Health on the Line

Adam Brimelow

Hello and welcome to Health on the Line. This is the podcast for policymakers and NHS leaders. It's produced by HealthcomsPlus and brought to you by the NHS Alliance, the independent membership body that represents and supports the health and care system across England, Wales and Northern Ireland. 

I'm Adam Brimelow and I'm delighted to be taking over in a podcast presenter's chair from Matthew Taylor, who's moved on to pastures new, and we wish him all the very best. 

I'm going to begin with a very quick reminder about a big event coming up soon. Do book your place at NHS Confed Expo, which takes place from the 10th to 11th of June in Manchester. You shouldn't miss out on what is an amazing breadth of content, incredible networking opportunities and, of course, the chance to speak to and hear from national leaders. So book now at NHSConfedExpo.org as places are going fast. 

Right. Let's focus now on the concerns, the challenges and also the opportunities faced by NHS leaders as we head further into the financial year 2026 to ‘27. 

How are they handling the pressures? What are they doing to stay on plan and at what cost? And what's the way forward to make things better for patients and staff in difficult times? We'll hear some frontline perspectives from an acute and community trust chief executive, Fuluke Ajai. 

But first, let's get a detailed overview of how financial pressures in the health service are making their mark. The NHS Alliance has been testing the temperature with members and has produced a report which draws on surveys, interviews and ongoing feedback from leaders to build a picture of what's being achieved, what's getting in the way of further progress and the risks of losing hard-won gains.

The report's called Targets and Trade-offs: the Cost of NHS Finance and Performance Ambitions in 2026/27. And here to talk about it, I'm joined by the NHS Alliance’s deputy director of policy, David Williams. 

David, welcome. What does this report tell us about the state and impact of NHS finances?

David Williams

I think it tells us that the financial situation in the NHS this year and reviewing looking back to last year is really tough. This report gives us a sense of the scale of the challenges that the frontline trust, ICB and GP leaders have been facing and will continue to face.

Adam Brimelow

So, David, a really tough picture there. It's in a context, though, where we've seen some significant progress on several fronts, haven't we, in terms of performance, finances, productivity, and all that achieved in the face of growing demand and, of course, industrial action. So there is a positive side to this as well.

David Williams

That's right. So if you cast your mind back to the beginning of ‘25/26, the service had a huge gap of about 7 billion between the resource that was being given and what it was initially planning to spend. Essentially plans had to be redone as a result of that last year. And that resulted in the NHS being handed the biggest financial savings challenge on record. It had to save about £11 billion last year.

And what the survey shows us is that, by and large, huge progress has been made on the finances. So roughly two thirds of people who responded to our survey were confident that they were going to hit their financial plans, which given where they were starting, is a really incredible achievement. And that's in the context of record activity levels across much of the service and some progress being made on some of the key waiting time indicators. And the beginning of a positive turnaround, in terms of public satisfaction with the NHS. 

So one of the stories of 25/26 is that the NHS collectively was set an enormous challenge to deliver, improve delivery and increase the rate of improvement and to control the money, and collectively responded to that. But the survey also tells us that the challenge for 26/27, in terms of the amount of money that needs to be saved, is the same or bigger next year. That's what members are telling us.

Adam Brimelow

So that's a huge challenge going forward. And what sort of steps are leaders considering as they see to square this circle in meeting their financial plans?

David Williams

The biggest one is they are looking to cut or redesign services. So we're expecting more of that in the year ahead than last year. So last year, only about a third said that they needed to cut the services to balance the books. And this year it's more like two thirds of ICBs and trusts. And the numbers are a bit lower for primary care, but it's a similar trend. 

So, more cuts and closures in the year ahead than last year. Also, a much bigger likelihood of services being redesigned, if not closed.

Adam Brimelow

So cuts to services, redesign, and that really translates, doesn't it, into a potential impact on care. What sort of changes could we potentially be talking about?

David Williams

So first thing to say is that trusts are really, really conscious of the importance of quality of care, the experience and the outcomes and the safety of services when you get treated. That is an absolute top priority and not one that trust or ICB or GP leaders are willing to compromise on. 

What they're telling us is that to hit the numbers in terms of the budget, they're going to need to look at services that aren't sustainable, for example, ones that are below the scale needed to be able to be run according to the budget or that are configured inefficiently, for example, across multiple sites. And they're going to need to change that. 

In terms of what people out there in their communities will notice, that might involve consolidating smaller units into larger ones or closing down services that don't generate enough income through the NHS payment system to cover their costs and that is just the consequence of living within their means. 

In terms of the things that our members are telling us that they're worried about this year, I think three things that are really worth focusing on: 

One is the patient experience. So more than six in ten of people in the trust and ICB sectors and three quarters of GPs are worried about patient experience in 26/27. 

And the final thing to think about is operational performance. And by that, we mean the amount of time typically that people have to wait to be seen or treated. 

So there was a lot of progress last year on performance against some of the key national targets for how long you have to wait. But order of four out of five trust and ICB respondents are concerned about both planned care and emergency care in the year ahead. And similarly, almost all GP respondents are worried about operational performance. Can you see people when they need to be seen? 

And then the final point I'd just like to pick out is the impact on staff morale. So one of the interesting things that the survey has told us is that in 25/26, one of the biggest impacts of the savings that people needed to make was that it had a bad effect on the morale of staff and you can completely understand why that is. They're expecting to make further cuts in 26/27, so we're likely to see more of that. But the problem is, apart from staff morale and burnout, which is there in the NHS staff survey, this is picked up in other sources too. Apart from that being a problem in its own right and disengaged, burnt out, depressed workforce is going to find it really difficult to go the extra mile to make further changes and further savings in the year ahead. So there's potentially a bit of a vicious cycle emerging of staff disengagement, cuts, making it harder to make further cuts, making people more disengaged.

Adam Brimelow

So David, real concerns there, as you say, for patients and for staff, but there's something more fundamental at play here, isn't there, in terms of the more strategic goals of the 10 Year Health Plan? How great is the risk that they could be derailed or at least put on pause?

David Williams

Yeah, the 10 Year Health Plan is a huge document trying to do multiple things over a really long period, right? But the three core principles that are going to be well known to people who are tuning in to this podcast, are those three shifts about moving from a hospital-based model of care to a community-based one, a treatment-based model of care to prevention, and from an analog service to a digitally-enabled one. And what we hear on those points is an interestingly mixed picture. So people say that because they had to focus on key operational targets and keeping the money contained last year, that some of the stuff that they would want to do, particularly around the shift to prevention, had to take a bit of a backseat last year. And I think people really want to get on with that transformation agenda, but they were given a set of priorities last year that they had to meet. And also, that the shift from analog to digital, the cuts they had to make actually helped accelerate that shift. So I think that's probably a result of people looking for things that are going to improve productivity, and the shift to digital is seen as a great enabler of that.

Adam Brimelow

So a slightly mixed picture there in terms of progress on the ten-year plan. Is there a clear message for national politicians from the centre in terms of the type of support that NHS leaders need to overcome the challenges you've been describing? 

David Williams

So, NHS leaders totally understand and recognise the importance and the scale of the challenge that they're facing. And they want to do their bit to make sure that the NHS continues to deliver, improves overall and also lives within its means. 

In order to do that, to play their part, they need political backing to make difficult decisions. So particularly, when it comes to reconfiguring local services. Normally we find that when people need to make changes, even where that improves the quality of care, improves the model of care, there is often public opposition. And when that happens, what local leaders need to do, they're willing to take those decisions, but they need political backing to do it, first thing. 

Second thing they need is that there are likely to be some unforeseen costs in 26/27, which weren't built into the budget when the budget was set last summer. For example, there are industrial disputes with sections of the workforce still going on. And we know that where industrial action is taken, that there are cost implications for that. And then there are also potentially inflationary pressures as well, which we're likely to see play out in the wider economy, but will impact the NHS just as much as everywhere else and that inflationary pressure might be beyond what was budgeted for. So where those pressures do come through, we need to make sure that there is appropriate support to mitigate those specific additional pressures. 

And then finally, they just want clarity and consistency from the government and national leaders on what they need to be prioritising this year. So what we don't want is a set of competing agendas. Or to be told by one section of the national leadership that you need to do this and then another section that actually know you need to be doing this. We need clarity and consistency and then they can get on and deliver. 

Adam Brimelow

David, thank you. A really rich picture there of the challenges that NHS leaders are facing and also what they need in terms of support from the centre. David Williams, thank you very much indeed. 

So let's get more of a flavour of how this is playing out in practice. Of course, there will be different perspectives in different types of organisations and this report is useful in teasing out commentary from a range of leaders, acute, mental health, community, ambulance trust leaders, and also from ICBs and GP leaders, as we were hearing from David. 

But we're going to turn now to Falouke Ajayi, chief executive at Airedale NHS Foundation Trust, which provides hospital and community services for a population of over 200,000 people across Yorkshire and Lancashire. 

Falouke, welcome to Health on the Line.

We know money's been really tight. How conscious are you of financial constraints in day-to-day decision making?

‘Foluke Ajayi

Hi Adam. Good to be here.

Yes, I think money has been very tight and day to day it is at the forefront of everybody's minds. Certainly in our organisation, we are very focused on making sure that we get the best out of the pound that we have. And so the decisions we make on a daily basis really is framed around the financial constraints and making sure that we get value in the way that we're working.

Adam Brimelow

So I suppose that's in some ways something you would bring to your job day after day, year after year. But is there something different now to previous years that you're up against?

‘Foluke Ajayi

I think that it's an environment in which the financial constraints have been ramping up over the last few years and I think every year has felt tighter and tighter. And therefore, last year was tough. The expectation is that they say it will be even tougher, and so continuing to reinforce the message to our colleagues, to the decisions that we're making, makes it really real.

The fact that we are maintaining a focus on our vacancy management and recruitment approaches alongside very tight control around discretionary spend and asking our colleagues to think twice before they spend any penny that they do and looking for alternative ways with every decision that we're making, I think reinforces the environment in which we're in.

Adam Brimelow

So you alluded there to some of the staffing decisions that you're having to make. Presumably that plays out in terms of the services you're able to provide as well?

‘Foluke Ajayi

I think we are thinking much more creatively is what I would say in our approach for service delivery and considering whether there are alternative ways for us to provide those services in a way that we minimise the impact on patient experience and that we certainly are very clear that quality remains at the top of the agenda for us. 

And so yes, we are having to think about the way we provide services. But also our experience is showing that commissioners are also thinking about that and therefore actually the way we work with commissioners in terms of what the service offer is, is changing. 

And that also includes how we're working with our partners across the system because this issue is not limited just to the NHS. Our partners in terms of local authority partners are also feeling the pinch and therefore we are being forced to think about, so collectively how are we going to do this differently?

Adam Brimelow

So in the face of these sorts of pressures, how do you safeguard quality? Is quality at risk because there's so much coming at you in terms of those pressures you have to contend with?

‘Foluke Ajayi

So I think if you think about the three elements of quality, then there are times when quality is at risk, particularly in terms of the patient experience element. Safety remains at the top of the list, if you like, as a priority. But patient experience is compromised because you are having to make some decisions around where can we have some compromise? Is it about the patient waiting slightly longer? Is it about where longer in terms of waiting list management? You don't want to do that all of the time. Delays in terms of when they might be seen on an urgent care pathway. 

Those sorts of things can affect the patient experience. But what we're very clear about is that we don't want to affect the safety of delivery, but we want to maintain quality as high as is possible.

Adam Brimelow

And when you're looking at these decisions, is it always a case of trying to find incremental gains here and there as and when, or are you being compelled to look at some bigger decisions around service design and letting go of some services because they're simply no longer viable?

‘Foluke Ajayi

It definitely is a combination of the two. Incremental improvements has its place and is valuable, but actually transformation in the long run is what's going to deliver the sort of efficiencies that we're talking about and really help us get a handle in terms of managing both the patient caseload that we have, but also delivering on the money in the way that we want to. 

And so that forces you to think in terms of are there collaborative approaches you can do with your partners, both in terms of looking at the patient pathway? Where can we collaborate and make a longer-term sustainable decision around how we're offering services? As well as actually what are the things we need to change within our organisations? And so you're having to balance both and the tension about what do we do today, but lean into what we need to plan for for the longer term. And so those are some of the issues that we need to balance.

And I think the other thing is about the impact on our teams. It means that our teams can sometimes feel that they're spread very thin because you're asking them to look at the hear and now as well as work with what the longer term can look like.

Adam Brimelow

So clearly you're being forced to think out of the box and look at things in different ways and collaborate in new ways. I mean, in some ways that sounds like a positive. Are there some positives that flow from these types of financial pressures in terms of forcing you to look at things differently?

‘Foluke Ajayi

Definitely, there are some positives. I think it forces you first of all to think about your benchmarking and where do you sit against the benchmark. And anything that improves the quality of service that you offer is a good thing. Anything that forces you to look at opportunities for improvement and transformation is a good thing. So that in itself, it's a good thing because it helps us to learn from each other and apply the learning. 

I think the other bit is about having much more joined-up services. And when you look at it from a patient perspective, joined-up services that means that I can get from A to B to C to D in a much more seamless way is also a positive, and so we have better links. And when we do things once rather than repetition, that is a good thing as well. And so there are some positives and I think it's about making sure that we stay focused on those positives rather than what can sometimes be a spiral downwards because of everything is too much. Actually, there are opportunities here that we need to really lean into and sweat the opportunities from.

Adam Brimelow

One of the things that came through in the survey was a sense that these immediate sort of front-of-mind pressures, the finances, relentless demand, having to deal with things like strikes as well, it's forcing people to focus on the here and now at the expense, potentially, of those big strategic shifts that were central to the 10 Year Health Plan.

Is that something you can relate to? Are you finding you're able to make headway on those strategic goals? Or are you being slightly pushed to the margins?

‘Foluke Ajayi

I can see why the survey might say that and I can understand why because, for example, the focus on delivering the money today for your organisation, delivering the waiting list ambition for your organisation, in a way diverts your attention from the opportunity you could do in collaboration with your partners. 

If we think about our approach in the probably 2020 onwards until about 2023/24, there was a lot of work on mutual aid. How do we help each other and really look at how we bring down waiting lists across systems, not just in individual organisations? I think where we are now, actually there will be a tendency to say, I just need to focus on making sure that my organisation can manage its waiting lists much more effectively. And therefore there is a risk that the approach to mutual aid takes second place. 

So I think the leadership challenge is how do we do both? Because we need to do both for the longer term. But it can mean that occasionally the focus will shift from the longer term to the here and now because you need to balance what's important to your organisation at a point in time.

Adam Brimelow

Yeah, obviously really important that area about mutual aid, but also in terms of thinking about things like the shift from analog to digital, hospital to community, treatment to prevention. Do you have any concerns for those goals being sort of eclipsed by dealing with immediate pressures?

‘Foluke Ajayi

I think particularly in the context of the shift in terms of hospital to community or really embracing the prevention agenda, I think the risk is much more about we can't spend the money twice. And so our ability to think about what do I stop doing, for example, in a hospital setting and having the confidence that there is capacity and capability to immediately shift it to the community setting is causing barriers for us. Because, you know, unless you get a significant change in the demands on the hospital, it's very difficult to see how you can immediately remove the resources from the hospital and put it in community when actually that is something that is developing. 

So we have to continue to be creative in our approach to doing that. And I think that that shift, in particular, is something that we have to work harder at to try and achieve some of those objectives in the timeframes that perhaps were initially thought. I think that's harder to do. It's not that it's not possible, but I think the financial constraints make it really difficult.

Adam Brimelow

Yeah. Now, ‘Foluke you're in the process of planning a new hospital at your trust, aren't you? Yes. That's because you've got very high levels of reinforced auto-claregarating concrete, the RAAQ problem, which has been obviously really prioritised in terms of renewing the NHS estate. What difference will that make as you go through with those plans in the immediate future and then when you've actually got that shiny, new hospital?

 ‘Foluke Ajayi

I think the difference in the current context is that it's an additional programme of work that requires our focus. So I talked earlier about the stretch that our teams are feeling and notwithstanding that we do have a dedicated programme team working on the new hospital, there is still an ask on our teams to help us develop what that approach will be in the longer term. So there is that capacity challenge that we experience in relation to that.

I think the other bit is about the work that we do today and the inconvenience, I think that's what people don't see, particularly in the context of Airedale, where building on the same site. And so the operational impact of building where you're working, it cannot be underestimated. And because of that, there are some consequences in the medium term around revenue consequences and how do we spend our money to mitigate some of those inconvenient issues.

When I say short term, it's short to medium term because I think over the next three, four years, we will live with significant inconvenience. But I think the longer term, there is hope because one of the things we are really keen to do is to build into the approach for the new hospital the vision for the longer term as the ten-year plan indicates. 

How do we build a hospital that's smarter technologically, that really provides us with the advances that we anticipate we will have? How do we collaborate with our immediate partners to look at the service offer and really think about what do we do once either in our hospital or in a neighbouring hospital and what things do we do in collaboration? And really think about the shift into community and into closer to home and therefore what are the services that we will retain in a hospital setting? 

And so it does provide us with the opportunity to deliver the vision of the ten-year plan. But the challenge is getting from here to there over the next period is what we have to continue to focus on on a day-to-day basis.

Adam Brimelow

Yeah, I can see that comes with some downsides, but obviously for the longer term, some really big plus sides for you. 

Fallukia, I'm going put you on the spot here a little bit, if you could offer one piece of practical advice to colleagues wrestling with the same sorts of problems that you've been describing, which have been highlighted in our survey report, what would be that one piece of cut-through advice?

‘Foluke Ajayi

That's very hard. A cut-through piece of advice. I think it's about how do we continue the conversation. It's very easy to put heads down and just think about my organisation where I am today. But I think continue the conversation with partners, with colleagues across the country to really harness the best ideas to help us push forward in terms of what we're here to do will give us hope and opportunity to achieve what we're trying to achieve.

Adam Brimelow

Brilliant, Faluke Ereje. Thank you and very best of luck to you and all your colleagues for the coming year. 

So I think that gives a real insight into the mindset of many leaders striving to maintain, improve and transform care in the face of multiple moving parts. And in that context, what's been achieved is remarkable, but it's equally clear that the hard-won gains of recent months may be at risk as financial pressures take their toll. 

So we'll be following progress closely on Health on the Line, offering NHS leaders perspectives as they navigate the difficult months ahead. 

Now, if you found this podcast useful or interesting, please do share it with colleagues across the NHS. Also, if you have an exciting or innovative programme of work that you would like to tell us about, please do, as we might cover it on a future episode. Just email us at healthcomsplus@thenhsalliance.org. 

Until next time, goodbye.