MIAA is a member of the Internal Audit Network (TIAN) which produces this monthly Insight report highlighting key publications covering NHS and social care.

Introduction

The Internal Audit Network (TIAN) comprises the 10 NHS internal audit consortiums and in house teams operating in England. These organisations collaborate across a number of areas to leverage their collective knowledge and expertise and drive efficiency and effectiveness. The monthly Insight Report is produced by CW Audit on behalf of TIAN and is shared across TIAN members and their clients.

NHS financial temperature check (HFMA briefing)

At the end of October 2022, the HFMA surveyed finance directors in England to understand the realities of the financial pressures that NHS bodies are facing. The responses to the survey were submitted before the funding announcements made in the Autumn Statement. The key messages are:

• Almost all finance directors who responded to the survey rate the financial challenge in 2023/24 between eight and 10, on a scale where one is achievable and 10 is impossible.
• The ratings for the current financial year are lower – more finance directors expect to meet their own organisational plan in year. However, they are less certain that system wide plans will be achieved.
• Organisations are taking action as a result of these concerns. When asked what national bodies could do to help, the key messages were to be transparent about available funding and realistic about what can be achieved with that funding.
• There is still concern about achieving various targets in 2022/23
• some organisations rate more than half of their efficiency plans as high risk
• All except one respondent did not expect to achieve the elective recovery target.
• Actions taken to meet efficiency targets are varied but the overall theme of responses was the reintroduction of pre-pandemic financial governance arrangements and additional grip and control.
• Finance directors are concerned that longer term measures in relation to prevention, population health and health inequalities will be delayed as resources are spent on more immediate concerns.
• Almost half of finance directors were concerned that quality will be impacted by financial constraints. This is already being seen in longer waiting times and restricted access to services.
• Capital programmes remain a concern, particular issues raised include the lack of clarity as to when permission to spend capital money will be received and the possibility of the release of capital funds in early 2023 that will have to be spent by the end of the financial year.
• Working on a system wide basis to resolve issues was mentioned by respondents, but they are also aware that there needs to be a cultural shift to working on this basis and there is still silo working in some places.

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HFMA Briefing – Streamlining charitable funds

Fund accounting is a key feature of charity accounting. The number of funds that each charity manages will be based on restrictions imposed by donors as well as trustee(s) decisions. Many NHS charities hold lots of small funds and some have undertaken a one-off exercise to review and rationalise or streamline their funds in order to achieve better value from the use of charitable donations. It is good practice to review the number and purpose of funds periodically. This briefing sets out what fund accounting is and what it means. It then discusses best practice in managing and reviewing funds, including the importance of communication. The briefing looks at the actions that need to be taken to start the process.
It concludes by considering the accounting implications of streamlining funds.

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NHSE publishes guidance on developing the joint forward plan and NHS priorities and operational planning guidance

This guidance supports integrated care boards (ICBs) and their partner NHS trusts and foundation trusts (referred to collectively in this guidance as partner trusts) to develop their first 5-year joint forward plans (JFPs) with system partners. The National Health Service Act 2006 (as amended by the Health and Care Act 2022) requires ICBs and their partner trusts1 to prepare their JFP before the start of each financial year.

This guidance sets out a flexible framework for JFPs to build on existing system and place strategies and plans, in line with the principle of subsidiarity. It also states specific statutory requirements that plans must meet. It should be read alongside guidance on NHS priorities and operational planning (which can be found here).

The JFP guidance can be found here. NHSE will also make specific JFP supporting resources available for guidance too.

For NHS bodies to implement before the end of the financial year

NHS Providers’ briefing on NHSE 2023/24 priorities and operational planning guidance

On Friday 23 December, NHS England (NHSE) published 2023/24 priorities and operational planning guidance. The guidance sets out three key tasks for the next financial year, the most immediate being to recover core services and improve productivity. As recovery continues, systems should renew focus on delivering the key ambitions set out in the NHS long term plan, and transforming the NHS for the future. This briefing highlights the key points from the guidance documents and includes NHS Providers’ view of the priorities for 2023/24.

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Hewitt review: call for evidence from DHSC

The latest instalment from Nuffield Trust’s project monitoring the effects of the UK’s exit from the EU on our health care system finds the clearest evidence yet that Brexit and its changing relationships with neighbouring countries are exacerbating the severe challenges facing health and social care in the UK today in terms of staffing, accessing essential medicines, and the overall economic picture.

Key points from the report:

• Across medicine, nursing and social care, there has been a decline in EU recruitment and registration since the EU referendum in 2016. This trend risks compounding widespread problems associated with the lack of workforce planning, unappealing conditions, and a need for a growing number of staff.
• For the total number of doctors and nurses, a rapid increase in recruitment from the rest of the world has compensated for the slowdown in EU workers. The number of nurses joining the UK register from the rest of the world has risen from 800 in 2012/13 to 18,000 in 2021/22. However, this is not sufficient to make up for ongoing shortages in nursing and cannot be a replacement for adequate workforce planning to recruit and retain staff domestically.
• Several essential specialties of medicine facing chronic shortages have seen EU and EFTA recruitment drop off without increases from other countries compensating for this. Cardiothoracic surgery’s previous reliance on European staff has slowed to almost nothing, with no increase in rest-of-world recruitment. Anaesthetics, a large specialty with high numbers of European staff, has seen EU and EFTA recruitment drop from a rise of over 20% in the years before Brexit to just 5% in the following years. Non-EU recruitment has also fallen.
• The rate of EU and EFTA dentists joining the register has halved since the EU referendum, without a clear increase in rest-of-world registration. Social care has seen a drop in EU and EFTA nationals which has not been compensated by wider recruitment.
• The NHS is not supposed to actively recruit staff from ‘red list’ lower and middle-income countries experiencing workforce shortages, but recruitment from these countries has increased in many English NHS trusts since the UK exited the EU single market and introduced new migration rules. This poses important ethical issues related both to the damage incurred by health systems in staff’s country of training, and to potential abusive treatment of staff in the UK where recruitment is not adequately monitored.
• There is clear evidence that Brexit is likely to be reducing the incomes of people in the UK relative to a counterfactual of continued membership, through its impact on GDP, investment, and trade. The current economic situation means that this is likely to be an additional reduction on already falling real incomes, rather than slower growth. The link between health and income is well documented, and this is likely to lead to worse health outcomes and higher demands of the NHS.
• There have been unusual spikes in medicines shortages since the UK left the single market in 2021, and to some extent in the preceding years following the EU referendum. The number of price concessions granted by the government when medicines cannot be found at the usual price has jumped repeatedly since 2016 and has recently soared to record highs. The latest shifts illustrate how drops in the pound due to Brexit and the September 2022 Fiscal Statement appear to make it difficult for the NHS to obtain medicines under the cost controls it has relied on.
• For other G7 states, medicine imports have risen steadily in total value since 2016. For the UK, they have reversed and fallen back to where they were a decade ago. UK data shows that 2021 was a particularly slow year for imports. This will partly reflect previous stockpiling but may also be associated with new trade barriers.

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Health and Brexit: 6 years on (Nuffield Trust report)

The Secretary of State for Health and Social Care has appointed the Rt Hon Patricia Hewitt to consider the oversight and governance of integrated care systems (ICSs). The review will consider how the oversight and governance of ICSs can best enable them to succeed, balancing greater autonomy and robust accountability. It will have a particular focus on real time data shared digitally with the Department of Health and Social Care, and on the availability and use of data across the health and care system for transparency and improvement.

The DHSC are therefore launching a call for evidence to gather views from across the health and social care system, as well as from patients, the public, and the wider voluntary sector.

The consultation deadline is 9 January 2023. Responses can be made here.

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Strategies to reduce waiting times for elective care (King’s Fund report)

In the face of record high waiting times for elective care, the King’s Fund undertook research to understand the strategies that have been used to reduce waiting times in England and elsewhere in the past 20 years. They found that successful strategies are typically associated with a concert of activities that simultaneously ensure sufficient supply of health care, manage demand and optimise the conditions within the health care system itself.

In England in the 2000s, a number of activities were associated with reduced waiting times. These activities were concentrated within the categories of increasing supply and optimising conditions within the health care system itself to achieve the goal of an 18‑week referral to treatment target by 2008. These activities were underpinned by a bigger idea about what the health service as a whole should look and feel like, and incorporated how waiting times are brought down as much as what activities might be used.

For the experts interviewed, the achievement of the 18 weeks target was made possible as a result of: valuing and investing in people working in the NHS; a clear, central vision and goal for waiting and an ambition that those working within health care felt equipped to take on; cultivating relationships and leadership at all levels of the health care system; accountability, incentives and targeted support to encourage performance against waiting times targets and other measures of quality of care; and seizing the momentum of wider NHS reform.

Whereas the improvement in waiting times performance of nearly 20 years ago took place in a very different political and economic context, the research highlighted not only hope but opportunities to reduce waiting times in the present day: by addressing shortages of health care staff and physical resources urgently; by working with integrated care systems in the spirit of prevention, collaboration, inclusion and community‑based models of care; and by aligning a vision for the health services with a plan that brings staff, patients and the public along on the journey to get there.

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Disclaimer: This briefing paper is intended to highlight recent developments and issues within the NHS that may be of interest to non-executive directors, lay members and NHS managers. It is not exhaustive and TIAN cannot be held responsible for any omission.

If you would like to discuss how MIAA can support your organisation, please contact our Executive Director of Assurance, Louise Cobain or call her on 07795 564916.