A Clash of Priorities: Unravelling the Inevitable NHS Standoff

A year ago, at the NHS Confederation’s annual conference, Amanda Pritchard urged us not to be "complicit in the language of despair". I left the event feeling cautiously optimistic, convinced that a credible plan was in place to set us back on track. Since then, however, a new government has taken charge, accompanied by fresh operational planning guidance and funding schemes. I now find myself increasingly disheartened, though not yet in the depths of despair. As both a healthcare user—having recently endured a five-hour wait in A&E —and a healthcare professional well acquainted with NHS policies, promises, and politics, I experience a profound incongruence that only deepens my concern.

I have been closely monitoring the evolving dynamic between Integrated Care Boards (ICBs) and NHS Trusts. The current approach pits ambitious performance targets against stark financial realities, creating a duality that threatens to exacerbate waiting lists and, ultimately, compromise patient outcomes.

The Financial Squeeze and Efficiency Mandates

Despite a nominal 4 per cent spending uplift in the latest budget, many systems are effectively contending with a real-term increase closer to 2 per cent when local cost pressures are considered. This constrained financial environment is further compounded by a mandate for providers to achieve a 4 per cent efficiency saving. With last year’s target at 2.2 per cent and historical productivity growth lingering at approximately 0.9 per cent, the pressure on Trusts is immense. Consequently, providers are being forced to make difficult decisions—often involving the closure of lower-value services—to maintain fiscal balance while striving to meet escalating clinical performance targets.

Ambitious Performance Targets Amid Capacity Constraints

The performance benchmarks set for elective recovery are undeniably aggressive, particularly in the context of funding caps on both NHS and independent sector activity—a matter that merits further exploration in a subsequent analysis. For Trusts, targets include treating 65 per cent of patients within 18 weeks by March 2026 and making significant improvements in referral-to-treatment and first appointment waits. Additional ambitions, such as reducing the proportion of people waiting over 52 weeks for treatment to under 1 per cent and enhancing cancer treatment standards, only intensify the operational challenges.

At the heart of the issue lies a stark misalignment: while policymakers push for rapid clinical improvements, Trusts are contending with a capped Excess Revenue Funding (ERF) that no longer rewards over-performance. As a result, many Trusts are recalibrating workforce planning based solely on existing capacity rather than anticipated future demand. This ‘let the chips fall where they may’ approach risks widening the gap between target aspirations and operational realities, potentially leading to longer waiting lists rather than the intended improvements.

The Stand-off: Trusts Versus ICBs

This scenario seems destined to result in deadlock, with neither side willing to yield. ICBs are focused on driving performance through stringent targets, while Trusts—under severe financial duress—are compelled to prioritise fiscal balance over service expansion. Such a standoff carries significant repercussions for patient care. If Trusts are forced to curtail services in order to meet efficiency savings, the overall risk is an exacerbation of waiting times and undermining of patient access.

Reconciling the Two Priorities: Potential Pathways Forward

One avenue for resolution lies in realigning incentives with capacity planning. Revisiting the capped ERF mechanism could prove beneficial; incentivising Trusts to exceed baseline performance, even marginally, might encourage proactive capacity planning. Rather than treating workforce establishment as a fixed baseline, a tiered incentive structure could motivate Trusts to invest in additional capacity that meets anticipated demand, thereby bridging the gap between financial constraints and clinical targets.

A more gradual implementation of efficiency savings may also be warranted. Mandating an immediate 4 per cent saving against the backdrop of rising local pressures appears overly aggressive. A phased approach over several years would allow Trusts to adjust operations incrementally, ensuring that genuine efficiency improvements are identified without compromising critical services.

Enhanced collaboration between ICBs and NHS Trusts is essential. Establishing joint task forces or collaborative forums to review targets, assess operational realities, and agree on realistic, mutually beneficial goals could help reconcile the tension between budgetary constraints and clinical ambitions. Such a cooperative approach would ensure that both financial sustainability and patient care remain at the forefront.

In today’s climate, the disconnect between lofty performance targets and harsh financial realities presents a significant challenge for managing patient waiting times. While the public narrative remains one of improvement, there is little credible evidence to suggest that these ambitions will be adequately funded. The drive for rapid improvements in waiting times and clinical standards—coupled with the expectation of drastic efficiency gains—places undue pressure on Trusts. Given the state of the country’s coffers, it is imperative that we are honest with the public about the true implications. Evading difficult conversations in favour of only sharing positive news will only lead to distrust and diminished confidence in healthcare leadership.

Without realigning incentives, introducing more flexible funding, and fostering closer collaboration between ICBs and Trusts, the challenges of elective recovery are likely to worsen. Ultimately, patient outcomes will suffer, with longer waiting lists and compromised care—a cost too steep for any healthcare system to bear.

Addressing these inconsistencies head-on may pave the way for a more sustainable future—one that judiciously balances fiscal responsibility with the imperative to provide timely, high-quality patient care. There is no silver bullet, and the path forward remains murky. Yet perhaps the best message to those feeling despair is to let that emotion serve as a catalyst for devising robust, innovative solutions.