NHS leaders say they are fighting to improve services in the face of unprecedented financial pressures.
But most believe that access to care will decline and that cuts in local authority budgets will lead to more people needing healthcare services.
These are the findings of a major survey of the leaders of NHS organisations, published today (Wednesday) by the NHS Confederation.
The survey shows, for the first time, the view from boardrooms around the country as the NHS sets out to save some £20billion over four years to keep pace with rising demand.
It covers 287 chairs and chief executives from some 243 different organisations including acute trusts, primary care trusts, ambulance trusts, mental health trusts and independent sector NHS providers.
Forty two per cent said the financial situation facing their organisation was "the worst they had ever experienced", while an additional 47 per cent said it was "very serious".
More than two thirds thought the financial pressure would increase over the next three years (67 per cent over three years/70 per cent over the next 12 months), with 39 per cent saying it would "increase significantly".
However, 82 per cent said they did not expect to overspend their budgets in the next 12 months, while 13 per cent thought they would overspend.
Quality of services
Encouragingly, 51 per cent felt the quality of services they delivered or commissioned would improve over the next three years, but only 18 per cent felt it would do so significantly. And a significant minority - one in five (20 per cent) - felt their quality would decrease over the next 12 months, while almost a third (30 per cent) thought it would over the next three years.
Looking at aspects of quality in the next 12 months, around half of respondents predicted improvements in clinical outcomes (58 per cent), safety (50 per cent) and experience of patients (48 per cent).
Around one in ten thought clinical outcomes (11 per cent) and safety (10 per cent ) would worsen. And, significantly, a third (32 per cent) felt that the experience of patients would suffer.
The area of greatest concern however was patient access, which encompasses the availability of care and waiting times. In all, 53 per cent felt this would worsen, while only 21 per cent thought it would improve.
The NHS Confederation also asked for views about the impact of cuts in local authority spending on the NHS. Three quarters of respondents (75 per cent ) said these would definitely impact on their services, while 85 per cent said the issue would be problematic and 24 per cent said it would be "extremely problematic".
The vast majority predicted an increase in demand for community (88 per cent), mental health (72 per cent), and primary care services (71 per cent). They also predicted increases in delayed discharges from hospital (86 per cent), acute admissions to hospital (63 per cent), emergency readmissions to hospital (63 per cent ) and A&E attendances (55 per cent).
Improving efficiency and quality
Despite the concerns, 76 per cent said they were confident of meeting their objectives for quality and efficiency over the next 12 months. But one in four (24 per cent) were not confident.
When respondents were asked to name the main steps being taken over the next 12 months to ensure their organisation delivers efficiency saving and productivity gains, the most common responses fell under the following categories:
- redesigning, reconfiguring or improving patient services to make them more efficient and productive (91 per cent of respondents);
- reducing general staffing costs (53 per cent);
- reducing management and administrative costs (39 per cent);
When respondents were asked to name the main steps being taken by their organisation over the next 12 months to safeguard and improve the quality of services, the most common responses fell under the following categories:
- reviewing and redesigning care pathways and processes (66 per cent of respondents);
- reviewing and strengthening clinical governance and quality management systems (46 per cent);
- increasing focus on patient experience and feedback (22 per cent).
The Confederation asked respondents to identify the issues external to their organisation that made it harder for them to achieve their objectives on efficiency and quality.
Delivering NHS reforms and savings simultaneously was the biggest barrier, with four out of five (85 per cent) ranking this among their top three concerns. The second biggest barrier was a lack of certainty over the reforms (top three for 70 per cent) followed by cuts in local authority services (top three for 51 per cent).
Identifying what would help overcome these barriers, respondents highlighted: certainty over NHS reforms (top three for 68 per cent);stronger partnerships with local government (top three for 53 per cent); effective patient and public engagement (top three for 40 per cent); and strong political support at the local level (top three for 32 per cent).