How is the NHS performing? December 2018 quarterly monitoring report

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Part of Quarterly monitoring report (QMR)

The King’s Fund published its first quarterly monitoring report in April 2011 as part of our work to track, analyse and comment on the changes and challenges the health and care system is facing. This is the 27th report and aims to take stock of what has happened over the past few months, including the recently announced funding offer for the NHS. 

This report once more finds that patients are waiting too long for care and NHS trusts and clinical commissioning groups (CCGs) remain under tremendous financial pressure. Midway through 2018/19 we are seeing waits for routine and emergency care that have not been seen for a decade, and half of NHS providers are forecasting a financial deficit. 

But if this doom and gloom about NHS performance sounds both familiar and intractable then it shouldn’t. As recently as 2013/14 accident and emergency (A&E) waiting time targets were routinely met, and in 2012/13 frontline NHS organisations were in financial surplus overall. There is hope in some quarters that the upcoming NHS long-term plan will help to buck the current downward trend and set the NHS on a path where financial balance for individual organisations is once more a realistic prospect, and the focus of providers and commissioners can return to improving services for patients. So to set the scene in advance of these important documents being published – what did our finance directors have to say about how the NHS is performing? 


When it comes to NHS finances, as one finance director notes, ‘red is the new black’. In 2018/19 support from central sustainability funding pots has risen to £2.45 billion for providers, and a £400 million fund to support commissioner finances has been created. Despite this, deficits in NHS providers and CCGs remain stubbornly hard to eliminate, and the latest figures from NHS England and NHS Improvement show that 48 per cent of NHS trusts are forecasting to end the year in deficit and 11 of the 195 CCGs are expecting to overspend their budgets.

Our survey confirms that despite this additional funding, tough choices remain for local organisations purchasing NHS care. 47 per cent of CCGs responding to our survey were expecting to delay or cancel planned spending in an attempt to remain within their budgets for this year (Figure 5). CCGs were also planning for longer waiting lists for surgery; stopping routine funding for treatments with limited clinical effectiveness; and increasing the use of eligibility criteria – such as smoking status and body mass index – to determine access to care (Figure 6). 

Some of these actions – such as reviewing whether existing treatments are really adding value for patients – should be taken even in a health care system with sufficient capacity and funding. But 2018/19 overall is proving to be another year of pain for CCG finances as funding fails to keep pace with rising demand and pressures on services. As a result, 35 per cent of CCG respondents we surveyed are fairly or very concerned about meeting their financial target by year-end, despite access to the £400 million Commissioner Sustainability Fund. 

The picture is no rosier for NHS provider trusts. Despite an original plan to break even this year, the provider sector overall is now forecasting a deficit of £558 million, with some individual trusts on course to report deficits well over £100 million each. 44 per cent of trust finance directors we surveyed were fairly or very concerned about meeting their 2018/19 financial control total. And, as in recent years, many NHS trusts will rely on financial loans from the Department of Health and Social Care to help fund their deficits and pay staff and suppliers (Figure 4), with one finance director starkly noting the scale of this dependency: ‘we rely totally on revenue support loans to continue operating’. 

In their latest report on provider finances, NHS Improvement expresses hope that the end-of-year provider deficit can be brought down to £439 million through further belt-tightening. NHS England have expressed similar hope that with further reserves and updated forecasts, the overall commissioning budget (ie, including services directly commissioned by NHS England as well as services commissioned by CCGs) will reflect an underspend of at least £450 million by year end. And so, despite the dire financial position of individual organisations, it is likely, on current forecasts, that the NHS as whole will financially balance in 2018/19 once again. 

This financial balance is nothing to sniff at – it has been the highest of high-wire acts for finance professionals at all levels at the NHS. But this financial balance at a national level has also come at tremendous cost to how NHS finances are managed and has resulted in short-termism (eg, restraints on capital spending), transferring of financial risk between providers and commissioners (and between different parts of the provider sector) and a general feeling of dysfunction pervading the NHS’s financial system. And this financial balance at the national level has also partially obscured the significant financial problems at some individual CCGs and trusts – it remains deeply questionable if the Prime Minister’s aspiration for ‘no NHS organisation to be in financial deficit in the medium term’ will be met. 

So, if the long-term plan is to paint a compelling vision of how health and care services will be delivered in the future, it must first paint itself out of a corner by rewriting the rules on how NHS funding and finances are managed. The behavioural and technical changes that are needed are substantial. Billions of pounds of sustainability funding that was purposefully kept outside of the control of CCG budget holders must eventually find its way back into mainstream allocations. A complex range of payment systems will be simultaneously operating throughout the country, with blocks, blends, tariffs and plenty in between. And the zero-sum game based around contractual challenge and distrust must be modelled out of the system nationally, regionally and locally. The long-term plan has left itself with quite a lot to do. 


Turning to NHS performance, as usual for this time of year thoughts often turn to pressures on emergency services. And if there was one record the NHS did not want to break it might have been the number of emergency admissions to hospital in a single month. But this is precisely what happened in November 2018 thanks to a 6.3 per cent increase in emergency activity compared to this time last year. 

Any system would struggle to cope with this level of increasing demand and, unsurprisingly, the high level of hospital bed occupancy was once again one of the issues that most concerned finance directors in our survey (Figure 15). And NHS finance directors are generally not prone to making hyperbolic statements – so it is deeply worrying when one of the finance leads in our survey says ‘bed occupancy levels are moving higher than is sustainably safe.’ 

A combination of rising demand, full hospitals and cuts to out-of-hospital services once more suggest that national performance targets will remain out of reach this year. The 2018/19 planning guidance set an expectation that by September 2018 the NHS would see 90 per cent of patients within four hours in A&E departments, that waiting lists for elective surgery would be no higher in March 2019 than March 2018 and that the number of people waiting more than 52 weeks for treatment should be halved by March 2019. Instead, in September, 88.9 per cent of patients were seen in four hours. And by October 2018, the waiting list for consultant-led care had grown by more than 6 per cent compared to March 2018 overall, with the number of people waiting more than 52 weeks for treatment also increasing by 2 per cent.

To improve the availability of hospital beds, national bodies have placed considerable focus on the NHS reducing the length of time patients spend in hospital – particularly for patients who spend more than 7 days in hospital. Reducing unnecessary stays in hospital is clearly important, but will it be sufficient to recover national performance targets? Unfortunately, it is likely that even with the best clinical and managerial will in the world, there are simply not enough staffed hospital beds in the country for national targets for both emergency and routine hospital care to be met in the near future. 

Once again then, the long-term plan is faced with an unenviable task. The proposed average annual funding increases of 3.4 per cent a year for the NHS are welcome but hardly a bonanza. The calls on the funding are legion. The NHS remains in the grip of a workforce crisis that is unlikely to end any time soon. And against this backdrop the demands on services from a growing and ageing population continue to push staff and services to their limit. 

The clinical review of NHS performance targets that was announced as part of the long-term plan will therefore inevitably involve trade-offs. For example, longer waits for routine planned hospital care might be the price for restoring A&E waiting times to the desired level. Certain clinical conditions may be deprioritised to ensure the national targets remain focused on patients with the greatest clinical need. Large chunks of the funding settlement are already committed to other priorities, and workforce shortages remain rampant. So if there are plenty of things the clinical review of standards might conclude, the one thing it cannot do is perpetuate the belief that the new funding settlement alone will be enough to return NHS hospital waiting times to the levels envisaged by the NHS Constitution. Tough choices then, despite this extra funding, remain. 

Mental health

Our quarterly monitoring reports have tracked national data and the views of finance directors on financial and operational performance for more than seven years. While acute hospital care often takes up much of the oxygen in the room when NHS pressures are discussed, recent years have also clearly seen pressures steadily mount in mental health services. This is despite commitments from the Prime Minister and NHS leaders that these services would be given parity of esteem with physical health services. For these reasons, in this latest QMR we asked provider and commissioner finance leads specific questions to help us better understand the financial and operational performance of NHS mental health services. 


A cursory reading of NHS Improvement’s data on the financial performance of mental health providers suggests it is in relatively rude health. The acute hospital sector is expecting to overspend its budget by £1.8 billion in 2018/19, with 65 per cent of hospital providers in deficit. In contrast, NHS mental health trusts are expecting to end the year £133 million in surplus, with only 19 per cent of these trusts in deficit. 

But it would be a misreading of this data to suggest that mental health providers are not experiencing substantial strain in an effort to make ends meet. Year after year NHS mental health services are asked to expand access to services without commensurate increases in funding under the block contracting arrangements that dominate the sector. Our survey reflected these financial challenges. Finance directors from mental health trusts noted factors such as the rising cost of local spending on psychiatrists due to workforce shortages and a heavy reliance on one-off measures to improve their financial position, such as the land sales more commonly associated with acute hospitals. Because of rising pressures on services, 56 per cent of finance directors from trusts providing mental health services were uncertain or concerned about making their planned level of efficiency savings in 2018/19. 


These financial and workforce pressures, which have built up in mental health services over previous years, are now inevitably having a material impact on the quality of patient care. Performance against the two national access and waiting time standards (for improving timely access to psychological therapies and early intervention for people experiencing a first episode of psychosis) introduced in 2015/16 remains strong, and these are a rare example of NHS national performance targets being reliably delivered. 

But these two standards do not reflect the comprehensive breadth of services offered by NHS mental health providers, and consequently do not reflect the full range of pressure these services are under. And the sector can expect more targets to be on the way, with further standards assessing how long patients in crisis wait for care. This raises the question of whether these new standards will lead to limited resources in mental health services being focused on these high-profile areas, at the expense of other areas of mental health care. 

Looking across the breadth of the services they provide, 80 per cent of trust finance directors and 51 per cent of CCG finance leads in our survey said financial pressures had led to longer waiting times to access mental health care overall over the past two years. Our survey suggested these pressures have impacted on the quality of care being delivered, as well as on access to care. Finance directors in our survey noted that financial challenges had also led to patients being offered fewer or shorter contacts with services and an inability to fund the range of treatments specified by the National Institute for Health and Care Excellence (NICE) (Figure 25). 

This correlates with the most recent community mental health survey for England, which highlighted a marked deterioration in the quality of care among people receiving care and treatment for a mental health condition. Research by Rethink Mental Illness has similarly highlighted long waits for assessment, limited access to core evidence-based treatments, and reports of people feeling they had not received support for a sufficient and appropriate length of time. 

One of the most high-profile recent examples that illustrate rising pressures on mental health services is the level of inappropriate out-of-area placements – which record instances where a person with acute mental health needs is admitted to a unit outside their usual network of services. These placements are often due to a lack of beds within a patient’s local area, and the latest provisional national data shows the worrying scale of the issue. Over September 2018 there were 660 such active placements due to unavailability of a bed. If that number is hard to contextualise, then other data in this national collection makes the cost to patients, and their carers and families, clearer. Of the placements that ended during this month, 120 were for patients who had to spend between 31 and 90 nights away from their local networks, with 15 patients spending more than 91 nights out of their local area. And for some patients, the term ‘out of area’ does not mean an adjacent town, it means a different part of the country. 

The government has an ambition to eliminate these inappropriate placements for adults in acute inpatient care by 2020/21. Our survey suggested some cause for optimism, with 65 per cent of trust finance directors and 51 per cent of CCG finance leads expecting moderate or significant progress to be made against this ambition. Mental health finance directors noted their organisations were not standing still in response to this challenge, and described how the need to reduce inappropriate placements was stimulating creative partnerships and collaboration with volunteers, carer hubs and third sector organisations. But the national data from NHS Digital suggests there is some way to go before this ambition becomes a reality, with the number of inappropriate placements rising in recent months. Even with more partnership working it is again hard to see how the targeted reductions in out-of-area placements can be achieved with the current number of beds available in the NHS. 


Of course, some of the financial pressures on mental health services were meant to have been partially addressed by the boost in funding under the Mental Health Investment Standard – which requires CCGs to increase their investment in mental health services in line with the overall growth in their budgets each year. It was hoped that this additional investment would support the expansion of services envisaged in the Five Year Forward View for Mental Health. And in 2017/18, 90 per cent of CCGs were reported as meeting this investment standard.

But tracking how that investment has filtered through to frontline services has proved remarkably challenging, as previous research has demonstrated. The King’s Fund’s own analysis of NHS provider annual accounts for 2017/18 suggests the overall income for mental health trusts has increased compared to previous years – supported in part by access to central sustainability funding (Figure 17). But only 79 per cent of mental health trusts reported an increase in funding from 2016/17 to 2017/18, less than the 87 per cent that saw income grow from 2015/16 to 2016/17. 

Like-for-like comparisons of this type are difficult to make. We have adjusted the data for mergers and acquisitions, which would otherwise affect any analysis of income changes for individual providers. Trusts that provide mental health services also often provide other services – such as community services for people with physical health problems. Yet even adjusting for this – where such spending can be identified – shows there are still mental health trusts that have seen their income fall this year. 

This then suggests that the central conundrum of the Mental Health Investment Standard remains intact: the vast majority of CCGs increase their investment in mental health services each year, yet some NHS trusts providing mental health services, which account for the bulk of the services these CCGs buy, are not seeing this income reach them. 

NHS England have made dogged efforts to track how the mental health investment standard has been used. This has include collecting and publishing mental health investment data in national dashboards, direct calls to finance teams at risk of missing the investment standards, and asking providers to co-sign off on CCG finance returns. This year NHS Improvement and NHS England are taking their forensic accounting to a new level with additional financial returns to cross-check mental health spend in commissioners with income in providers – the latest in the series of national initiatives to try to ‘follow the money’. The commitment to audit the trail of this funding and solve this three-year investment riddle is to be genuinely commended. But at the same time it is hard not to feel that this is another example of mental health services having to go the extra mile to receive that which is due to them. 

In a wider reflection of the lack of parity for mental health services, our survey asked what priority mental health services are given in planning within integrated care systems and sustainability and transformation partnerships. Overall, while there was a general sense of progress, with mental health services given more prominence now compared to the early days of sustainability and transformation plans, as one respondent to our survey noted ruefully, in some parts of the country investment and parity for mental health services unfortunately still feel like a high priority in principle but a low priority in practice.

Source: The King’s Fund QMR27.



Stepping back for a moment, the picture our survey paints of mental health services captures many of the issues that are present in the wider NHS. And this offers both cause for concern and cause for hope. The long-term plan and five-year funding settlement find the NHS in a fragile place. Financial and operational performance targets are largely missed, and staffing pressures are rife across all sectors. 

But alongside problems to address there is also progress that can be built on. The introduction of access targets in mental health demonstrates that the NHS retains its muscle memory for delivering step changes in performance when given the right conditions for success. But providers and commissioners must receive the resources they need to replicate this progress across a wide range of mental health services, not only those services that have the light of a national target shone on them. 

The leaders of NHS Improvement and NHS England have already said that 2019/20 will be a transition year for NHS services, and transitions can be painful. The depth of the workforce shortages in key areas, and the depth of financial problems in some organisations, are substantial. All too often in recent years, we have seen five-year plans and annual planning guidance that were overly optimistic and inevitably led to disappointment once NHS finances and performance started to go adrift. Perhaps then, what is most needed from the upcoming long-term plan is not a new vision or set of aspirational targets – what is needed is a sense of realism. 

This quarter’s report is based on an online survey of 84 NHS trust finance directors and 43 CCG finance leads (covering 53 CCGs). 

Respondents were asked about their organisation’s forecast end-of-year financial situation for 2018/19 and the financial outlook for their local health economy over the past and forthcoming financial year; the state of patient care in their area; the key organisational challenges facing trusts and CCGs; workforce issues. We also asked respondents about the following. 

1. Forecast end-of-year financial situation: 2018/19

  • In our recent survey, 43 per cent of trust finance directors forecast that their organisation would end 2018/19 in deficit (Figure 2) and 56 per cent reported that their forecast position for 2018/19 would depend on significant financial support from the Provider Sustainability Fund (Figure 4). Trusts providing acute hospital care were more likely to be in deficit.  
  • Of the 77 trusts we surveyed who had agreed control totals for 2018/19 (or were in the process of agreement), 44 per cent were either fairly or very concerned about meeting their target (Figure 7). 38 per cent of providers expecting to receive Provider Sustainability Fund monies still forecast a deficit by the end of 2018/19.
  • While only 16 per cent of CCGs were expecting to overspend in 2018/19 (Figure 3), 47 per cent of all CCGs were expecting to delay or cancel spending plans to support their end-of-year position for 2018/19 (Figure 5). Furthermore, 74 per cent of CCG respondents were considering extending the number of low-value treatments and prescriptions that will not be funded, and 33 per cent were considering extending waiting lists or reducing activity for certain elective specialties (Figure 6). 35 per cent of all CCGs were fairly or very concerned about meeting their expenditure control total for 2018/19 (Figure 8).

Source: The King’s Fund QMR survey.
Note for subsequent QMR charts: QMR1-4 based on a panel of 50 finance directors.


There are a number of unresolved risks that need to be resolved in order to meet the forecast.
Trust finance director
Subject to landing by 31 March a substantial one-off transaction, which is under threat.
Trust finance director


Source: The King’s Fund QMR survey.
Note for subsequent QMR charts: 43 CCG finance leads answered this question for the 53 CCGs they cover collectively. CCGs only surveyed since their establishment in April 2013.


Source: The King’s Fund QMR survey.
Note: Only foundation trusts are allowed to retain surpluses. Respondents were allowed to select more than one form of additional financial support.


A number of non-recurrent actions.
Trust finance director
Tough financial targets mean we are still working flat out all year to achieve the target.
Trust finance director


Source: The King’s Fund QMR survey.
Note: 43 CCG finance leads answered this question for the 53 CCGs they cover collectively. Respondents were allowed to select more than one form of additional financial support.


All uncommitted investment reserves have been applied to offset acute cost growth, meaning that we cannot invest in primary care or mental health as we would have wished.
CCG finance lead


Source: The King’s Fund QMR survey.
Note: Respondents were allowed to select more than one option.


Other than extending waiting lists, all the actions listed have already been implemented in previous financial years, and continue to be in place.
CCG finance lead
Acute contracts have been protected from savings which must come from all other spend areas.
CCG finance lead


Source: The King’s Fund QMR survey.
Note: 77 respondents (for whom this question was applicable).


The control total was always aspirational/high risk.
Trust finance director


Source: The King’s Fund QMR survey.
Note: 43 CCG finance leads answered this question for the 53 CCGs they cover collectively.


Very dependent on winning contractual challenges – which does not fit with how we'd want to work but only option when activity is flat but cost of that activity is rising at a staggering rate.
CCG finance lead

2. Cost improvement programmes (CIP) and quality, innovation, productivity and prevention (QIPP) programmes (2018/19)

  • 48 per cent of all NHS trust finance directors and 53 per cent of all CCG finance leads were either fairly or very concerned about achieving their CIP targets this year (Figure 9 and Figure 10). 

Source: The King’s Fund QMR survey.
Note: QMR1 and QMR5 excluded as wording of responses not compatible with other quarters’ data. QMR 2–4 based on a panel of 50 finance directors.


Source: The King’s Fund QMR survey.
Note: 43 CCG finance leads answered this question for the 53 CCGs they cover collectively; CCGs only surveyed since their establishment in April 2013.


QIPP target for 18/19 is double that achieved in 17/18... any QIPP for a commissioner more than 2 per cent is unrealistic, unless, and only if, the main acute provider is on board and willing to take a hit on income.
CCG finance lead
Non-recurrently the target will be met, but only around one-third of the gap will be closed through recurrent schemes meaning we carry a pressure forward into next year.
CCG finance lead

3. The state of patient care

  • 38 per cent of finance directors and 35 per cent of CCG finance leads felt that patient care had worsened in their local area in the past year (Figures 11 and 12).

Source: The King’s Fund QMR survey.
Note: Question not asked before QMR6.


Far greater pressure on emergency departments, greater pressure in some GP practices. No real improvement seen from better demand management.
Trust finance director
Clinical teams are working very hard to try to deliver and sustain quality but operational pressures are putting huge strain on them as teams and individuals.
Trust finance director

Source: The King’s Fund QMR survey.
Note: CCGs only surveyed since their establishment in April 2013.


Rapidly deteriorating position across the health and care economy in the locality against a backdrop of accelerating demand.
CCG finance lead
Improved quality but range of care is challenged.
CCG finance lead

4. Financial outlook over the next 12 months

  • When asked for their views about the financial state of their wider local health and care economy over the next 12 months, 79 per cent of trust finance directors and 63 per cent of CCG finance leads were fairly or very pessimistic (Figures 13 and 14). 

Source: The King’s Fund QMR survey.
Note: Question not asked before QMR3; QMR 1–4 based on a panel of 50 finance directors.


Too many trusts are under multiple pressures – financial, workforce, demand growth to be anything but pessimistic.
Trust finance director
The system needs a fundamental reset and space to deal with underlying financial issues to allow time and space to enable realistic and deliverable long-term sustainability planning.
Trust finance director


Source: The King’s Fund QMR survey.


CCG is relatively stable but local acute provider is in significant deficit and the CCG is struggling to provide any further financial assistance without putting its own financial position at risk.
CCG finance lead
Eager to see allocations enabling us to answer this question more completely, but sceptical the full £20 billion will find its way to CCG budgets in a way which will address the recurrent financial gap.
CCG finance lead

5. Organisational challenges

  • For trust finance directors, staff morale remains the main concern for this QMR (Figure 15) – for a second QMR in a row – followed by the A&E four-hour waiting time standard and the bed occupancy rates (introduced as an option in QMR21). 
  • For CCG finance leads, the A&E four-hour waiting time standard continued to be their main concern for a seventh QMR in a row (Figure 16). Their second biggest concern was cancer treatment waiting time targets, followed by the 18-week referral to treatment (RTT). 

Note: Respondents were asked to choose their top three concerns. Figures expressed as a percentage of the total number of concerns in each survey. A new option, bed occupancy, was introduced in QMR21.


Note: Respondents were asked to choose their top three concerns. Figures expressed as a percentage of the total number of concerns in each survey. New options have recently been added, implementation/delivery of the Five year forward view for mental health (introduced in QMR21), and pressures on general practice (introduced in QMR23).



  • Tracking investment in mental health services is challenging. NHS England and NHS Improvement have committed to an additional data collection for 2018/19 to enable cross-checking of mental health spending by commissioners with mental health income of providers (NHS Improvement 2018).    
  • Our analysis of NHS trust annual financial accounts for 2017/18 shows a continued increase in the income of mental health trusts from 2016/17 in cash terms. Similar to the previous year, growth in income has been supported by funding from the Sustainability and Transformation Fund in 2016/17 and 2017/18 (Figure 17).  

Source: The King’s Fund analysis of NHS trust finances.
Notes: Data has been adjusted for mergers and acquisitions of mental health trusts. Data is percentage change in spending compared to the 2012/13 baseline.


  • NHS England’s own data shows that 186 out of 207 CCGs increased their investment in mental health in proportion to increases in their baseline allocations. The proportion of mental health trusts with an increase in funding in cash terms has fallen from 87 per cent in 2016/17 to 79 per cent in 2017/18 (Figure 18). This is concerning given the commitment to parity of esteem and the introduction of the Mental Health Investment Standard. 

Source: The King’s Fund analysis of NHS trust finances.
Notes: Data is in cash terms. 


  • NHS mental health trusts also provide non-mental health services, such as community services for people with primary physical health problems. Where it is possible to separate these data, approximately 20 per cent of NHS mental health trust income was allocated for community services for people with primary physical health problems. But even when we adjust income to account for this, there are still mental health trusts that have seen their income fall. 
  • Even if individual mental health trusts have seen falls in their income year on year, the majority of NHS mental health trusts  and the mental health provider sector in aggregate  ended 2017/18 in surplus (Figure 19). 

Source: The King’s Fund analysis of NHS trust finances.
Notes: Data is in cash terms.


Reducing avoidable variation 

  • In May 2018, NHS Improvement published Lord Carter’s review into unwarranted variations in mental and community health services. The review identified opportunities for savings that could be made in efficiencies by 2020/21. This included improving workforce issues, such as e-rostering, effective job planning and ensuring appropriate use of skills mix (both current and future). It also included improved utilisation of current NHS estates and reducing the costs of corporate service functions. 
  • We asked respondents how much progress they thought their organisations (or the organisations from which they commission services) would make by 2020/21 on a number of key recommendations from the Carter review
  • Just over half of providers thought they would make significant progress towards eliminating out-of-area placements and the majority thought they would make significant or moderate progress towards improving the use of technology, maximising use of e-rostering and improving utilisation of NHS estate and facilities (Figure 20). Ongoing work in improving rostering and addressing out-of-area placements supported by NHS Improvement may be contributing to this optimism, and overall finance directors of mental health trusts were much more optimistic about making progress than commissioners (Figure 21). 

Source: The King’s Fund QMR survey.


Source: The King’s Fund QMR survey.



  • Access and waiting time standards were introduced in 2015/16 as a key means of driving improvement in the provision of mental health services. Current access and waiting time standards have been implemented for a discrete number of services including Improving Access to Psychological Therapies (Figure 22), early intervention in psychosis (Figure 23), and most recently eating disorder services for children and young people (Figure 24). 

Source: The King’s Fund analysis of NHS England data.


Source: The King’s Fund analysis of NHS England data.


  • The latest data shows that those performance standards for two of these services have been met, while implementation of the latest access standard for eating disorders shows gradual progress towards meeting the target by 2020. 

Source: The King’s Fund analysis of NHS England data.


  • A further area of performance targeted for improvement is the reduction of inappropriate out-of-area placements. Inappropriate out-of-area placements result from insufficient bed capacity within local areas leading to someone being admitted to a service outside their local network. This impacts negatively on patient experience and quality and safety of care on discharge. In 2016 the government set a target to eliminate inappropriate out-of-area placements for adults in acute inpatient care by 2020/21. 
  • Findings from the Commission on Adult Acute Psychiatric Care highlights the availability of housing and quality of resourcing for community teams as integral to tackling high levels of bed occupancy and out-of-area placements. Experimental data developed by NHS Digital shows that progress in reducing out-of-area placements has been variable, with these inappropriate placements rising over the last three months. 
  • Our previous work has raised questions about quality of care in mental health and the impact of financial pressures. Given the workforce and financial pressures faced by mental health, we asked respondents what impact the financial pressures had had on mental health services over the past two years. Overwhelmingly, NHS trust finance directors (80 per cent of respondents) and commissioners (51 per cent) felt that patients had had to wait longer to access care (Figure 25). 21 per cent of CCG finance leads and only 4 per cent of mental health trust finance directors felt that the financial pressures had had little or no impact on services over the past two years. 

Source: The King’s Fund QMR survey.
Note: Respondents could select as many as applicable.


  • The most recent community mental health survey for England highlights a marked deterioration in the quality of care (Care Quality Commission 2018) among people receiving care and treatment for a mental health condition, while a survey of 1,600 people conducted by Rethink Mental Illness highlighted long waits for assessment, limited access to core evidence-based services and with many people feeling that they had not received support for a sufficient and appropriate time (Rethink Mental Illness 2018). 
  • The disparity between reported performance data and the experiences of those accessing mental health support suggests that although there has been some progress towards parity in key areas, in other areas that progress has failed to be realised or has deteriorated. 

This report details the results of an online survey of NHS trust finance directors carried out between 16 October and 5 November 2018. We contacted 230 NHS trust finance directors and 84 responded (37 per cent response rate). The sample included 42 acute trusts; 33 community and mental health trusts; 3 specialist trusts; 4 ambulance trusts and 2 provider organisations that were not categorised. In addition, we contacted 141 clinical commissioning group (CCG) finance leads, and 43 responded. Between them these finance leads covered 53 CCGs (27 per cent of all 195 CCGs). 


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