Reflections on NHS Confed Expo - 'what culture am I responsible for creating?'

It has been a few weeks now since the NHS Confed Expo, and we have taken time to ‘listen with fascination’ and reflect on all the things we heard.

There is no doubt that across the health & care system, there are multiple priorities that people are working incredibly hard on.  There were lots of conversations about the financial challenge, and the need to ensure we continue to balance high quality care, in a context where savings of close to 10% are required across some systems; a real commitment from executives and their teams support the drive to reduce waiting lists; enhance the progress of digital solutions; redesign care pathways to truly integrate care; and support greater collaboration across providers, and ambulance Trusts.  It certainly is a busy time in the NHS!

Central to these changes of course is workforce. Pay represents around 70% of the revenue for each health organisation, and therefore to achieve any of the target areas referenced earlier, we are going to have to think differently about a workforce challenge that was there long before Covid hit us.  Significant vacancies, often in areas that support the drive to reduce waiting lists, will lead to increases in agency spend at a time when many Trusts and Systems are providing greater oversight and scrutiny of spend in this area, and there was much talk about whether the NHS is an attractive place to work given the culture challenge, and public satisfaction.

It is widely acknowledged that some of the challenges are unique to their respective part of the system.  For example, mental health nursing has seen higher vacancy rates than acute based nursing over recent years, and anecdotally, we also know that vacancy rates in social care and community care have risen too.  The impact for patients/service users is felt right across the system, whether that be delays in receiving care at home, implementation of packages of care (resulting in discharge delays), ambulance delays, or waiting for diagnostic and elective treatment.

Creating a ‘one system workforce’ must be a priority for health leaders, but the case for change needs to be compelling.  Talking generically about mobilisation of a workforce across a system sounds like an obvious solution, but if we are honest, there are so many things that Trusts and Systems are performance managed against, and creating a one system workforce isn’t currently one of them.  The development of the NHS Long Term Workforce Plan was largely seen as a positive move forward, and whilst a plan for social care (via Skills for Care) is being developed, the fact that they haven’t been developed together may result in different strategic aims, and a lack of alignment – ultimately with the outcome being a lack of progress toward creating a one system workforce.

That compelling case for change must include the things that health leaders, patients and their representative groups are asking for.  Our reflections from NHS Confed Expo on the top 5 are summarised below:

1)    Greater accessibility of care provision at home, or closer to home. 

There will be examples across the country where a fair number of emergency department presentations each day are as a result of workforce shortages in social and community care; patients who have become more unwell, and now need acute care.  The saddest thing is that many of these patients may spend weeks, or even months in hospital due to their care needs changing – it could be argued that with the right level of workforce in social care, that these examples could be avoided. 

We see in the work we do across the Country on UEC, that with the right approach, sustainable improvements can be made (Integrated care - KPMG UK)

Acknowledging the variation in terms & conditions and pay, it is worth considering how a more flexible employment model could better support the provision of care across the system.  For example, could lead employer models be established, with rotational roles across the different sectors - if a percentage of healthcare assistant roles and/or the associated budget be transferred from a hospital setting to social care, could we see a reduction in emergency department presentations?  Rotational roles already exist in the NHS (e.g. Physiotherapy), with some moving across employers.  If doing this in other key roles that would see reductions in areas where a lack of provision in social care results in hospital admissions (such as long-term conditions like COPD, or, falls), surely its worth now really considering.

 2)    Greater productivity

Productivity was certainly a word we heard many times at Confed Expo.  With many integrated care systems reporting an off plan financial position this year, the challenge is on to improve productivity, and manage the finances.  Investing more in to social care will undoubtedly see benefits both operationally, and financially – analysis from NHS Confederation shows that the greatest economic return comes from investing in primary and community care – seeing £14 added to the economy for every £1 invested, and a tangible reduction in demand for hospital and emergency care – a stark contrast to the NHS, where the same analysis shows that for every £1 invested, there is a return of £4 in gross value added (GVA). 

Therefore, regardless of the unpredictable funding streams, if we are to achieve the triple aim of reinforcing the workforce in social care, reducing demand in hospital and emergency care, and achieving financial balance, it may seem prudent for ICS’ to relook at which parts of the system would benefit from greater investment, and provide a greater return.  We also note from political manifestos, that some parties intend to invest more in primary care, and less in hospitals – a move that may expedite integration.

One challenge we reflected on was whether productivity was being considered beyond this financial year.  Productivity needs to be aligned to workforce, cost and activity over the next 5-10 years, and most systems have no way of knowing whether they are training enough people for the future, or whether the workforce model meets the demand in each speciality in the future (How the KPMG Strategic Workforce Planner will help you to respond to the NHS' workforce challenges).  Only with an integrated workforce planning solution can systems really plan for the future, and start to redesign care that then evidences improvements in productivity. 

 3)    Safe, Effective & Responsive Care

Without question, most of the people we spoke to at Confed Expo were concerned about the ability to continue providing safe, effective and responsive care in the context of the financial challenge. Those working in ‘the system’ are doing their absolute best, and with retention rates improving slightly, perhaps there is a glimmer of light that the pressure will start to ease.  However, will it ease quick enough, and are there ways that integrated care systems can develop an integrated workforce solution that will further ease the burden, and ensure safe, effective and responsive care across all parts of the health & care system.  At last years Confed Expo, we heard David Sloman say that all parts of the health system need to be ‘healthy’ in order for it to flourish, and when one part of the system is unwell, others should step in and get them healthy again.

With public satisfaction with the NHS at the lowest level since 1983, its clear that there is a lot to do for integrated care systems to restore confidence to the communities they serve; Waiting times have increased for those waiting over 12 hours for an emergency admission over the busy winter period; but overall, waiting lists are improving, albeit there are still almost 8m people waiting for treatment.  Much of the statistical focus is on the NHS, but unless there is an integrated solution, it is fair to question whether there will be the necessary improvement and intervention in areas such as social and community care.

 4)    Financial Balance

The elephant in the room, but one that everyone acknowledged was there.  Most Systems had recently submitted their response to the NHS operational planning guidance, and there was much discussion about the challenge of achieving financial balance this year.

We know that, in the face of increasing financial pressures, the typical response is to fall back on traditional, blunt, cost-out methods, and non-recurring schemes rather than transformational ones was something most systems were relying on in 2024/25.  With targets across some systems of almost 10%, you can see why some may be pushed into short term initiatives, but the real sustainable change comes from a proven methodology for continuous quality improvement to deliver sustainable change, and to not see things as an isolated challenge.  As an example, the financial challenge cannot be solved without considering the workforce impact; the productivity challenge cannot be solved without alignment of workforce and cost, and the waiting list challenge cannot be solved without considering finance and capital.

There is an argument that there is still a lack of financial efficiency in the NHS, and we certainly see elements of that in the work we do with our clients.  Yet simply seeing this as an annual issue needs a rethink, and we need to start thinking about the financial challenge across 2-3 years – this includes investment in capital and digital solutions to drive efficiency in patient services, and consolidation or scaling of corporate services too.

We think its time for a new approach to financial recovery https://www.linkedin.com/posts/robert-arthur-ca_nhs-financial-sustainability-time-for-a-activity-7198980227941711873-YT44?utm_source=share&utm_medium=member_desktop

 5)    Digital Transformation

It was genuinely great to hear and see the examples of true innovation at Expo.  It is clear that some Trusts and Systems are embracing digital transformation, and it is having a positive impact for patients.  Yet we also heard that many Trusts and Systems simply do not have the money to invest in digital solutions, and therefore are wedded to traditional ways of delivering care, in the full knowledge that there are better and more efficient methods out there.

We know (from a new Forrester study with KPMG) that fewer than one in five senior healthcare executives (19%) believe their organisations’ attempts at digital transformation have been completely successfully and more than half of them admit that their transformation efforts are hampered by a lack of a coherent technology strategy. A lack of staff training, budget constraints and concerns over security also feature prominently on their list of barriers to a more successful transformation.

These findings come from research undertaken by Forrester Consulting on behalf of KPMG – for which senior digital decision-makers from across the entire public sector were canvassed (you can read the full article here Work still to be done on accelerating digital transform - KPMG UK)

With every challenge, there are greater opportunities, and the resilience, optimism and commitment from managers across the health system remains resolute.  However, the investment in digital transformation needs sharper focus, with systems learning from each other quickly about what works well in tackling the key challenges of UEC, finance, workforce and elective & diagnostic recovery – and dare I say, learning from health organisations across the world who have tackled similar issues with greater success.

Lastly, we heard a lot about leadership from Lord Victor Adebowale, and in particular the need to drive the right culture.  He asked the audience to take a moment, and ask an honest question – what culture am I responsible for creating? It was certainly something that leaders were talking about later in the day, particularly in the context of the 5 areas I have referenced above.

So, I will ask it again, but with a twist.  ‘What culture are we creating, and importantly, what legacy are we leaving?’

You can read more healthcare insights from KPMG here Healthcare - KPMG UK

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Michael Allen Jenny Panes Jason Parker Beccy Fenton Amit Sethi Dr Jaz Dhaliwal, MD, MBA Chris Gibbons Robert Arthur Sarah Bickerstaffe Gina Naguib-Roberts Richard Mills