Waiting times will increase as a result of reforms, top health managers tell NHS Confederation conference

The concerns were outlined in the results of a survey unveiled by the NHS Confederation at its annual conference in Manchester last week.

In the longer term there is a limit to service re-engineering that does not end up making patient care different and probably worse.

The research covered 287 chairs and chief executives from 243 NHS organisations, including acute trusts, primary care trusts, ambulance trusts, mental health trusts, and independent sector providers. Where finances are concerned, 42% of the managers questioned said the situation facing their organisation was 'the worst they had ever experienced', while an additional 47% described it as 'very serious'. What's more, 67% thought the pressure would increase over the next three years, and 70% thought it would get worse over the next 12 months. However, 82% said they were not expecting a budget overspend over the next year, with 13% fearful of going into the red.

When quizzed about the impact of cutbacks on the quality of healthcare services moving forward, only 18% said there would be significant improvements over the next three years, with 20% expecting quality to decrease. Around one in 10 think clinical outcomes and safety will be negatively affected, and 32% expect the patient experience to suffer.

But the greatest area of concern was around patient access, including waiting times and availability of care, with 53% expecting it to worsen.

There are also increasing fears that the cuts to local authority spending announced last week will mean patients who no longer get community-based care will instead rely more heavily on NHS services, further increasing costs and driving up waiting times.

We need reform that helps us deal with the complexity of competition and collaboration, not a political fix. We need reform that balances the need for national consistency and local flexibility. We need proper governance, but freedom to act swiftly without burdensome bureaucracy. And we need a proper assessment of the resources needed for the effective management of the NHS

Among the comments collected during the survey were the following quotes from managers:

• "Over the next 12 months we will take the opportunity to reconfigure services so they will improve. In the longer term there is a limit to service re-engineering that does not end up making patient care different and probably worse"
• "It will take some time to find models which cost less and deliver as much or more. Doctors are not engaged enough so models will be forced on them which, in the short term will mean poorer care"
• "Some services will be cut back and many services currently thought to be important will be deemed unnecessary"
• "The problem is that there is no science to this. We will do all that we can to maintain quality and safety, but if we are forced to reduce headcount without a reduction in patient demand there will be inevitable compromises in patient care"
• "Generally there will be an increasing postcode lottery and the fragmentation of the NHS will occur. The underlying issues around value for money will not be addressed"
• "The process of transition and mergers will inevitably lead to eyes being taken off the ball financially and in terms of service availability and quality. Too much optimism is vested in speculative changes and transformations that have no empirical evidence behind them or have been tried before with mediocre outcomes"
• "There may be a beneficial reduction in procedures of limited clinical value, but patients will feel denied treatment and satisfaction levels may fall. There is a risk we may cease to be a fully comprehensive service; IVF is an area where savings may be made at great personal cost to patients"

But the survey also revealed how managers are battling to protect the quality of services, despite the lack of funding; with 76% confident they will meet their objectives for quality and efficiency over the next 12 months. When asked to name the main steps being taken to ensure their organisations delivered the necessary efficiency savings, the most-popular answers included reducing general staffing costs (53%), reducing management and administrative costs (39%), and redesigning or reconfiguring patient services (91%). When asked how they intended to safeguard the quality of services, 66% said they were reviewing clinical pathways and processes, while 46% said they were strengthening clinical governance and quality management systems. Just over 20% said they were increasing the focus on the patient experience and gathering feedback.

We will do all that we can to maintain quality and safety, but if we are forced to reduce headcount without a reduction in patient demand there will be inevitable compromises in patient care

Asked to single out the biggest barrier to improvement, 85% said it was delivering the NHS reforms and savings simultaneously; while 70% cited a lack of certainty over the changes; and 51% highlighted the cuts in local authority services.

Commenting on the results, Mike Farrar, the new chief executive of the NHS Confederation, said: "People will overlook these worrying results at their peril. This is the view of those who run the service, who will implement the reforms, and on whom the immediate future of the NHS depends. They are unconcerned with the political knockabout and they don't have the luxury of the armchair commentators. The picture they paint is of pressure on money now and of pressure on money mounting down the line. It is getting harder to maintain the great progress we have made on the quality of care, and there is now real concern about the speed of access to services. The NHS also feels pressure as a consequence of the difficult financial settlement for social care. This highlights that the NHS is not an island. The health and social care system has got to work together or it won't work at all."

And he warned that the uncertainty over the Health and Social Care Bill has meant good managers have left their posts, taking with them a vital insight into the running of integrated health services.

He said: "We have to act now, and that means sheer hard work, an ability to deal with the ambiguity yet take brave decisions, and to do today's job while safely bringing the new system into place.

"I have seen throughout the country people leading and taking responsibility even when uncertain about their personal future. I fear we may have lost considerable time over the past 12 months as a consequence of the policy uncertainty and the drain of senior management we have also seen around us."

It is getting harder to maintain the great progress we have made on the quality of care, and there is now real concern about the speed of access to services.

He added that there were still serious doubts and concerns over the proposed reforms, but urged managers to take the bull by the horns and continue the 'tough task' of securing efficiencies while protecting standards.

He concluded: "There are many things that are good in principle about the reforms, such as the increasing role of clinicians; and I have no doubt that we are in a better place as a result of the 'pause'. But, despite this progress, there is still much to worry about. We are concerned about excessive centralisation, bureaucratic restrictions on the freedom to act of local commissioning groups, the continued attack on management, and the lack of political courage when reconfiguration of services is justified on quality, safety, and, let's name it, on cost grounds.

"We need reform that helps us deal with the complexity of competition and collaboration, not a political fix. We need reform that balances the need for national consistency and local flexibility. We need proper governance, but freedom to act swiftly without burdensome bureaucracy. And we need a proper assessment of the resources needed for the effective management of the NHS."