Case Study

Acting early to restart elective work at Bolton NHS Foundation Trust

How Bolton and system partners in Greater Manchester approached restarting elective services.

7 October 2021

Bolton NHS Foundation Trust took a risk by restarting elective work before funding arrangements were clear but this has allowed it to keep waiting lists and times under control. However, workforce remains a constraint affecting the amount of extra work it can do and running both COVID-19 and non-COVID-19 pathways has raised costs.

What the organisation and system faced

Finance director Annette Walker had to take some deep breathes as her trust moved back to doing elective work – and accept some risk to the financial position.

Bolton NHS Foundation Trust, like much of Greater Manchester, has seen persistently high levels of COVID-19 for much of the pandemic, reflecting the deprived and ethnically diverse area it serves. But when an opportunity to restart elective work presented itself earlier this year, the trust felt it had no option but to go for it, even though there was still uncertainty around the funding.

“We took a financial risk – we had to,” she says. “We felt that in the long term it would be more expensive to keep people waiting because they would decline further and that would be costly.  In the end we took the decision to try to recover as much as could.

“We felt if we did not, we might be back into the winter before we could understand what money was available."

What the organisation and wider system is doing

At the time whether the trust would be adequately reimbursed for this work was unclear and there were mixed messages – operational directors were being told to go for as much work as possible while directors of finance were told to make the books balance, she says. Restarting elective work meant the trust could potentially have £2m to £3m at risk – which the board decided was acceptable for a £400m turnover organisation.

Results and benefits

Acting early has helped the trust keep its waiting list down to under 27,000 in June, its 18-week achievement to a reasonable 68 per cent and it treated more than 80 per cent of cancer cases within 62 days,   

In the end, the trust was reimbursed for the work it did, meeting its elective recovery fund targets for April to June. However, she points out there are perverse incentives in the ERF and once trusts miss the target for restoration of elective work they may be better off financially by not doing any elective work at all.

Overcoming obstacles

Restoring elective work is expensive, she says, requiring trusts to have parallel pathways for covid and non-covid patients and separation within intensive care units. Staff can’t move between the two, reducing flexibility in how they are deployed. In Bolton, three wards which would normally be closed during the summer have been kept open, adding to costs.

The limitation on how much work the trust can do has not been money but availability of workforce: staff are exhausted and reluctant to do extra hours, almost regardless of the rate of pay on offer. The trust has been paying enhanced rates to try to attract staff but tries to work collaboratively with other Greater Manchester trusts to avoid a bidding war.

Sticking to this can be challenging. “There’s a general consensus to try and work collectively but you can’t allow your services to become unsafe,” says Ms Walker. “When you are faced with a situation where you don’t have a clinician over the weekend you have to pay the going rate.”

She suspects these staffing shortages will last for some time and possibly several years– potentially until the available workforce increases with new entrants completing their training. Repeatedly vaccinating the population will also add to workforce pressures. “We will run out of people before we run out of money at the moment,” she says.

In Greater Manchester, the trusts have all set aside some money to address problems collectively – for example, setting up hubs for some procedures. While progress on this so far has been limited, it is likely to be important moving forward. But she adds getting people to travel for care may need approaches such as funding transport costs to encourage them to use the hubs. And different financial arrangements may be needed with trusts being pragmatic about billing arrangements. “All the normal financial barriers have to be dismantled,” she says. “We can’t keep on charging each other small amounts of money.”

The trust was awarded some capital during the pandemic and has been able to make some improvements – a new oxygen tank, a modular same day emergency centre and so forth – but she points out that it is hard to spend capital quickly. Trusts which have run a surplus over years have been able to improve their estate and facilities, she adds, while more financially-challenged trusts have not: this may need to be recognised in future capital allocations.

The second half of this financial year is likely to be challenging, she adds. Funding details are still uncertain, as is the impact of any covid wave over the winter, so it is hard to be clear about what will be asked of trusts but she warns once things stabilise “very significant financial decisions” will need to be taken. At the moment any serious attempt to drive cost improvements is difficult: with many clinicians and managers still grappling with the pandemic, it is difficult to suddenly switch into “cost improvement and transformation mode,” she says. 

“We are still doing cost savings in the background but every time we say we need to concentrate on our cost improvement plan then we go into another wave of covid. When we started on this we did not know we would be in it for the long haul. It is like a mountain that you never get to the top of. And the winter we are facing now is probably far more difficult than the first peak of the pandemic.”

Takeaway tips

  • Trusts may need to accept some financial risk in return for being fleet footed and taking opportunities when they present themselves. If this risk can be quantified, boards may be happier to accept it.
  • Don’t be hidebound by old ways such as not funding patient transport to other sites when planning innovative solutions – the money spent on transport is likely to be minimal compared to the benefits of working differently.
  • As collaborative working develops, trusts will need to find a way to share costs and income without chasing each other for every penny.


For more information, contact Annette Walker.

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