Revealed: ICBs plan pay bill squeeze and provider consolidation

A third of integrated care board leaders even said they expect cuts to substantive clinical staff numbers in their system, while 85 per cent are putting in place controls and rules to reduce temporary staff spend.

Most ICBs are also planning consolidation of teams, services, waiting lists, and leadership across their NHS providers.

The plans are set out in a survey of 43 chief executives, chairs, medical directors, and finance and nursing chiefs across 39 of 42 ICBs, carried out by HSJ between January and March.

Asked about significant plans for the coming 12–18 months on costs, efficiency and productivity for their system:

• 85 per cent said they would reduce agency staff spending via system-wide spending controls, with 42 per cent also planning cuts to numbers of non-clinical substantive staff and 32 per cent to reduce clinical substantive staff;
• 73 per cent said more staff would be shared across NHS providers;
• 63 per cent plan merging trusts’ back-office or support functions; and
• 56 per cent plan moving to shared elective waiting lists.

Nearly all ICBs are reducing their own pay bill after steep cuts to admin spending announced last year, with 66 per cent saying they would have significantly reduced ICB staff by this month and 89 per cent saying they will have done so by April next year. Ten per cent said they had not and would not make cuts in this area.

ICB leaders’ plans

Forty-one per cent said trusts in their system would move to more shared leadership or merger, which would continue the rapid consolidation — often encouraged by ICBs — in recent years.

And, asked what national policies would be helpful, three-quarters backed both “accelerating trust consolidation/groups/collaboratives” and “abolish remaining foundation trust independence (eg removing governors, enabling NHSE/ICBs to direct FTs)”. However, the most popular proposed national policy change was to “drastically reduce data sharing restrictions”.

NHS Confederation ICS Network director Sarah Walter said of the findings: “Given the deteriorating financial position our members are in it is no surprise to see that some are making drastic plans to try to balance their budgets.

“We are concerned the NHS has entered the new financial year in a worse underlying position, which is being compounded by the financial crisis facing many local councils.

“Health leaders are committed to identifying efficiency savings wherever they can but the last thing last thing they want to do is cut clinical and non-clinical staff numbers or close services, but they are being left with few options…

“That is why we are calling for the next government to invest an extra £6.4bn per year in capital to boost productivity across the NHS by 2% a year, get best value for money and avoid service cuts.” 

Staffing and cost control

Asked for details about their most successful actions to date on costs, efficiency and productivity, ICB leaders revealed how new system levers were being utilised to apply familiar, and sometimes drastic, cost-control measures.

System-wide staffing and productivity reviews were common, along with temporary staffing controls. Several said they’d introduced “triple lock” approvals where multiple CEOs and finance directors in the system have to sign off on any significant spending and investment.

One leader said they were introducing a system “control centre” for workforce, including agency spend and finances. One said, “we increasingly look at productivity across the system”, and another said “a united finance community” was improving efficiency.

Many are putting system-wide bank pay rates in place, and some said they were “reducing substantive staff” as well as agency spend and taking a “system approach in recruitment of staff and managing bank/agency”.

Other commonly cited actions were better system leadership and joint decision making; elective productivity, such as moving to system coordinated lists for some specialties; consolidating services onto single non-emergency sites; and shifting more overnight operations to day cases.

The map shows the “most successful” interventions so far, as identified by ICB leaders, split into four regions:

Transforming services

Asked about plans for improving and transforming services, only 9 per cent cited “buying more independent sector elective capacity” compared to 24 per cent who plan “restricting independent sector elective activity/choice” to make savings.

This contrasts with statements by the government and opposition that more outsourcing and choice of provider are important for recovering elective care.

Many responses focused on joining up and coordinating services and decision-making across trusts and other existing providers.

The most common — cited by 88 per cent — was to develop integrated neighbourhood teams across existing primary and community care.

Giving their most successful interventions to improve and transform services since ICBs were created in July 2022, the most common topic was urgent and emergency care, which often focused on joining up leadership and decision-making, improving flow in and out of hospitals, and expanding community services like frailty clinics, intermediate care, urgent care centres/hubs, and virtual wards.

The second-most cited area was workforce — specifically, better hiring and retaining of staff by, for example, spreading good practice around the system; “inclusive recruitment” to get long-term unemployed into stable jobs; “micro recruitment” in targeted areas; and using an NHS trust to help recruit social care staff.

Other common areas were prevention, inequalities and community development; primary care/integrated neighbourhood teams; and improved system leadership and development, with one leader saying more “common cause and mutual understanding” was bearing fruit.

The map shows the “most successful” interventions in this area, as listed by ICB leaders, split into four regions: