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report cover showing the entrance to St Christopher's hospice

End of life care

“Good end of life care should mean that people are treated with dignity and respect and, where possible, in their preferred place of care. Some people receive high standards of care in their final weeks, days and hours, but others do not. Organisations responsible for the care of people approaching the end of their life need to improve the planning and delivery of services, particularly support in the community. There is scope to make these improvements by using both existing and planned additional resources more efficiently and effectively.”

26 Nov 2008
Report cover showing an older patient

Ensuring the effective discharge of older patients from NHS acute hospitals

“Many tens of thousands of older people each year find themselves unable to leave hospital, even though their treatment has been completed. This significantly reduces their quality of life and undermines the ability of hospitals to treat more patients and meet testing targets.

“The Department of Health has made strides in the last 18 months to address this problem but the pressures on the health and social care systems are unrelenting. This is a classic case of the need for ‘joined-up government’ with the NHS, local authorities and private and voluntary sector care providers working together. The Department should ensure that it is doing everything it can to allow this to happen.”

12 Feb 2003
Report cover showing a rail accident

Facing the Challenge: NHS Emergency Planning in England

“Since the events of September 11, the NHS has made a concerted effort to improve its planning and preparedness for dealing with major incidents and in many respects has succeeded. But there is still room for improvement in the systems in place to ensure that the NHS response is as good as possible.

“I recognise that there are limits to what can be done in improving readiness. Some incidents are of a scale for which no organisation could expect to be fully prepared. And it does not necessarily make sense for everyone in the NHS to be prepared for every eventuality.

“However, the nature of the threats now potentially facing us means that the Department of Health and the Chief Executives of hospital, ambulance and primary care trusts need to continue to act with determination to improve their planning and readiness.”

15 Nov 2002
Report cover showing two people discussing complaints

Feeding back? Learning from complaints handling in health and social care

“The complaints systems for health and social care are not yet as accessible and responsive as they could be. There is a lack of learning from complaints, and providers are not making clear to users that services are being improved as result. Adequate staff training; proper tackling of complaints; and evidence of improvements in response to complaints are key pointers for the planned introduction of a new comprehensive complaints system across health and social care next year.”

10 Oct 2008
Report cover

Financial management in the NHS – NHS Summarised Accounts 2003-2004

“Financial management is now a matter of major concern for the NHS. The Department’s welcome policy of greater transparency on financial matters means that many of the old practices which obscured the year-end financial position are no longer possible. We can now see where the real financial problems lie which is the first important step on the way to addressing them. Important reforms like Payment by Results and the new financial regime for NHS Foundation Trusts are also increasing the risks and demand first class financial management. All NHS bodies need to reassess their own financial management arrangements in the light of this report. We will help in that process. For the first time our auditors will now score PCT and NHS Trust financial management arrangements and show clearly what needs to be done to secure improvement.”

NAO head Sir John Bourn said today:

“2003-04 was a relatively stable year in terms of challenges facing NHS financial management but, even so, a number of bodies clearly found it difficult to manage their resources effectively. The major developments taking place in 2004-05 and beyond will pose unprecedented challenges with which all bodies in the NHS will have to deal.

“The NHS faces the considerable task of improving its financial management to meet the new challenges. Both the NAO and the Audit Commission are committed to supporting the NHS in this task.”

Background information

In 2003-04 auditors gave unqualified audit opinions on the truth and fairness of the accounts of all Strategic Health Authorities, Primary Care Trusts and NHS Trusts. The NAO’s Comptroller and Auditor General was therefore able to give an unqualified opinion on the truth and fairness of the summarised accounts of these bodies.

Furthermore the appointed auditors gave unqualified opinions on the regularity of expenditure on all of the Strategic Health Authorities’ and Primary Care Trusts’ accounts, except for 53 Primary Care Trusts in 2003-04. These qualifications arose because of 42 breaches of resource limits and 13 instances of other irregular expenditure (two of these accounts were qualified both for resource limit breaches and for incurring other irregular expenditure). However, NAO head, Sir John Bourn, did not qualify his opinion on the summarised accounts of Primary Care Trusts, since there are no overall resource limits for the aggregate expenditure of these organisations. He also gave an unqualified regularity opinion on the summarised accounts of Strategic Health Authorities.

Financial performance in 2003-04

The aggregate underspend for all NHS bodies was £72 million (0.12 per cent of total expenditure) compared with an underspend of £96 million (0.18 per cent) in 2002-03. 106 NHS bodies (18 per cent) failed to achieve in-year financial balance, compared with 71 (12 per cent) in 2002-03. 24 per cent of NHS Trusts did not achieve break-even and 14 per cent of Primary Care Trusts failed to keep expenditure within their revenue resource limit. In most cases the deficits were small both in absolute terms and in proportion to turnover.

A small number of NHS bodies are struggling to manage large deficits. The number of significant in-year deficits (of over 0.5 per cent of income or available revenue resources) increased to 13 per cent (from 8 per cent in 2002-03). 12 NHS trusts reported a deficit of over £5 million in 2003-04, compared to seven in 2002-03. Four Primary Care Trusts had revenue resource limit overspends of over £5 million compared to three in 2002-03. The number of bodies with significant deficits and the size of those deficits would have been greater without specific financial support either from Strategic Health Authorities or centrally.

No Strategic Health Authority reported revenue overspends in 2003-04. However, Strategic Health Authorities have a target of delivering financial balance in aggregate across the NHS bodies within their area. Seven Strategic Health Authority areas reported an aggregate overspend in 2003-04 compared with six in 2002-03.

Key themes for improved financial management

The NAO and Audit Commission looked at four key financial management themes and made specific recommendations to aid improvement aimed at both the Department of Health and individual NHS bodies.

The four themes are: the role of the board in improving financial management; improving forecasting of the year-end position; the earlier production and audit of the annual accounts; and increasing the transparency of financial reporting.

Financial issues arising in 2004-05 and beyond

There are a significant number of financial management issues that NHS bodies faced for the first time in 2004-05.

Some NHS bodies have experienced increased financial pressures in 2004-05, with auditors currently reporting concerns about financial standing at 32 per cent of NHS bodies and the NHS as a whole forecasting a small financial deficit. The Department is estimating that at least 12 Strategic Health Authority areas will report an aggregate overspend in 2004-05, compared with seven Strategic Health Authority areas in 2003-04 and six Strategic Health Authority areas in 2002-03.

The creation of the first foundation trusts from 1 April 2004 and the need for services to be commissioned from them using Payment by Results has meant that NHS bodies are having to change the way they operate financially. They will in particular have to enhance their risk identification and forecasting skills. These changes will support the Department’s wider agenda for system reform which the Department expects will offer the potential for improved performance.

The introduction of new contracts of employment and the National Programme for IT are also placing pressure on scarce resources. The new consultants’ contract caused particular difficulty in 2004-5 and the Department has made extra money available in 2005-6 to meet the pressures.

Hard copies can be obtained from The Stationery Office on 0845 702 3474. The Comptroller and Auditor General, Sir John Bourn, is the head of the National Audit Office which employs some 800 staff. He and the NAO are totally independent of Government. He certifies the accounts of all Government departments and a wide range of other public sector bodies; and he has statutory authority to report to Parliament on the economy, efficiency and effectiveness with which departments and other bodies have used their resources.

National Audit Office press enquiries:
Barry Lester, Tel: 020 7798 7937
Mobile: 07748 181692

The Audit Commission is an independent body responsible for ensuring that public money is spent economically, efficiently and effectively, to achieve high quality local and national services for the public. Our remit covers around 11,000 bodies in England, which between them spend more than £180 billion of public money each year. Our work covers local government, health, housing, community safety and fire and rescue services.

As an independent watchdog, we provide important information on the quality of public services. As a driving force for improvement in those services, we provide practical recommendations and spread best practice. As an independent auditor, we monitor spending to ensure that public services are good value for money.

For further information about the Audit Commission, visit our website at

Audit Commission press enquiries: Nigel Watts, Tel: 020 7166 2129
Mobile: 07813 315538

2 Jun 2005
Report cover showing hospital with ambulances

Financial management in the NHS – NHS Summarised Accounts 2004-2005

‘There is no single cause of the deficits at NHS bodies and no single answer either. There are some systemic issues that have contributed to the deterioration in financial performance, but there are also local failings. The Commission is exploring this in more depth in two forthcoming reports – the review of the NHS financial management and accounting regime requested by the Secretary of State and Learning the Lessons from Financial Failure. Both of these reports will make recommendations to help put the NHS back onto a firmer financial footing.

‘One thing is clearer than ever: financial balance can only be achieved with commitment from finance staff, managers, clinicians and Board members. However the requirement for high quality, timely accounts must not be overlooked. There have been acknowledged weaknesses in the accounts of the NHS bodies and in 2004-05 there was evidence of inappropriate adjustments or omissions in more than a fifth of the accounts submitted for audit by NHS bodies. We have worked with NHS bodies, the Department of Health and NAO to address the weaknesses and hope to see an improvement in the quality of the 2005-06 accounts.’

Sir John Bourn, head of the NAO, said:

‘Many NHS bodies are managing their finances well, but it is worrying that a significant number are in deficit. All parts of the NHS and staff throughout the organisation must act together and take responsibility for improving financial management.

‘It is especially vital that financial control is not weakened as NHS bodies prepare for the impact of mergers and restructuring, as well as implementing Payment by Results and other national initiatives. It is also imperative that NHS bodies improve the quality of information underpinning both management and annual accounts. As well as supporting NHS Boards in informed decision-making, this will also allow local and national NHS accounts to be prepared, audited and published sooner.’

7 Jun 2006
Report cover showing stethoscope

Financial Management in the NHS: Report on the NHS Summarised Accounts 2007-08

“The surplus of £1.67 billion is equivalent to about one week’s funding for the whole NHS. The organisations in the NHS are performing better financially and this surplus has created an element of certainty for financial planning that has not existed in recent years. This is especially reassuring given current financial pressures throughout the economy.

“Auditors have found matters to be addressed, such as localised accounting issues, and there are long-standing financial problems affecting a minority of trusts. The significant challenges for the NHS next year are in meeting new International Financial Reporting Standards and tougher deadlines on closure of accounts, but it looks as though most NHS bodies are well placed to cope.”

Tim Burr, the head of the National Audit Office, said:

“Good financial management is not just about achieving a surplus. It is also about meeting delivery targets within the resources available. The surplus was generated through good financial management: NHS bodies delivered more cost savings than expected while still delivering against targets and improving the quality of healthcare. But better forecasting of the outcome could enable resources to be deployed more flexibly in-year.”

16 Dec 2008