingly, the ‘NHS five year forward view’ (Forward view),
published last October, set out a welcome and more upbeat vision for the future of our publicly
funded English health service. Our second annual financial health review considers key indicators
of financial performance, financial governance, strategic financial planning and financial control,
to provide a summary update on local NHS bodies’ financial resilience.

NHS financial headlines
Since our last report, in November         In many respects, our own analysis supports increasing financial
2013, much has been written about          pressure facing the sector:
the state of NHS finances. News                     of non-FTs and 25% of FTs recorded a FY14 deficit – a quarter of these
media increasingly tells alarmist tales    44%      unplanned and indicating the strain on many FTs
of an NHS in crisis. Reports from the
National Audit Office (NAO), Audit          9%      of CCGs reported an overspend against allocation in FY14
Commission and many others describe                 of trusts did not meet their CIP target, including after relying on
a sector that is feeling the financial     48%      non-recurrent measures
strain of sustained long-term trends
                                                    of trusts required non-recurrent savings in their FY14 CIP programmes
in demand, coupled with the cost           72%      (50% FY13)
of addressing access and service
quality standards.                                  of CCGs did not meet their savings target (QIPP) with heavy reliance
                                           40%      on non-recurrent savings

                                                    of trusts that met their CIP target relied on planned or unplanned
                                           63%      non-recurrent savings (44% FY13)

                                           In our sample, based on identified issues with financial resilience:

“Closing the gap between the least         51%      of non-FTs received a qualified auditor’s value for money conclusion

and most efficient and introducing         15%      of CCGs had a ‘matter to report’ on their value for money conclusion
new and more efficient ways
                                                    of non-FTs and 26% of CCGs were subject to a referral to the Secretary
of delivering services offer the           26%      of State for Health
opportunity to continue achieving
2% efficiency over the next                13%      of FTs had a modified audit opinion.
Parliament.”
                                           Source: Grant Thornton analysis
‘The forward view into action:
planning for 2015/16’

2   NHS FINANCIAL RESILIENCE REVIEW 2015
Affording the future vision                       Government. For now, the ‘Forward                 Reducing variation between
The ‘Forward view’ set out a vision               view’ states that “action will be needed      more and less efficient providers and
based on a number of ideas, many not              on ... three fronts – demand, efficiency      delivering care in more efficient ways is
necessarily new or radical, but based             and funding”. All are crucial and the         needed in order to continue to sustain
on common sense and an increasingly               report is clear that underachievement         up to 2% annual efficiencies. NHS
accepted view of how public healthcare            on one will place greater demands on          England believes efficiency could rise
needs to develop and innovate. The key            the others.                                   to 3% by the end of the next Parliament
principles include a focus on prevention                                                        if preventative approaches and new care
over cure, breaking down the health               The need for rapid change                     models are implemented at pace.
and social care divide, encouraging               In recent history, the NHS has been               Wider questions around how
better partnership with communities               able to achieve up to 2% efficiency           massive transformational change will
and voluntary organisations, providing            per annum. ‘The Forward view into             be funded and what share of the public
more support to older people living in            action: planning for 2015/16’, planning       purse will be devoted to the NHS
care homes, incentivising and developing          guidance published in December,               over the next five years will need to be
NHS people and embracing 21st century             suggests that 40% of this efficiency          answered in the next Parliament.
technology in providing healthcare.               has been achieved through top-down
    How can we afford this encouraging            initiatives such as pay restraint and         “To sustain a comprehensive
future vision for the NHS? The                    drug price caps. The guidance                 high-quality NHS, action will be
Forward view does not contain detailed            recognises that these types of measures       needed on ... three fronts – demand,
financial projections for how the £30             cannot be solely relied upon for the          efficiency and funding.”
billion funding shortfall can be bridged.         medium-term.
These are questions for the next                                                                ‘NHS five year forward view’

                                                        Funding
‘NHS five year forward view’ –
                                                        Key questions raised:
Three fronts for action
                                                        • How will the necessary transformational
                                                          change be costed and funded?
                                                        • How will economic conditions and
                                                          policy impact the level of increase
                                                          in NHS funding?

                                                                                                Efficiency
                                                                                                •   Breaking organisational silos
                        Demand                                                                  •   New models of care
                        •   Prevention and public health                                        •   Innovation
                        •   Patient control over their care                                     •   Payment and regulatory
                        •   Primary and community focus                                             flexibility
                        •   Third sector involvement

                                                                                                         NHS FINANCIAL RESILIENCE REVIEW 2015   3
Implementing accepted good                              Nineteen CCGs (9%) reported an         commissioning sector are starting to
practice                                           overspend against allocation in FY14 and    impact upon leadership capacity within
In the short-term, we believe that the             a slightly greater number are reporting     CCGs. Finding sufficient time and
“non-transformational” 2% per annum                potential overspends in FY15. However,      skills to manage key developments
savings presents a challenge. Our analysis         there is a mixed picture with some health   in service redesign, collaborative
indicated that trusts’ deteriorating               economies reporting a balanced position     commissioning of specialised services
position for FY14 looked set to continue:          while in some areas both the NHS            and co-commissioning of primary care
                                                   commissioners and the providers are in      is challenging. CCGs are investigating
                                                   deficit.                                    options to address this capacity including
                                                        Trusts and CCGs struggling with        using the legislative reform order to
                                                   CIP and QIPP performance can make           create ‘mergers’ or ‘joint committees’.

       65%                        58%              some progress in moving towards
                                                   their more efficient peers through the
                                                                                                    The wider challenge of ensuring the
                                                                                               engagement and support of NHS people
    did not have their        looked unlikely to
                                                   adoption of accepted good practice          during what will be a sustained period
     CIP programme            be able to deliver
                                                   disciplines for CIP planning, delivery,     of change should not be underestimated.
    ready in advance            their FY15 CIP
                                                   reporting and control. These are set out    Modern inclusive and collaborative
         of FY15                     target
                                                   in the body of this report.                 leadership and behaviour will need
                                                                                               to become the new norm across the
                                                   Engaging the NHS’s greatest asset           NHS. The NHS Leadership Academy
Indeed, delivery of savings has been a             On workforce, our analysis indicates        recognises this need and the 2013
continued issue in FY15. The HFMA’s                improvement in sickness absence in          Healthcare Leadership Model includes
December 2014 ‘NHS financial                       FY14, but high and increasing levels        these expected behaviours. The model is
temperature check’ found that the two              of agency spend. Finance directors          not mandatory and any approach is only
main reasons for deteriorating trust               recognise this as a priority area for in-   as good as how well it is applied in the
financial performance in FY15 were                 year savings, but fear the impact on        local context. Therefore, it will be critical
CIP under-delivery and rising pay costs,           access to services. The Forward view        that, at a local level, a focus on the right
particularly agency.                               talks of moving away from such costly       sort of behaviours is maintained. This
    CCGs reported their main cost                  staffing solutions and to better staff      is the only way to ensure that all NHS
pressures as coming from continuing                planning across the system to deliver       people are fully engaged in the shift away
healthcare costs and emergency care                the service of the future, but this will    from historical and familiar models of
costs. Our analysis demonstrated that              take time.                                  care to a truly patient-centred approach
48% of CCGs did not have their FY15                    There are early signs that the          that challenges previous organisational
financial plans ready by the start of the          financial and other pressures in the        cultures and boundaries.
year. 40% of CCGs did not deliver in
full against their FY14 QIPP targets and
there was heavy dependence on non-
recurrent savings.
                                                   “We can design innovative new care models, but they simply won’t
                                                   become a reality unless we have a workforce with the right numbers,
                                                   skills, values and behaviours to deliver it.”
                                                   ‘NHS five year forward view’

4     NHS FINANCIAL RESILIENCE REVIEW 2015
Nineteen CCGs (9%) reported
                                                                                           an overspend against allocation
                                                                                            in FY14 and a slightly greater
                                                                                           number are reporting potential
                                                                                                 overspends in FY15.

Making collaboration real                     “It is ... essential that providers and commissioners work together, with
Since the NHS structural reforms in           partners in primary and social care, to develop accurate demand and
2013, the responsibility for the strategic    capacity plans that fulfil both the planning requirements and ensure
leadership across health economies has        patients have access to high quality services.”
become fragmented. The roles previously
                                              ‘The Forward view into action: planning for 2015/16’
carried out by primary care trusts
(PCTs) and strategic health authorities
(SHAs) have been split out across local
                                              better progress in the use of the fund       Closing comment – Success rests
authorities, the Trust Development
                                              were those where there were already          on embracing change
Agency (TDA), the new CCGs and
                                              well-established relationships based on      The Forward view suggested that
different parts of NHS England.
                                              mutual empathy and trust. Without this       continuing with a comprehensive,
    Occasionally tensions can surface
                                              focus on relationships and alignment of      tax-funded NHS in England was
within this structure, particularly where
                                              behaviours at a local level, the extent of   ‘doable’. Achievement of this aim will
there are differences in opinion as to how
                                              genuine collaboration needed will never      rely on a number of factors, including
to work together to ensure the overall
                                              be achieved.                                 national policy, funding and the actions
health system holds together. Some
                                                   For next year and beyond, this need     of other players in the wider system.
CCGs comment that they miss the co-
                                              for close and productive collaboration       What is clear is that the NHS will need
ordination role previously carried out by
                                              with a focus on system-wide                  to play its own very significant part.
the former SHAs.
                                              sustainability will be key to success.       Doing existing things better, learning
    To avoid the game of ‘who fails first’
                                              This will remain challenging and will        from the best, will go some way.
– referred to in December 2014 by TDA
                                              require substantial discipline from all      However, locally tailored and locally-
director of finance, Bob Alexander –
                                              parties to not retreat into tribalism        led (rather than nationally determined)
providers and commissioners will need to
                                              at the first, second or third sign of        transformation to the way patient/
work together closely and collaboratively
                                              trouble. The interim chief executive of      user-centred care is delivered is the real
to ensure that the interests of the health
                                              the emergent UnitingCare Partnership         prize. The success of this exciting new
system are put above individual bottom
                                              in Cambridgeshire and Peterborough           phase in the development of our care
lines. A tightening financial position can
                                              recently captured the challenge perfectly:   services will fundamentally depend
reinforce silo thinking and, in some areas,
                                              “We are having to unlearn 20 years of        on how local leaders and their teams
we have seen this increasing. Consistency
                                              competition and, boy, can that be painful    seize the opportunity to embrace
between commissioner and provider
                                              at times.”                                   essential change.
planning assumptions is, rightly, being
promoted by NHS England with greater
vigour through the FY16 planning              “There are viable options for sustaining and improving the NHS
guidance.                                     over the next five years, provided that the NHS does its part, allied
    Our September 2014 report,                with the support of government, and of our other partners, both
‘Pulling together the Better Care Fund’,      national and local.”
highlighted some of the challenges
                                              ‘NHS five year forward view’
involved in working together across
health and social care and demonstrated
that those areas that were making

                                                                                                   NHS FINANCIAL RESILIENCE REVIEW 2015   5
Key indicators
of financial performance

Consistent with FY13 results, this theme contains the highest percentage of trusts with a red rating.
Nationally, the NAO has reported that 22% of non-FTs and 28% of FTs recorded a FY14 deficit. Of the
trusts in our sample, 39% were in deficit, and a quarter of these deficits were unplanned.

We have seen further polarisation in          Strategic financial targets
relation to trusts’ financial performance,    In FY13, we saw a downturn in
with red ratings and green ratings having     performance, with red ratings emerging
risen by a similar proportion. Only           for 17% of trusts. This trend continued
25% of trusts now sit somewhere in the        into FY14 with a further 6% assessed as
middle, compared with 60% in FY12             red – making nearly a quarter overall. All
and 40% in FY13.                              the reds were acute non-FTs. The three
    Improvements made under the               key reasons for trusts being assessed

                                                                                                48%
themes of financial planning, governance      as red this year are that they reported
and control tend to contribute to             a deficit, needed to rely on financial
improvements in key indicators, as trusts                                                      of trusts did
                                              support during the year or materially
                                                                                              not meet their
are better able to mitigate the worsening     failed to meet their CIP targets. Perhaps
                                                                                                CIP target
financial climate. Those trusts that can      unsurprisingly, in most cases it was all
                                                                                               (44% FY13)
improve do, and the trusts that do not        three combined.
have the capacity to make changes get
deeper into difficulty.

    Strategic financial targets criteria
    This category reviews performance against the following financial criteria:
                                                                                                72%
                                                                                             of trusts required
    • statutory requirements:                                                              non-recurrent savings
       – breaking even on the income and expenditure account                                 in their 2013/14
       – meeting the external financing limit (EFL) – the difference between the             CIP programmes
           amount a trust plans to spend in a year and what it can generate through             (50% FY13)
           its operations
       – meeting the capital resource limit (CRL) – the amount of capital
           expenditure a trust may incur in a year
    • performance against the cost improvement programme (CIP)
    • levels of liquidity.
                                                                                                63%
                                                                                              of trusts that
                                                                                           met their CIP target
                                                                                            relied on planned
                                                                                           or unplanned non-
                                                                                            recurrent savings
                                                                                                (44% FY13)

6    NHS FINANCIAL RESILIENCE REVIEW 2015
The widespread use of non-recurrent          To inform our RAG ratings in this
                                                                                            Continuity of services risk rating
savings measures is increasing the           category we considered the results of
                                                                                            (COSRR)
financial challenge for FY15 and beyond,     the ratings framework adopted by each
                                                                                            This contains two components:
when many trusts are already having to       trust in FY14, whether the FRR or the
                                                                                            • Liquidity: how many days
identify stretch savings.                    COSRR, as the requirement to be able to
                                                                                               expenditure can be covered
    In FY14, 38% of trusts needed            progress to foundation trust status is the
                                                                                               by readily available resources
revenue funding support and 50%              same – an overall rating of 3.
                                                                                               (cash or cash-equivalent forms),
needed balance sheet cash support, with          Performance against the Monitor
                                                                                               including wholly committed lines
three-quarters needing both types. All       risk rating is the strongest category
                                                                                               of credit available for drawdown:
of the trusts requiring support were         within this theme with green ratings
                                                                                               rating from 1 (bad) to 4 (good)
acutes. Without this financial support       rising from 59% to 77%. This figure is
                                                                                               relates to the number of days
from elsewhere within the NHS, trusts’       much higher for FTs, with 94% rated as
                                                                                               cover
reported financial performance would         green and none as red. All of the trusts
                                                                                            • Capital servicing capacity:
have been a lot worse in FY14. In FY13,      rated as red (12%) reported a deficit and
                                                                                               the degree to which the
revenue funding support was only             those rated as amber (12%) achieved low
                                                                                               organisation’s generated income
needed by 27% of trusts.                     scores in respect of their liquidity. Under
                                                                                               covers its financing obligations:
    There were no reported breaches of       FRR, the score-capping regime in place
                                                                                               rating from 1 to 4 relates to the
the CRL during FY14. However, this           prevented a trust from qualifying for FT
                                                                                               multiple for cover
potentially masks slippage in capital        approval status if it had major liquidity
programmes during the year. While            issues. However, under COSRR the               These components are equally
it may be tempting for trusts to make        capping regime no longer applies and           weighted in the calculation of the
immediate cash savings by delaying           the assessment gives equal weighting to        overall rating, which is the average
capital spend, and also avoiding the         liquidity and capital servicing capacity.      rounded up. This determines
additional recurrent revenue expenditure         Despite better performance on              Monitor’s regulatory approach,
associated with capital developments, this   Monitor risk ratings in FY14, 25% of           with an overall 4 meaning no
is not necessarily a sustainable longer-     FTs (44% non-FTs) recorded a FY14              evident concerns and no regulatory
term solution.                               deficit. FY15 figures show the FT sector       action, and a 1 meaning serious risk
                                             as being significantly further off plan this   and potential investigation and/
Monitor financial and continuity             year than their non-FT counterparts,           or appointment of a contingency
of services risks ratings                    indicating the increasing financial strain     planning team.
Monitor’s financial risk rating (FRR), as    on many FTs.                                       A successful application for FT
set out in the Monitor’s FY14 compliance                                                    status requires a COSRR of 3.
framework, was replaced on 1 October                                                            Unlike the former FRR, there
2013 by the continuity of services risk                                                     are no caps, so it is possible for a
rating (COSRR).                                                                             trust with a liquidity rating of 1
                                                                                            and a capital servicing capacity of 4
                                                                                            to achieve an overall COSRR of 3,
                                                                                            whereas the FRR would have been
                                                                                            capped at 2.

                                                                                                  NHS FINANCIAL RESILIENCE REVIEW 2015   7
Public sector payment policy (PSPP)            Sickness absence levels remained above
                                               target in 60% of all trusts in our sample,     Good practice
The PSPP requires all trusts to pay
95% of their invoices within 30 days.          compared to 89% in FY13, though it             Regular monitoring of key indicators
While the number of trusts rated as            is not clear whether this improvement          of financial performance:
red has increased slightly from 11% to         reflects real reductions or simply more        • Progress against statutory targets
15%, trusts’ performance overall has           realistic targeting.
                                                                                              • Progress against agreed CIP/QIPP
improved, with 50% rated as green in                In contrast to sickness absence,
                                                                                                programme
FY14 compared with 30% in FY13.                significant board turnover levels rose
                                                                                              • Effective liquidity management
Trusts’ ability to pay invoices within the     in FY14 to 37% of trusts (24% FY13).
                                               We define significant board turnover as        • Levels of long-term borrowing
required timeframe is clearly related to
                                                                                                compared to prudential borrowing
any liquidity issues as we noted that 85%      three or more changes in the year. This
                                                                                                limits
of those that were rated amber or red for      can result in a number of issues including
                                               reduced scrutiny if non-executive              • Performance against Monitor’s
PSPP also had poor liquidity. However,
                                                                                                Continuation of Service Risk Rating
not all trusts that had poor liquidity also    director (NED) posts are vacant, or
                                                                                                components
had PSPP issues, demonstrating that it is      possible over-involvement by NEDs in
                                                                                              • Performance under the Better
still possible for some to better support      operational rather than strategic matters
                                                                                                Payments Practice Code
suppliers through prompt payment.              if executive positions are experiencing
                                               high levels of turnover. ‘Acting up’           A robust organisational approach and
Workforce                                                                                     focus on absence management to
                                               arrangements and the use of interims can
NHS trusts continue to face significant                                                       improve productivity, reduce costs and
                                               also impact continuity and effectiveness.
                                                                                              enhance customer service.
challenges in managing their workforce,             The FY14 temporary staff cost to
although our work found a mixed                total staff cost ratio rose slightly in non-
picture. Compared with the other areas         FTs to 11%. In FY14, this fell in FTs
assessed, there were proportionately           from 8% to 6%. However, Monitor’s
fewer red ratings in FY14.                     performance report for the six months
    One of the reasons for this is the         ending 30 September 2014 showed that
improvement in levels of sickness              spending on contract and agency staff
absence. For FY13, we reported that            was 120% above plan (£453m). We
43% of non-FTs had seen a rise in their        recognise that some of this increase is
sickness levels, whereas this year the         driven from central directives on ward
figure is 21%. For FTs, 56% saw a rise         staffing numbers.
in sickness in FY13, with only 39%                  The forward view recognises the
experiencing this rise in FY14. Absolute       critical importance of workforce in                         The absolute levels
reductions in sickness absence were a          delivering the vision of a modern and                 of sickness absence in trusts
factor in achieving an improved rating         comprehensive tax-funded NHS. There                    – at an average of 4.21% –
in some trusts. However, the absolute          is much to do.                                          remains higher than many
levels of sickness absence in trusts – at an                                                         other sectors and is an area
average of 4.21% – remains higher than                                                                for continued attention and
many other sectors and is an area for                                                                        improvement
continued attention and improvement.

8   NHS FINANCIAL RESILIENCE REVIEW 2015
Strategic financial planning

Strategic financial planning remained the second weakest performing theme in FY14. The small
deterioration in performance (more red, less green) is due largely to a poorer performance in respect
of the focus of trusts’ medium-term financial strategies.

FTs continued to out-perform NHS               Adequacy of planning assumptions                 Improvements in ratings were
trusts, in our assessment areas, and           Trust planning assumptions is now the        associated with trusts making positive
while their levels of green ratings have       weakest category across all four of our      changes to the processes for identifying
not improved there were no red ratings         theme areas. Despite an improvement          and calculating assumptions, especially
recorded this year.                            in the percentage of greens from 35%         CIP.
                                               to 43%, red ratings have also increased,
Focus of the medium-term financial                                                          Links to annual plan (Non-FTs only)
                                               from 17% to 21%. It is also a very
strategy (MTFS)                                volatile category for non-FTs, with 50%      This category considers the extent to
This category considers whether trusts         getting changed ratings – 25% getting        which the proposals set out in trusts’
are focusing on the most important             better, and 25% getting worse. FTs are       MTFS are reflected in their budget
priorities at a local and a national level.    more consistent, with 75% staying the        setting as well as in key strategic
     FY13 saw red ratings for the first        same and the majority of the remainder       documents such as the workforce,
time in this category, relating solely to      getting better. This is perhaps reflective   information and IT strategies.
non-FT acute trusts. In FY14 the number        of the historically tighter focus from           In FY14, a quarter of all non-FTs
of red ratings for trusts increased from       Monitor on the robustness of planning.       have amber ratings, from 15% in FY13,
10% to 36% and, for the first time, there          Red ratings were very closely            mainly as a result of not keeping their
are mental health trusts with red ratings.     associated with a combination of an          strategies updated to remain consistent.
All red ratings for this category are          expected deficit in FY14 and issues with     Red ratings for non-FTs remained static
associated with trusts forecasting a deficit   the proposed CIP programme for FY15,         at 15%. Lack of alignment in strategies
position at some point over the medium-        the latter also being the primary cause of   threatens effectiveness as insufficient
term.                                          amber ratings.                               consideration of any one dimension can
     The percentage of FTs rated as green          Common CIP issues resulting in a         undermine an otherwise successful plan
fell from 92% to 81%. Although a much          continuation of, or a move to, poorer        or initiative.
better performance than for non-FTs,           ratings included:
the worsening ratings for all types of         • the programme not being ready at the
trust indicate an increasingly challenging         start of the year
financial environment in which to              • having to compensate for the use of
produce robust financial strategies for the        non-recurrent CIP in the prior year
medium-term.                                   • not having any headroom in the plan
                                               • a higher required level of CIP than
                                                   the typical 4%.

                                                                                                    NHS FINANCIAL RESILIENCE REVIEW 2015   9
Review processes (Non-FTs only)
                                              Top tips – planning CIP/QIPP                     Good practice
Clearly it is important for trusts to keep
their plans properly updated, as this is      • Put in place a suitably independent            • Focus on achievement of
the only reliable way of maintaining an         team – a programme management office             corporate priorities is evident
                                                (PMO) – that has the project management          through the financial planning
understanding of the potential future
                                                expertise and the organisational influence       process. The medium-term
options in order to avoid short-term            to set up and manage the process. As             financial strategy (MTFS) focuses
decisions that may lead to problems later.      QIPP plans are more and more about
                                                                                                 resources on priorities
Although red ratings were up from 3%            service redesign, PMOs with CCG
to 9%, the proportion of green ratings          representation, or run jointly with the        • The MTFS includes the
                                                CCG, are advised                                 assumptions that would be
remains high at 76%. Red rated trusts has
                                              • Ensure the prior approval of every               expected
known problems and were forecasting
                                                constituent QIPP scheme which involves:        • CIP/QIPP are developed alongside
deficits for FY15.
                                                – detailed project identification forms          the MTFS and the annual budget.
                                                – the complete case for the scheme               There is an effective approach
Responsiveness of the plan                      – its clinical and financial impact              for developing CIP/QIPP projects
(Non-FTs only)                                  – allocation of project responsibility to an
                                                                                                 which considers how robust and
It is good practice for trusts to consider         individual with the necessary experience,
                                                                                                 realistic they are
                                                   skill and influence to see it through –
alternative options prior to finalising                                                        • The trust is managing its financial
                                                   which, depending on the scheme,
their MTFS and their budget. This can              may mean someone from the CCG                 risks, including the financial
only be done reliably in the light of           – milestones for implementation                  positions of its contractors
for example detailed risk identification           and delivery
                                                                                               • Annual financial plans follow the
and mitigation, scenario planning             • Require headroom in the programme. Ask           longer-term financial strategy
against proposed options and exploring          for more schemes to be approved than
                                                are strictly necessary to reach the target     • There is regular review of the
alternative delivery models. Some non-                                                           MTFS and the assumptions made
                                                so that there is built-in scope to deal with
FTs have improved their rating by doing         slippage. Without this approach, slippage        within it. The trust responds to
precisely these things. However more            can only be dealt with by developing extra       changing circumstances
failed to keep their plans updated or did       schemes during the year. These can only        • The MTFS includes scenario
not employ scenario planning. Therefore,        have a part-year effect and are often non-
                                                                                                 planning and benchmarking
in FY14 the proportion of trusts rated as       recurrent
                                                                                               • The MTFS is linked to, and
green in this category is down from 64%       • Ask for all schemes to be rated – at
                                                commencement and then at regular                 is consistent with, other key
to 55%.                                                                                          strategies, including workforce
                                                intervals – on their likelihood of success.
     For the first time, there was a red        This will help everyone understand where       • KPIs can be derived for future
rating in this category for a mental            the potential weak areas are and mitigation      periods from the information
health trust, related to failing to respond     strategies can be developed in advance           included within the MTFS
adequately to a deficit position.               and deployed in a timely fashion
                                              • Ensure cooperation between providers
                                                and commissioners on QIPP schemes, to
                                                ensure that provider CIP schemes are safe
                                                for patients with no reduction in quality
                                              • Providers and commissioners should work
                                                together to ensure that they take adequate
                                                account of each other’s assumptions
                                                underlying their respective CIP and OIPP
                                                schemes
10 NHS FINANCIAL RESILIENCE REVIEW 2015
Financial governance

Financial governance remained the best performing theme in FY14 and the only one with no overall
red ratings. There was a year-on-year increase in green ratings from 78% to 82%. Each individual
category within this theme has seen improvement in the number of green ratings.

Budget reporting – revenue and              Risk management
capital                                                                                  Top tips –
                                            Effective risk management cannot be
                                                                                         reporting CIP/QIPP
This category considers whether the         achieved unless boards receive clear and
budget reporting which underpins            up to date information to enable them        • Use your PMO to determine and
decision-making at board and committee      to challenge the trust’s identification,       manage the process by which
level contains appropriate information      monitoring and mitigation of risks.            individual projects are reported.
that is accurate, reliable and timely.          Reversing a trend reported for           • Improve progress reporting to:
    In FY14, this became the strongest      FY13, there has been an increase in            – reflect the position on every
financial governance category, with 92%     green ratings (74% to 87%); the highest          project not just progress against
of trusts rated as green, up from 85%.      proportion of green ratings in this theme.       the overall target
This shows that trusts are addressing       This was typically due to improved risk        – detail the issues affecting
the improvement areas identified in our     management processes. However, our               progress to data and potential
FY13 report, for example around more        wider work with the NHS and other                progress in the rest of the year
comprehensive reporting and better use      sectors highlights the importance of           – estimate the expected outturn
of service line reporting.                  looking beyond process.                          on each project.
                                                Discussions in our recent NHS
Director and NED engagement                 non-executive workshops suggest
Director and NED involvement in             that risk management still needs to be
financial governance processes is key       better focused on the key risks facing
to trusts making the right decisions.       the organisation. It is recognised that
This category considers the extent of       registers are widespread and regularly
leadership and challenge in respect of      updated, but some question over the
the budget setting and CIP approval         extent to which this is demonstrably
processes.                                  improving the management of risk on the
    Last year’s red ratings have            ground. Some audit committees bring
disappeared and the green ratings           departmental directors into meetings
have increased from 83% to 87%,             to challenge on these questions, and
driven largely by these trusts’ ability     conduct ‘deep dives’ on particular risks
to minimise board turnover (working         to improve the quality of the assurance
against the wider sector trend). When       they receive. We believe that this level
considering the ratings specifically for    of challenge will become increasingly
FTs, performance is even stronger in this   important in an increasingly complex
area, with green ratings for 94% in FY14,   and risky operating environment.
up from 85% in FY13.

                                                                                               NHS FINANCIAL RESILIENCE REVIEW 2015   11
CIP reporting
                                             Good practice
CIP reporting showed some
improvement in FY14 but remained the         • Regular reporting to NEDs and executive directors
weakest category within this theme. The      • Actions have been taken to address key risk areas
primary movement within this category        • Use of a rolling 12 month cashflow forecast
is in respect of FTs, where there are now
                                             • Directors and managers understand the financial implications of current and
no red ratings (17% in FY13). There
                                               alternative policies, programmes and activities
was a less significant deterioration in
                                             • There is engagement with stakeholders including budget consultations
respect of non-FTs, where the red ratings
increased from 4% to 6%.                     • There are comprehensive policies and procedures in place for NEDs, executive
                                               directors and budget holders, which clearly outline responsibilities
     Red and amber ratings on CIP
reporting are largely due to reporting and   • Internal and external audit recommendations are not overdue for implementation
challenge not being sufficiently robust      • Board and relevant committees regularly review performance and are subject to
to prevent slippage against savings plans.     appropriate levels of scrutiny
This sort of rating is clearly associated    • There are effective recovery plans in place (if required)
with other issues with CIP processes, as     • The board has the capacity and capability required to perform its role effectively
94% of those rated red or amber relied
on non-recurrent schemes in FY14 and
92% did not have their FY15 plans ready
by the start of the year.

12 NHS FINANCIAL RESILIENCE REVIEW 2015
Financial control

While the effectiveness of trusts’ financial control and the reliability of their systems for managing
and monitoring their financial positions remains the second strongest theme this year, performance
has fallen marginally overall.

Finance department resourcing                Board assurance framework (BAF)              discussions also indicated that board
An effective, efficient and stable finance   As a key risk management tool, the           agendas may be too rigid, not allowing
team is pivotal to maintaining strong        BAF supports trusts in understanding         for sufficient focus on discussing the
financial control in any organisation.       and mitigating against risks which may       priorities and objectives in the BAF.
This is becoming increasingly relevant to    threaten effective financial control.        Overall, on the BAF (and on risk
the NHS with ever increasing pressures            For FY13, we reported that 75% of       management) there appears to be a real
not only to reduce costs, but also to        trusts were rated green for maintaining      desire for simplification of processes
improve the quality of patient care.         effective BAFs. We also reported that        and language, to enable a focus on what
With these two potentially conflicting       many of those rated as amber were in         really matters.
objectives, it is important for finance      the process of improving their BAFs
departments to work closely with             to include more information on how
frontline services in order to develop a     gaps in control are being mitigated and        Top tips –
clear understanding of the impact any        monitored. Trusts rated green in FY14          Controlling CIP/QIPP
financial decisions could have on the        increased to 84%. The remaining 16%
quality of care being delivered.             of trusts either failed to keep their BAFs     • Introduce a dedicated CIP team,
                                                                                              usually chaired by the chief executive
    In FY14, we saw a slight downturn in     up to date and relevant or the BAFs were
                                                                                              or NED, to review progress and
green ratings by four percentage points      not fit for purpose. A number of trusts
                                                                                              ensure remedial action is identified
to 70%. However, there are still no red      still have work to do to use the BAF as a
                                                                                              and implemented when CIPs go
ratings, suggesting finance departments      live document and a process which drives         off track
are largely coping for now.                  the board agenda.
                                                                                            • Ensure a process of post-
    Lower ratings tended to relate to             Discussions in our recent NHS non-
                                                                                              implementation review of CIP
a lack of finance department capacity.       executive workshops suggest that the             schemes to learn from what has
Of particular interest is that this is one   BAF remains a document shrouded in               worked and what has not, to
of only two categories in which FTs          mystique in respect of what it means and         strengthen future CIP management
performed worse than non-FTs, with           how boards should be using it. Much of           and control.
only 63% rated as green, down from           the discussions at audit committees and
77% in FY13. Some FTs seem to have           board meetings are currently focussed
been affected by high turnover, limited      on presentational issues rather than
capacity and, in some cases, capability      using the BAF as a tool to support
                                                                                                      Finance department
issues. In these instances, independent      active management of assurance over
                                                                                                    resources is one of only
reviews of the finance function may be       key strategic risks. Our non-executive
                                                                                                    two categories in which
appropriate.
                                                                                                     FTs performed worse
                                                                                                          than non-FTs.

                                                                                                  NHS FINANCIAL RESILIENCE REVIEW 2015   13
Controlling the CIP                              Good practice
Where there is effective control over            • Budgets are robust and prepared in a timely fashion and the trust has a good
a trust’s CIP, savings plans will be               track record of operating within its budget
prepared prior to the start of the financial     • Budgets are monitored and officers are held accountable for budgetary
period and the planned savings will                performance
exceed requirements so that there is             • Financial forecasting is well-developed and forecasts are subject to regular
headroom to accommodate potential                  review, including trend analysis, benchmarking of unit costs, risk and sensitivity
slippages. The programme will be                   analysis
underpinned by robust monitoring                 • There is a robust process for the management and monitoring of CIP/QIPP and
arrangements enabling the board to                 ensuring that planned savings are being delivered
proactively manage its delivery.
                                                 • Key financial systems have received satisfactory reports from internal and
    In FY14, 11% of trusts were red                external audit
rated in this category (15% in FY13) and
                                                 • Financial systems are adequate for future needs
amber ratings have grown from 37% to
                                                 • The capacity and capability of the finance department is fit for purpose for
42%, demonstrating a continued area of
                                                   effective financial planning and financial management
challenge for some trusts.
                                                 • There is an effective internal audit which has the proper profile within the
    Issues related to trusts either not
                                                   organisation and agreed internal audit recommendations are routinely
having fully developed and agreed
                                                   implemented in a timely manner
their savings programmes by the start
                                                 • There is an assurance framework in place which is used effectively by the trust
of the financial year or not having
                                                   and is how business risks are managed and controlled
strong enough arrangements in place to
address slippage against planned targets         • The Annual Governance Statement gives a true reflection of the organisation
throughout the year.
    There is still a considerable difference
in this category between FTs, for which        appropriate degree of challenge when           did not maintain that rating and the red
there are no red ratings and 73% green         setting the budgets and throughout             ratings are all new this year. We believe
ratings, and non-FTs, with 15% rated           the year. Adapting to changing                 that some of this turbulence arises from
as red and only 38% as green. This is          circumstances, reviewing and revising          turnover at board level and in finance
likely to be a product of FTs historically     spending forecasts and taking corrective       departments.
having had to demonstrate strong               action on variances are all essential               Where a trust’s performance has
financial control arrangements as part         requirements.                                  deteriorated, it is because the trust either
of FT authorisation and subsequent                 In FY14 we saw a degree of                 failed to keep its costs under control,
monitoring.                                    polarisation in this category with             or its budgetary control processes were
                                               increases in green ratings from 63% to         inconsistently applied across the trust.
Budget setting – revenue and capital           66% and in red ratings from 5% to 11%.         Once again, there were no red ratings for
Budget management is about more than           Beneath this overall net picture, there        FTs in this category.
just setting budgets at the start of the       has also been significant movement by
year and then monitoring whether they          trusts from one rating to another. Thirty
are delivered as planned. It requires an       per cent of trusts previously rated green

14 NHS FINANCIAL RESILIENCE REVIEW 2015
Clinical commissioning groups

Having formed on 1 April 2013, CCGs faced a number of significant challenges during FY14,
including getting the relevant processes in place and embedded and to get workable first-year
contracts up and running. The level of funding for CCGs for FY14 was 2.3% above the equivalent
share of PCT funding in FY13. This was reviewed for FY15 in order to better reflect population
change and include a specific deprivation measure to address unmet need. We considered whether
CCGs were learning from their FY14 experience in planning for FY15 and beyond.

Commissioning plans                                In the future, the role of the CCGs     memory required to make effective
CCGs needed to develop their                  is likely to include some responsibility     commissioning decisions in these areas
commissioning plans from scratch for          for primary care co-commissioning            may not be readily available or affordable
FY14. The plans had to take into account      and specialised secondary healthcare         to the CCGs. Close collaboration with
the needs of the local population while       commissioning. This is likely to pose        neighbouring CCGs, with specialist teams
aligning to the existing plans of the local   further challenges for CCG management        in NHS England and with the local CSU
health economy and the local authority,       time and capacity. Some of the skills,       will be essential.
as well as other third sector parties.        historical knowledge and corporate
    NHS England’s publication ‘The
NHS belongs to the people: A call to
action’ tasked CCGs with formulating            Example questions for CCGs to challenge their commissioning plans
three-to-five year plans to help solve a        Has the CCG:
funding gap of £30 billion by 2020/21.          • provided a very clear vision of commissioning intent?
    In the context of this significant          • focussed on delivering improved outcomes for the population and reduced
challenge, for FY14 there were only a             health inequalities?
small number of CCGs (3%) rated as              • assured itself that it is commissioning the right care for patients, at the right
red in relation to their commissioning            time and provided in the right place?
plans and 80% rated as green. These             • ensured health and social care services are working closely together wherever
red ratings were related to the plans not         this is to the benefit of our patients and their carers?
containing sufficient detail, presumably        • considered commissioning care closer to home for patients?
on account of the CCGs being newly              • encouraged innovative ways of providing care, through better use of
formed organisations so, in some cases,           technology, a wider skills-base and team support for individual members
not having sufficient time or capacity to         of staff, or development of shared care-planning with patients?
develop robust plans in this first year.        • commissioned accessible, high quality, efficient patient care?
    Some CCGs had made a very clear             • secured best value for money in care from a wide range of providers?
statement of commissioning intent               • given patients a choice of providers wherever appropriate?
following consultation with patients and        • addressed the specific needs of patients with the most serious long-term
there had been strong involvement and             conditions?
engagement from board members in                • achieved a balance between prevention and treatment?
developing the commissioning plans.

                                                                                                    NHS FINANCIAL RESILIENCE REVIEW 2015   15
Financial planning and management
  Good practice                                                                            Statutory financial requirements
                                            Equally as challenging as developing the
  challenge                                                                                • To achieve revenue breakeven or
                                            CCG commissioning plans in the first
  questions for managing                                                                     better against the revenue resource
  successful QIPP programmes                year was developing the financial plans          limit
                                            that underpin them. 48% of CCGs did
                                                                                           • To achieve capital breakeven against
  • What are the clinical gains that the    not have their FY15 financial plans ready
                                                                                             the capital resource limit
    CCG is trying to deliver through        by the start of the year.
    QIPP?                                                                                  • To achieve breakeven on the cash
                                                Consequently, financial planning and
                                                                                             limit
  • What is the size of the gap between     financial management proved to be the
    budgeted QIPP and schemes                                                              • To manage within the running cost
                                            worst performing category for CCGs in
    agreed?                                                                                  allowance
                                            FY14. Only 68% of CCGs were assessed
  • Are the CCG and its governing body      as green, while red and amber ratings
    agreed on the amount of savings         made up 16% each.                                 This is the second worst performing
    required?                                   Three-quarters of the red ratings were    theme in FY14, with 75% of CCGs
  • What contingency plans are in place     associated with the extent of the financial   rated as green and 15% as red. The
    should QIPP not be delivered in full?   challenge facing some CCGs as reflected       majority of the red ratings were the result
  • How will the CCG monitor the            in their setting a deficit budget for FY15.   of CCGs having posted deficits, two-
    delivery of savings and clinical        Of those planning deficits, half also had     thirds of which were unplanned. 40%
    outcomes for each scheme and            QIPP programmes that were considered          of CCGs did not deliver in full against
    how regularly? Are these built          unreliable or unrealistic because of their    their QIPP targets, and there was heavy
    into agreements with providers                                                        dependence on non-recurrent savings.
                                            high levels of risk.
    with associated Key Performance                                                       Savings also appear in many cases to
                                                Of the amber ratings, over 80% were
    Indicators?                                                                           have been identified by top-slicing
                                            associated with unreliable or challenging
  • How robust are QIPP plans? Are                                                        budgets rather than through a carefully
                                            QIPP programmes.
    there project managers for each                                                       thought-out programme of savings.
                                                The red ratings were predominantly
    scheme and a defined project plan                                                     While this approach was inevitable
    and timeline? Are the clinicians and    associated with the extent of the financial
                                            challenge facing some CCGs as reflected       in the first year of the CCGs, more
    local partners fully engaged?
                                            in their setting a deficit budget, and the    sophisticated approaches to savings need
  • Are the CCG and its governing body
                                            amber ratings with QIPPs that were            to develop as the organisations mature.
    assured that each QIPP plan will
                                            considered unreliable or unrealistic          This is particularly important, given
    contribute to patient safety and
                                            because of their high levels of risk.         the challenges of meeting the quality
    care quality?
                                                                                          improvement aspects of QIPPs.
                                            FY14 key indicators                               As FY14 was the first year of
                                            We considered outcomes against the            operation for the CCGs, all the board
                                            statutory financial requirements that         members and lay members were new in
                                            CCGs are required to meet, namely,            post. Nevertheless, turnover of Board
                                            delivery of savings plans (QIPPs) and         members has been an issue for some
                                            workforce-related indicators including        CCGs, with 10% reporting 3 or more
                                            sickness absence and turnover at              Board changes in the year. While this is
                                            board levels.                                 less than the level experienced by NHS
                                                                                          providers, it increases the challenge of

16 NHS FINANCIAL RESILIENCE REVIEW 2015
maintaining a clear strategic vision across                         on which to base decision making.                                     This supports our findings on the
the health economy.                                                      Although 96% of CCGs were rated                              turnover of CCG board members and
    Average sickness levels across CCGs                             as green and there were no red ratings,                           also on the amount of time that GPs and
were generally low, and approximately                               there are some indications that the                               other clinicians are spending attending
half the level being experienced by                                 capacity of CCGs is becoming stretched                            CCG board and committee meetings,
NHS providers.                                                      by the agenda CCGs are managing.                                  and the challenge for these clinicians
                                                                    CCGs are investigating options to                                 of balancing their time between direct
Leadership                                                          address this capacity including using                             patient contact time and their duties as
Since the NHS structural reforms in                                 the legislative reform order to create                            CCG board members.
2013, the responsibility for the strategic                          ‘mergers’ or ‘joint committees’.                                      Some CCGs have also taken steps to
leadership across health economies has                                   For example, NHS Gateshead CCG,                              enhance the specialist financial expertise
become fragmented. The roles previously                             NHS Newcastle North and East CCG                                  at board level by appointing an additional
carried out by PCTs and SHAs have                                   and NHS Newcastle West CCG will                                   lay member or associate lay member with
been split out across the new CCGs,                                 become a single statutory body from 1                             a background in finance or accountancy.
local authorities and different parts of                            April 2015. In other areas, CCGs are                              This has helped relieve some of the
NHS England – for example primary                                   exploring closer working short of a                               workload of the existing board members.
healthcare commissioning, specialised                               formal merger.
healthcare commissioning, dental services                                Some CCGs have concerns that                                 External relationships and the
and some public health services. Many                               management capacity is too stretched                              Better Care Fund
other public health responsibilities                                to deliver important strategic change                             Since FY14 CCGs have been working
transferred to local authorities who also                           programmes. The capacity of some audit                            closely with their local authorities and
maintain their responsibility for social                            committees to effectively fulfil their                            provider trusts to develop joint plans to
care services.                                                      governance role has also been questioned                          address the requirements of the Better
     Some funding to NHS providers is                               by some CCGs. In other areas we have                              Care Fund, with the aim of reducing
also now channelled to provider trusts                              noticed issues around the capacity                                hospital admissions. The strength of the
from the TDA.                                                       in finance teams, with difficulties in                            relationships which CCGs have with
    Occasionally tensions can surface                               permanently filling senior posts.                                 their stakeholders plays an important
within this structure, particularly where                                                                                             part in their ability to develop and agree
there are differences in opinion as to how                          Recent research from the                                          the plans, particularly given the key role
to work together to ensure the overall                              King’s Fund                                                       played by the local health and wellbeing
health system holds together. The role                              A recent King’s Fund report1 highlighted                          board (HWB) in overseeing and
of the CCG in providing local clinical                              a range of challenges in respect of the                           approving the Better Care Fund plans.
leadership is essential.                                            clinical leadership provided by the GPs                               We rated 93% of CCGs as green
    All CCGs should now have an                                     on CCG boards. This was particularly                              for the effectiveness of the external
effective governing body in place that                              evident in terms of recruitment                                   relationships, although there was also
provides strategic direction, has a BAF                             and retention, GP engagement and                                  evidence from CCGs that some of these
which addresses the risk for its strategic                          influencing the wider GP community.                               relationships were becoming strained,
priorities and objectives and receives                                                                                                as a result of the financial pressures in the
good quality performance information                                                                                                  health economies.

1
    http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/risk-or-reward-the-changing-role-of-CCGs-in-general-practice.pdf

                                                                                                                                               NHS FINANCIAL RESILIENCE REVIEW 2015   17
Key Actions

  The health and wellbeing boards              The health and wellbeing boards                    Fully
  need to:                                     and those organisations involved                 approved

                                                                                                 6
                                               in planning and delivering the
                                               Better Care Fund outcomes

                                                                                                4%
                                               should:

  •   understand their role and                •   understand the strength of
      responsibilities to enable them to           relationship with partners, the impact
      be focused and effective and have            that various cultural differences can
      clear direction and purpose                  have and the benefits to be gained
                                                   from improving these relationships
  •   establish who is responsible for
      managing risk and performance            •   consider how they can work more
                                                                                                Approved
      managing the Better Care Fund                effectively together, including NHS
                                                                                               with support
      outcomes                                     providers, primary care, the third
  •   ensure that NHS providers are fully
      engaged and aware of the planned
                                                   sector and other health and social
                                                   care providers.                             91
      changes if the plans are to achieve
      their agreed objectives.                                                                60%
    There are also significant variations in   findings strongly support the widespread
the profiles of the health and wellbeing       view in the sector that the plans, while
                                                                                                 Approved
boards within each local authority.            containing suitable outcomes over their
                                                                                              with conditions
In some areas, we observed that the            time scale, lack operational detail and
meetings were relatively infrequent,
with mixed levels of commitment and
                                               robust implementation arrangements,
                                               including key milestones and targets,
                                                                                               49
attendance from its membership. Our
recent report ‘Pulling together the Better
                                               which would make the visions realistic
                                               and achievable: 45% of the amber ratings       33%
Care Fund’ highlighted the large variety       related to this point. A further 27% of
in the composition of the local health and     amber ratings related to plans being late,
wellbeing boards and the extent to which       and in one case to the plan not being
the arrangements had been established to       approved in the first place.
                                                                                                  Not
support effective collaboration across the         Given the ratings from our own
                                                                                                approved
health economy.                                research, it was perhaps not surprising that
    On CCG approaches to the Better
Care Fund, our research showed a large
                                               the approval process from NHS England
                                               in October 2014 also raised concerns              5
number of amber ratings, indicating
that there is still much to be done. Our
                                               when it approved the 151 plans submitted
                                               by the health and wellbeing boards:              3%
18 NHS FINANCIAL RESILIENCE REVIEW 2015
You can also read