Impact of the Spending Review on health and social care Contents

2The current state of health and social care finances

9.Over the last parliament the Department of Health budget grew by an average of 1.1% a year, from £109.3 billion in 2009–10 to £116.6 billion in 2015–16.8 Unlike many other departments, the Department of Health’s budget has been protected from spending cuts in recent years, while other Government expenditure set at Spending Reviews has declined (from £421.6 billion in 2009–10 to £356.7 billion in 2015–16). As a result, the Department of Health’s share of that expenditure9 grew from 25.8% in 2009–10 to 32.7% in 2015–16.10 Nevertheless the rate at which the budget has increased has been at historically low levels.

Figure 5: Total Health expenditure in England from 2009-10 to 2015-16








expenditure, cash terms (£m)








Annual change, cash terms (%)







expenditure, 2015/16 prices (£m)








Annual change, real terms (%)







Note: Health expenditure is measured as total department expenditure limit, excluding depreciation

Source: HM Treasury. Public Expenditure Statistical Analyses 2015.

10.Figure 6 shows that public spending on health in the UK as a proportion of GDP has fallen in recent years. We were told that overall (public and private) healthcare spending is also low relative to that of comparable countries.11 The figures for 2013 show that the UK spent 8.5% of GDP on public and private health.12 This is lower than the average for OECD countries (9.1%) and for the EU-15 (10.1%).13 Of the EU-15 countries only Luxembourg and Ireland dedicated less of their GDP to health. Austria, Belgium, Denmark, France, Germany, the Netherlands, and Sweden all chose to spend over 10% of their GDP on health care in that year.14 However, a 2014 report by the Commonwealth Fund suggests the UK is a leader in maximising the value from its resources, ranking first out of eleven healthcare systems on measures of efficiency.15

11.John Appleby of the King’s Fund told us that its projections for 2016 suggest NHS spending as a proportion of GDP will fall in 2016, because the UK economy is growing at a faster rate than increases in health spending.16 Likewise, it follows that were a country’s GDP to fall, the measure of health spending as a proportion of its GDP may increase, even if health spending were to remain the same.

Figure 6: Public spending on health in UK as a percentage of national income 1991-92 to 2014–15 (in 2014–15 prices)

12.However, international comparisons of health spending are difficult because the proportion which is spent by individuals, families and charities and the proportion spent by governments and other public bodies varies considerably from country to country. What counts as “health spending” is also the subject of discussion. Five years ago the OECD changed its methodology for defining health spending, removing some things such as capital spending and adding others such as health-related social care and long-term care. Since we finished taking evidence for this inquiry, the Office for National Statistics has published figures for UK health spending for the years 2013 and 2014 using this changed OECD methodology.17 On this basis, the UK’s spending on health in 2013 was 9.9% of GDP—closer to that of other comparable countries, as shown by the following chart, which sets out public and private spending on health combined.

Figure 7: Total (public+private) current health spending in OECD countries, 2013

Source: John Appleby, “Is the UK spending more than we thought on healthcare (and much less on social care)?”, BMJ, 2016;353:i3094 (

13.The UK also fares better in international comparisons if public spending on health is separated from private spending. The chart below shows healthcare spending per person in US$ in 2013.18

Figure 8: Government, private and total expenditure per person on healthcare in 2013, converted to 2013 US dollars at purchasing power parity

Source: Nuffield Trust, using figures from (accessed 14 June 2016)

14.Public satisfaction with the NHS is the second highest it has ever been, and people are just as likely to think the NHS has improved as they are to think it has deteriorated over the past five years.19 On some measures quality has improved. For example, Health and Social Care Information Centre data shows significant improvements in survival following hospital treatment over the past decade for stroke, non-elective surgery, coronary artery bypass grafts, fractured proximal femur and myocardial infarction. On the downside, although waiting times are shorter than they were in 2004–05, they have been getting longer since 2007–08. Part of this may be explained by the increasing demand for services: compared with 2004–5, hospitals are treating 4 million (32%) more patients, the number of GP consultations has increased by an estimated 25% and community care activity has increased by 14%.20

The current financial situation in health

15.Many submissions to the inquiry noted that deficits in NHS providers have been growing and are widespread. In 2014–15, NHS trusts and NHS foundation trusts reported a combined deficit of £843 million.21 This reflects a continued decline in performance from the trusts’ £592 million surplus reported in 2012–13 and the £91 million deficit reported in 2013–14. In total, 115 trusts were in deficit and 125 trusts were in surplus in 2014–15.22

16.NHS Improvement’s provisional data for 2015–16 suggests that the financial situation in trusts continued to deteriorate in 2015–16.23 It reports that NHS trusts and NHS foundation trusts had a combined deficit of £2.45 billion in 2015–16. Halfway through the year, the NHS had predicted an end of year loss of £2.8 billion. As John Appleby of the King’s Fund told us in February, “You can see the downward trend […] this is not just a few isolated mismanaged trusts. This is 95% of all acute trusts—essentially everybody—now looking at a deficit by the end of the year.”24 The point is reinforced by the news that even Salford Royal Foundation Trust, which we visited during our inquiry and which is generally recognised as an example of a well-run and well-managed trust which has made important progress in a number of areas towards the service transformation envisaged in the Five Year Forward View, ran a deficit in 2015–16.25

17.We heard that the deficits can be attributed to three main factors:

Increasing demand

18.It has long been Government policy to try to curb the increasing demand for services and to encourage less expensive alternative forms of care provision, but as Professor Sutton of the University of Manchester explained, initiatives for keeping people out of hospital have so far failed:

We have had 4% growth in emergency admissions last year—but also in planned care and elective admissions. Elective admissions rose 5% and outpatients rose 5%. Although we talk about the important things being prevention, quality, keeping people out of hospitals and treating them closer to home, essentially none of the existing initiatives has been working and there is more activity going through hospitals. If you look, for example, at accident and emergency departments, the increase in attendances there is 2%, but then the people waiting over four hours has risen by 11%. It is clear that there is activity rising, but it is controlling or coping with that level of activity that has been the problem.26

19.Nigel Edwards of the Nuffield Trust shared these views, adding that nowhere in the world has managed to “bend the curve on admissions”.27 Julie Wood of NHS Clinical Commissioners told us that “commissioners are trying to deal with that rise in demand, in terms of contracting for it, and providers are seeking to deliver services with more patients going through, and that has also contributed in part to the deficit that we see.”28

20.Anita Charlesworth of the Health Foundation added that providers report that delayed discharges of care are a “big part of their problems at the moment”.29 Likewise, Professor Briggs, Consultant Orthopaedic Surgeon at the Royal National Orthopaedic Hospital Trust, told us that “at any one time, up to 30% of patients are ready to be discharged. They are blocking beds, which cost about £1,000 a day. We have to unblock those beds. By doing that, you make the whole system much more productive, more efficient and at the same time reduce variation.”30

Payments to providers

21.In response to our questions about deficits, Mr Edwards explained:

If you do not give the trusts the money that they need to deliver what they need and you set them efficiency targets that have never been achieved anywhere in the NHS’s history, do not be surprised if the income separates from the expenditure over time, particularly against a background of growing demand.31

22.The national tariff is the price that hospitals receive for treating particular types of patients. The NHS has historically achieved annual productivity improvements of 0.8%, which have increased to 1.5%–2% in recent years, but the tariff prices have been reduced by an annual 4% efficiency factor since 2011–12.32 John Appleby of the King’s Fund explained to us that “over the last five or, I think, six years the tariff has been reduced in real terms each year to encourage hospitals to be more productive”. However, he added “cost-improvement programmes are yielding less and generating more savings over time has become tougher”. He explained that the result is that costs have become greater than income, and the deficits are the result.33 The Secretary of State for Health acknowledged to us that the 4% efficiency factor used in recent years was “too high” and confirmed that it would be reduced to 2% for 2016–17.34

23.NHS Clinical Commissioners told us that the tariff system “works against long-term priorities by concentrating money and resources on hospital activity”. It explained that the tariff was originally introduced to address hospital waiting list times, therefore rewarding expensive hospital activity, rather than keeping the population healthy and out of hospital.35 Similarly, Professor Mays of the London School of Hygiene and Tropical Medicine told us that the integrated care pioneers have reported that it is difficult to remove the incentive in the tariff to pay for hospital activity. The payment mechanism had therefore acted as a barrier to providing more integrated and coordinated care.36 Professor Sutton of the University of Manchester pointed out that financial strategies that focus on maximising activity in order to maximise revenue may push trusts into deficit if there is an insufficient consideration of costs.37

24.The Chief Executive of NHS Improvement, Jim Mackey, told us in oral evidence in January 2016 that the tariff mechanism is “not fit for what we need to do in the future—or even now”. He said:

We need to look at our payment mechanisms and make sure there is standardisation, where necessary. We support local initiatives. We will create a framework that encourages and supports people to do the things I have just described. That moves away from the kind of widget-counting tariff mechanisms we had a few years ago and will require different instruments. Those instruments might change over time depending on what the issues are.38

Whilst there is a an important role for the “widget-counting” to which Mr Mackey referred insofar as it has provided a degree of transparency about hospital activity which had been difficult to achieve prior to the tariff mechanisms—transparency which it will be important to retain in any reformed system—nonetheless we agree with him that different instruments need to be found to achieve the right incentives within the system.

25.In response to our questions in April 2016 about progress to reform the tariff, Bob Alexander, Executive Director of Resource and Deputy Chief Executive of NHS Improvement, told us:

The tariff function within NHSI is working with colleagues in Simon’s organisation [NHS England] to determine changes that need to be made to payment mechanisms to enable the sorts of changes that the Five Year Forward View articulated and supported. That piece of work needs to go as an enabler of change, not as a leader of change, I think. You need to balance that, and we have started it with some of the things that we did immediately for 2016–17, by calling a halt to tariff changes, the consequences of which were not clear to see. We want to move payment mechanisms; we want to improve them; we want to make them more fit for purpose across the range of service. But the most important thing is to be clear that we understand the consequence of those changes such that when they are implemented they have the desired effect rather than effects that maybe particular organisations or particular services recognise.39

26.The financial situation in the NHS has become increasingly tight. Health spending rose at an historically low rate of 1.1% in real terms between 2009–10 and 2015–16. NHS provider deficits have become so widespread that there is a risk that running a deficit is no longer taken seriously as a sign of poor financial management. The need to manage deficits also risks skewing attention and draining resources from other NHS priorities.

27.We have heard compelling evidence that the current payment system does not drive greater efficiency or support the transformation that is required across the system. The payment system needs to be reformed, so that it does not continue the perverse incentives which can drive inappropriate hospital admissions. It must however ensure that hospitals are paid a fair price, and that the system encourages them to manage their costs appropriately, with care being carried out in the right settings. Whilst we recognise that reforms of this scale cannot be rushed, we note that we and our predecessor Health Committees have been hearing concerns about the payment system for many years. We therefore recommend that NHS England and NHS Improvement set out a clear timetable for reforms to the payment system, and clarify the underlying problems that the changes will address.

Staff costs

28.A key driver of higher costs across the NHS has been the rising dependency on agency staff. NHS spending on this has increased from £2.2 billion in 2009–10 to £3.3 billion in 2014–15.40 The Secretary of State for Heath told us that spending was expected to be as high as £3.7 billion in 2015–16, although it has a target to reduce that to around £2.5 billion in 2016–17.41

29.Anita Charlesworth of the Health Foundation explained how staff shortages have contributed to the problems with agency spending:

The NHS was planning on needing fewer workers; its plans were not to grow the number of workers. We reduced the number of nurses we brought in from other countries in the early years of this decade, we reduced the numbers in training and we have also seen many fewer numbers coming through on return to practice. That was predicated, in essence, on both ability to reduce demand—the number of admissions that would come into the system—and a belief that we could work those nurses harder through reducing ratios. That proved to be unsustainable. We saw the numbers of nurses employed falling; then from 2013 onwards, crudely, we re-employed them but we employed them more expensively.42

30.Professor Cumming of Health Education England told us that “roughly speaking, at the moment, about 7.5% of all clinical posts across England are vacant, but that hides a number of issues. In parts of London, that figure is 15%, and in parts of the north-west that figure is 3.5%, so it is very variable. Our number one issue has been getting the balance right in terms of overall number but also geographical number.”43 Evidence from Professor Cumming in November last year to an earlier inquiry reinforces the point about geographical variation: discussing GP training fill rates, he told us “we have filled all the training jobs in London and the south-east and drawn predominantly from the north and the east, with bits of the west midlands and the east midlands thrown in. In the north and the east numbers have gone down, in London the numbers have gone up.”44

31.Anita Charlesworth told us that “critical to being able to hold down the pay problem and to hold down the agency costs problem is being able to recruit and retain”. She argues that a failure to have a “fit-for-purpose workforce strategy” is an underlying issue at the heart of the deficit.45 She reflected that workforce planning needs to include an understanding of why so many nurses leave the profession and a programme of work to address those concerns. Some 24,000 nurses left the nursing register in 2012–13, for example, to retire from practice or change career. However, the number completing return to practice courses has reduced from around 18,500 between 1999 and 2004 to around 4,800 from 2010 to 201446. The Secretary of State acknowledged to us that the issue of workforce planning has been “a problem over decades”.47

32.Christina McAnea of Unison told us “in terms of an individual’s choice to go and work for an agency, part of that is because of the pay rates that they get—so they get extra money—but a big part is also about flexibility and they feel they have more control over the hours they are having to work by choosing to work for an agency.” She added that people who leave the profession say they do so because of low pay and wanting more flexible working and the feeling of being valued and rewarded.48

33.To help reduce the size of the provider deficits, the Department announced in June 2015 that it would introduce controls on agency staff spending by trusts. These include an annual ceiling on the level of nursing agency spend (implemented from 1 October 2015) and a shift-based or day/hourly rate-cap for agency staffing (implemented from 23 November 2015). The Secretary of State for Health told us that since introducing these controls, the NHS had saved £290 million compared with its trajectory of agency spending, which had been forecast to be £4 billion in 2015–16. He added that two thirds of trusts say they are making savings as result of the controls and nurse agency costs are 10% lower than in October.49 We welcome this progress, although note that the NHS has some way to go if it is to meet its target of reducing agency spending from £3.7 billion in 2015–16 to around £2.5 billion.

34.Contrasting with the growing cost of agency staff are the constraints which have been placed on pay for permanent NHS staff. The British Medical Association told us that “staff have borne a disproportionate burden of efficiency savings so far”. It highlighted that in 2011–12 and 2012–13, some £1.7 billion of savings were made from pay freezes.50 Christina McAnea of Unison told us “between 2010 and until now, if I use a nurse as an example, if it had kept pace with RPI, a nurse would be earning £4,700 more today than they currently earn.”51 Similarly, the Shelford Group, which represents ten academic NHS organisations, expressed concern that what it called the “disparity between private and public sector will result in potentially significant difficulties in public sector recruitment and retention.” The Group recommends reviewing the public sector maximum pay awards, particularly in light of challenges around nurse shortages and the need to ensure safe staffing across health and social care services.52

35.In March 2016, the Government announced that the NHS will hold pay at 1% a year over the spending review period—a move which may be unsustainable. The Office for Budget Responsibility has estimated that pay rates for the rest of the economy will increase by between 2.6% and 3.6% annually over the spending review period,53 widening the NHS pay gap with comparable roles in other sectors. There is a risk that a rigid long-term squeeze on pay will impact on the ability to recruit and retain NHS staff, and increase the reliance on more expensive agency staff.

36.There is no doubt that spending on agency staff on the scale seen since 2009–10 has been a major contributor to provider deficits. The cap on agency costs and rates has helped to turn the corner, but this may be undermined by the widening gap between NHS pay and that for comparable jobs outside the NHS. Over the previous Parliament, much of the efficiency gain was achieved thanks to a pay freeze, but a long-term pay squeeze has unintended consequences for recruitment and retention, which may drive higher costs. The problems with agency spending are likely to remain until the underlying issues of workforce supply and staff shortages are addressed. We therefore call on the Government to set out its plan for how it will recruit and retain the NHS future workforce, including by making working as a permanent member of staff a more attractive option.

Managing the financial situation

37.The Department of Health came extremely close to exceeding its £111 billion revenue budget authorised by Parliament in 2014–15, underspending by just £1.2 million, or 0.001%.54 In February 2015, the Department needed to increase its overall budget for 2015–16 by £205 million to avoid breaching its limit.55 In addition, the Department made a capital to resource budget transfer of £945 million to cover the deficits in the provider sector. The Director General of Finance at the Department of Health told us that it was too soon to know whether the Department has stayed within its control total for 2015–16: those figures will be published with the Department’s Annual Report and Accounts, expected in the summer.56

38.This is the second year in a row that the Department has used money originally intended for capital projects to cover deficits in current spending. Anita Charlesworth of the Health Foundation told us that “the underlying finances are worse than the current financial picture looks because much of the current finances are predicated on capital to resource transfers. That is fine for the short term, but we are overtrading and we are using what should be investment funds to bail out day to day running costs.”57 The Department’s written submission shows that current spending on capital will remain at £4.81bn over the spending review period. This means that, by 2020–21, capital spending will have decreased to £4.37bn in real terms (after adjusting for inflation).58 This figure will be further eroded if there are ongoing capital to resource transfers.

39.Commentators are concerned about the squeeze on capital investment. NHS Providers said that “as we look to create a world class health service for the 21st century, the upgrade of NHS estate and diagnostic equipment is essential to patient safety and operational efficiency. Essential work needed between now and 2020 must be properly assessed and considered against the significant restrictions on capital expenditure resulting from the settlement, which members tell us are a cause of concern.”59 This will reduce the capital-to-labour ratio, the likelihood being that this will reduce NHS productivity. In response to our questions about capital funding, Simon Stevens said it was not yet possible to judge whether there would be sufficient funding. He added that local sustainability and transformation plans will be produced by the summer of 2016 outlining “what it would take to lubricate change” in their area and “then we will have some tough prioritisation to make, but we will be able to exemplify what the case would be for good capital investment in some of those geographies.”60 We took a clear message from his responses to our questioning that the level of capital investment in the NHS over the spending review period is a matter of some concern. For instance, asked whether he was confident that the NHS capital budget was going to be sufficient, Mr Stevens said that he would not be able to answer that question until he knew more about the backlog of maintenance and other capital requirements for the NHS.61

40.Concerns have also been raised that in 2015–16, NHS Improvement told trusts that “we need boards and executive teams to pursue all possible and legitimate savings that can be made from reviewing balance sheets (specifically reviewing areas such as accruals and bad debt provisions)”.62 The Director General of Finance at the Department told us that “it is not just clever accounting, but, as you will know from the 2014–15 accounts, the overall out turn at group level is quite tightly managed and we want to make sure that we are making every effort this year as well to deliver within the sums voted out by Parliament.”63

41.However, we remain concerned that the NHS may be using accounting devices to balance the books. Changes to accounting estimates do not change the underlying financial position, but may, for example, push expenditure into successive years. The overall impact of such measures is to give a false impression that the current financial situation is better than it is.

42.We are concerned that the Government has resorted to short-term measures to deal with the financial situation. Capital was transferred to revenue for the second year running in 2015–16 and trusts were encouraged to review their accounting estimates for savings. We are concerned that these measures are masking the true scale of the underlying financial problems facing the NHS. We are also concerned about the consequences of repeated raids on the capital budget to meet current spending, especially as that budget is already set to reduce in real terms over the spending review period.

43.Anita Charlesworth of the Health Foundation reflected that NHS and policy has been “too focused on short-term tactical solutions.” She explained that many of the savings in the NHS have been made by one-off changes such as abolishing primary care trusts and strategic health authorities. She added “we dealt with it as a short-term problem to get through and then thought everything would return to normal rather than tackling the underlying challenge of embedding improvement in the way we work.”64

44.The conclusion we draw from the evidence we have heard is that the proposed strategies for reducing costs—cutting the tariff price (albeit at a lower rate), strict pay restraint, imposing agency price caps and reducing capital spending—are not sustainable ways of securing long-term efficiencies. The NHS will need a new approach if it is to adapt to increasing patient demand and funding constraints.

The current situation in social care

45.Alongside pressures on health spending there have been even tighter financial constraints in local authority social service departments. The National Audit Office (NAO) estimates that government funding to local authorities reduced in real-terms by 37% between 2010–11 and 2015–16.65

46.Many of the submissions to the inquiry stressed the financial pressures currently faced by local government and generally in social care. ADASS told us that “local authorities have shouldered more of the spending cuts than the rest of government” with central government funding for local authorities having been cut by 40% in real terms over the last spending period.

ADASS reported that adult social care budgets reduced by some £4.6 billion (31%) from 2010–11 to 2015–16.66 Sarah Pickup of the Local Government Association (LGA) told us that pressures on social care funding have been compounded by demographic changes as a result of an increasing number of older people with greater need, as well as increases to national insurance and pension fund costs.67

47.ADASS, the LGA and others reported that local authorities have responded to budget pressures by reducing the availability of social care. ADASS told us that in June 2015, some 400,000 fewer disabled and older people received social care than in 2009–10. It highlighted the results of its survey of councils which in 2015–16 found that some £228 million (28%) of reported “efficiencies” were in fact met by reducing volumes of care packages.68 Ray James of ADASS explained that “in essence, what we have probably seen is people with lower-level needs not being supported as much by councils.”69 In other words, this has resulted not only in reduced numbers of people who have been eligible for care but in a reduction of the packages of care received.

48.Local authorities have reduced the prices they pay for social care and we have heard that in some cases, the rates are no longer financially viable. Sarah Pickup of the LGA told us that there was already evidence that some providers were moving out of the local authority market.70 Professor Green of Care England shared these concerns, adding that its work has identified that around 50% of services would no longer be viable in some areas. He told us:

It is already happening. We have seen people withdrawing from contracts. We have seen it in the domiciliary care sector. Certainly, some organisations are saying, “We are no longer going to develop services in particular areas” and it will not be long before they start saying, “It is not viable and we are going to close in certain areas”.71

49.Care England told us that, in the interest of financial viability, some care homes are no longer taking local authority clients, creating the risk of a “two-tier system” of care emerging between those who can and cannot fund their own care.72 Professor Green was concerned this may have an impact on the geographical distribution of services:

In some areas, particularly those where there are large numbers of self-funders, we are getting the development of some new services. But when we look across other parts where we are dependent upon public funding, we see lots of services that are in danger of closing. What I think we will see is the demand and supply equation changing as a result of this. It will not happen immediately but it will happen over a period of probably a year to 18 months but it will definitely have an impact, so there will not be the services available in some areas. One of the challenges is that it will be very geographical and there will be some areas where more services will go down because they are reliant on public funding.73

The impact of pressures in social care funding on health

50.The reductions in social care funding have led to adverse consequences for the NHS. Dr José-Luis Fernández of the London School of Economics told us “there is now growing evidence that there is a clear interrelationship between health and social care. For example, by providing more social care you reduce demand, to some extent, on the healthcare system, or there is complementarity between the two systems so that by providing social care you make the activity on the healthcare side more effective.”74

51.Supplementary evidence to our inquiry from NHS England (NHSE) referred to the adequacy of funding for social care as one of the “five tests” which NHSE used to assess the outcome of the Spending Review relative to the Five Year Forward View:

[…] the Forward View made the obvious point that the level of patient demand on the NHS is partly a function of the availability of social care, particularly for frail older people. The SR makes some welcome moves to hypothecate new funding streams for social care, but the overall funding quantum nationally and the distributional effects across England still imply a widening gap between growing need and available services. If unaddressed this would result in extra demand on GPs, community health services and hospitals over and above the FYFV NHS cost estimates. Our ‘fifth test’ should therefore be regarded as ‘unfinished business’.75

52.The Secretary of State for Health told us his department is “very conscious” of how pressures in social care are impacting on health. For example, reduced social care support may mean that people go to A&E when their problems become critical; and difficulties putting adequate care packages in place contribute to delays in discharging patients from hospital.

53.We are concerned about the effect of reduced access to adult social care as a result of the cuts to funding and the impact of this on the NHS. Given the evidence of the linkages between health and social care, we were concerned that none of the senior officials giving evidence from the Department of Health, NHS England or NHS Improvement were able to quantify the financial cost of one of the most visible interfaces between health and social care, namely delayed transfers of care as a result of not having adequate social care packages in place. The supplementary evidence sent to us by the Department, NHS England and NHS Improvement following the session was able only to refer us to estimates from a recent National Audit Office report.76

54.We recommend that the Government urgently assess and set out publicly the additional costs to the NHS as a result of delayed transfers of care, and the wider costs to the NHS associated with pressures on adult social care budgets more generally. That assessment should be accompanied by a plan for adult social care which demonstrates that the Government is addressing the situation in social care and dealing with its effect on health services.

8 The Department of Health budget is measured as the Total Department Expenditure limit (DEL) in 2015-16 prices, excluding depreciation.

9 This excludes about half of total government spending, which is harder to control, volatile and/or demand-led, and therefore not subject to the firm multi-year limits that are set at Spending Reviews. The main such area of spending is benefits and tax credits.

10 Source: House of Commons Scrutiny Unit

11 CSR 0091, para 1.4; Q4; Qq 49–50.

13 The EU 15 are the member countries in the European Union prior to the accession of ten candidate countries on 1 May 2015. They are comprised of the following 15 countries: Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Luxembourg, Netherlands, Portugal, Spain, Sweden, and the United Kingdom.

15 The eleven healthcare systems examined by the Commonwealth Fund are: Australia, Canada, France, Germany, Netherlands, New Zealand, Norway, Sweden, Switzerland, the UK and the USA.

16 Q 48

17 The UK Health Accounts 2014, Office for National Statistics, published May 2016

18 Using the old definition of healthcare spending: equivalent figures using the new definition are not yet available.

19 Appleby J, Robertson R, Taylor E. Public Attitudes towards the NHS in Austere Times; 2015:1-20.

20 Professor Andrew Street (CSR0094), para 5 and 8.

21 National Audit Office, Sustainability and financial performance of acute hospital trusts, 16 December 2015

22 ibid.

23 NHS Improvement, Quarter four sector performance report, 20 May 2016. (accessed 12 July 2016)

24 Q47

26 Q2

27 Q47

28 Q92

29 Q70

30 Q112

31 Q47

32 National Audit Office, Sustainability and financial performance of acute hospital trusts, 16 December 2015

33 Q47

34 Q317

35 NHS Clinical Commissioners (CSR65) para 4.11

36 Q11

37 Qq18-19

39 Q322

40 National Audit Office, Managing the supply of NHS clinical staff in England, February 2016.

41 Q313

42 Q47

43 Q165

45 Q47

46 National Audit Office, Managing the supply of NHS clinical staff in England, February 2016.

47 Q354

48 Q186

49 Q311

50 British Medical Association (CSR0063), para 2.2.

51 Q147

52 The Shelford Group (CSR0093),para 4.1.

53 Table 1.1: Overview of the economy forecast,

54 National Audit Office, Sustainability and financial performance of acute hospital trusts, December 2015.

56 Q301

57 Q70

58 Department of Health (CSR42) para 16. See also figure 2 above.

59 NHS Providers (CSR36) para 15

60 Q304

61 Qq 305-06

62 NHS Improvement, Quarterly report on the performance of the NHS provider sector: 9 months ended 31 December 2015.

63 Q302

64 Q47

65 National Audit Office, Financial sustainability of local authorities 2014, p. 4, 19 November 2014

66 Association of Directors of Adult Social Care (CSR86) paras 3, 55. According to the ADASS Budget Survey for 2015, the organisation had, since 2010, “tracked a total of £4.6 billion budget reductions for Adult Social Care. This is equivalent [to] 31% of the 2010/11 Net Adult Social Care budget, and the £4.6 billion cumulative savings over 5 years equates to cash reductions of £1.6 billion, demographic increases of £1.75 billion and price pressures of £1.25 billion.”

67 Q 195

68 ADASS (CSR86) para 7

69 Q196

70 Q206

71 Ibid.

72 Care England (CSR5) para 2.3

73 Q198

74 Q31

75 Supplementary evidence from NHS England (CSR107), Chapter 4.

76 CSR108, section 4.

© Parliamentary copyright 2015

15 July 2016