Short of a surprise Treasury health spending spree in this week’s Autumn Statement, the NHS currently faces a £2.4 billion hole in its budget by the end of the financial year in March. This is equivalent to 1.4% of its budget at a time when ministers have been keen to see NHS spending fall, rather than rise, in real terms.
That hole is the result of a rate of spending in the first half of the financial year that threatens to overspend the health service’s resource budget (for everyday items such as staff pay and clinical supplies) by as much as £3 billion. This has been somewhat offset by around £450 million added from the Treasury earlier this month to the budget for the year for NHS England – at times referred to by the Treasury as representing spending for the “front-line NHS”, with a further £150 million found from within NHS’s central budgets.
However, most of that additional funding will come from the Department of Health and Social Care’s relatively small budget intended to cover spending such as on public health and NHS equipment, buildings and technology spending, which means that what little extra relief it might offer the NHS in the short term may well be paid for through greater pains and pressure in the longer term.
Back to the short term, the NHS’s mounting financial pressures left NHS England this month with the unenviable task of communicating an urgent need for NHS organisations to scale back the rate of spending they have been showing in the first seven months of the year, in a somewhat desperate hope to turn the NHS ship around and end the year on 31 March 2024 in financial balance.
Thanks to funding from the Nuffield Foundation, the Nuffield Trust will be tracking the NHS’s financial health over the next 12 months and putting it into context with recent spending and funding trends, as we lead up to the next general election where funding for health and social care so far promises to be the elephant in the room.
As the first instalment of our tracker shows, in terms of NHS England’s hope for financial balance this financial year, there is a long way to go.
Tracking the numbers
In-year reporting at NHS England board level suggests a rate of spending by mid year (end of October) which would entail full year spending of around £4.2 billion above the level of funding. That rate of spending includes the direct cost of strikes between April and October in the medical workforce, which have increased pay costs as striking doctors have been replaced by temporary staff, and cancelled clinics and theatre sessions have been partially made up for by staff working overtime shifts – often at premium pay rates. This is the point our deficit tracker starts, with a key consideration being the extent to which that £4.2 billion can be mitigated.
£720 million of the current projected overspend has been evident since the start of the year, as it’s been the gap between local NHS system spending plans and their original allocations. NHS England has stated that this original local “planning gap” is one of the first calls on its £5 billion “Transformation and Reserves” budget line, as it has effectively had to hold money back from intended investment in new services and initiatives – such those aimed at reducing health inequalities and expanding capacity in GP primary care – to offset spending-above-plan on existing services.
NHS England is no stranger to the need to hold back investment or “transformation” funds to offset overspend on business-as-usual services, so it would be reasonable to assume it tucked a little more down the back of the metaphorical sofa than the stated £720 million – not least because initial system spending plans suggested an end-of-year deficit approximately twice the level we currently project. Our tracker thus assumes that the original £720 million deficit offset in the reserve was rounded up to around £1 billion, and then supplemented by a further £200 million in September when the government announced additional “winter funding”. That was genuine new money from the Treasury, but was not allocated out to NHS organisations as it represented a fraction of the rate of overspending that had already occurred by that point.
That reserve offset brings the £4.2 billion threatened overspend down to the £3 billion mark, where it stood before the Treasury’s agreement to increase the NHS England budget by around £450 million, with a further £150 million being provided from NHS England’s central budget for administrative costs.
But it is from the resulting £2.4 billion overspend – after that budget boost and central saving has been banked – that things get tricky.
NHS England has estimated that medical workforce strikes between April and July are responsible for around £550 million in additional costs during those months. Those estimates suggest that something in the region of £700 million could be saved between November and March compared to the rate of spending seen between April and October. Those savings could be in the form of reduced overtime and temporary staff pay spending, but also in the form of cost efficiencies which have been near-impossible to achieve when management time has been consumed with both the logistics and workplace politics of rolling industrial action.
This could bring this year’s overspend down to around £1.7 billion. However, there are huge question marks over the likelihood of improved industrial relations being achieved in the next few weeks, and perhaps even more doubts over whether any improvement can be achieved without a countervailing hefty increase in the medical pay bill. (Although it will be NHS England’s hope that any agreement to increase medical staff pay will be fully funded by Treasury and so, in effect, at worst is cost neutral to the deficit position for this year at least.)
Further uncertainty hinges on the extent to which the NHS can achieve such a level of cost savings over the winter months, when it can expect not only higher volumes of patients requiring urgent and emergency care but also possibly higher levels of staff sickness, which may well undermine many of the potential savings gained through an end to the strikes.
That uncertainty provides some of the context behind NHS England’s letter to boards in early November, which signalled an abrupt scaling back of ambitions to further increase elective (planned) activity. Before November, NHS organisations had been chasing a target to increase elective activity to at least 105% of the level seen in 2019 (measured in terms of the financial value of that activity). To do this, NHS organisations have incurred substantial costs in staff overtime, through running clinics and theatres at weekends, for example, and outsourcing procedures to private health care providers.
This has been relatively good news for patients, as it means more patients have been seen and treated than would otherwise be the case. But it has been bad for the financial bottom line. By reducing the activity target to just 103% of 2019 levels, NHS England has effectively moved the goalposts significantly closer to where the NHS is already, in the hope it can reach the revised goal by the end of the year, but with a much lower rate of extra spending seen in the first six months.
Our tracker currently estimates the potential saving here at around £360 million, but this is a figure that will need to be watched and updated in the coming months as NHS organisations replan their priorities at the same time as dealing with winter pressures.
These last two significant potential cost mitigations set out in our tracker total in the region of £1 billion, and would bring the projected deficit for the year down to the region of £1.3 billion – still a formidable challenge and which would be close to the cost of the NHS pay bill for an entire week.
Difficult decisions ahead
NHS plans to mitigate this last tranche of overspending will be set out over the next few weeks, as both NHS England and local NHS systems rapidly revise their original plans for investing in service quality and improvements this year. Much of that investment would have made use of the NHS England Service Development Fund, which it described in its October board report as “fully committed”. Releasing in the region of £1.3 billion from that fund to offset overspending will involve postponing or fully reneging on those commitments – difficult decisions which are being made across the NHS this week and next, and which will be reflected in subsequent updates to our tracker.
Although the threatened NHS deficit this financial year may be very significant, it is not unique. The health service has squeezed against its budget again and again. As a result, governments have often felt they need to increase the budget to take in the overspending – jettisoning successive plans to control it.
To explore this further we have constructed a time series of spending for the NHS in England going back a full decade. This shows how actual NHS spending compared to the two multi-year plans set out for it, one at the 2015 Spending Review and one in 2018 around the NHS Long Term Plan.
NHS spending almost immediately began to rise faster than was anticipated in the 2015 funding settlement, which was set out with some fanfare in a Spending Review accompanying the NHS Five Year Forward View.
In 2018, the new governments of Theresa May and then Boris Johnson announced and legislated for a new set of spending increases, accepting higher and faster spending growth. These funded a new “Long Term Plan” published by NHS England. But as the Covid-19 pandemic hit, the promised real-terms increases out to 2023/24 were overtaken again by the government agreeing, as costs and demands rose, to increase the budget even further.
An accompanying article explores how these repeated spending increases pushed above what governments planned and expected. The current government has now asked the NHS to “converge” back to the original Long Term Plan trajectory. Our article looks at how the NHS is responding to this ambition in the context of an ongoing deficit and makes some tentative projections about the current spending trend.
The planned spending levels are shown in the charts that follow in real terms, adjusted for increases in cost over the last decade.
The first chart shows the government’s preferred measure of inflation in the domestic economy, the GDP deflator, against which government spending commitments are set. The second provides the same analysis but uses a measure of inflation in the particular set of goods and services that the NHS must pay for – often reflecting settlements on staff pay and medicines.
These two measures diverged quite significantly at points over the course of the pandemic, for reasons explored in more depth in our article.
*The Nuffield Foundation is an independent charitable trust with a mission to advance social well-being. It funds research that informs social policy, primarily in Education, Welfare, and Justice. The Nuffield Foundation is the founder and co-funder of the Nuffield Council on Bioethics, the Ada Lovelace Institute and the Nuffield Family Justice Observatory. The Foundation has funded this project, but the views expressed are those of the authors and not necessarily the Foundation. www.nuffieldfoundation.org; @NuffieldFound