Publication: Integration Joint Boards finances continue to be precarious

It’s budget-setting season for IJBs and never has it been more challenging or important for IJBs to be transformational in their delivery of services and in the setting of budgets. In July last year, the Accounts Commission reported in its IJB Finance and Performance report 2024, that ‘the financial outlook for IJBs continues to weaken with indications of more challenging times ahead.’

Our review of the 2023/24 accounts and annual audit reports show that although funding increased by four per cent (in real terms) from 2022/23, the financial position of IJBs has become yet more precarious. The Accounts Commission is concerned about the deepening risks in the sector. It urges each IJB to work closely and have candid conversations with its NHS board and council partners about the savings that need to be made to set balanced budgets for 2025/26. The budgets and proposed savings need to be achievable and sustainable. IJBs, alongside their partners, need to be transparent with communities about what that means for services and actively engage with communities about the decisions that need to be made. A continued high turnover of chief officers and chief finance officers in IJBs does not help this process, adding further to the risks around effective strategic planning and decision-making.

On behalf of the Accounts Commission, Audit Scotland has published an on-line tool that shows the facts and figures nationally and for each IJB from the 2023/24 annual accounts and annual audit reports. It includes some contextual data from the 2022 Census that illustrates the increasing population pressures nationally and significant variation across Scotland that have implications for the level of demand on health and social care services, the logistical challenges of delivering services and the availability of workforce. The IJB Finance Bulletin tool is available on the Audit Scotland website. We have published this as early as possible to help inform budget setting discussions. Further information will be added to the data tool as it becomes available and, by the Autumn 2025, it will also include performance and outcome data.

The overall picture, set out in the IJB Finance Bulletin is concerning. It shows a continued picture of overspending, depletion of reserves and reliance on one-off rather than recurring savings. There is a need for transformational changes in the way services are being delivered and for the identification and delivery of significant recurring savings.

Of the 30 IJBs across Scotland, 29 have published their accounts for 2023/24. Twenty-four of the 29 have overspent on providing services. As well as pay and other inflationary pressures, IJBs are reporting that prescribing budgets are under considerable strain. They are also seeing more demand for services and increasingly complex care needs which are increasing the costs of care. Difficulties in the recruitment and retention of staff persist, but the related savings from holding vacancies, that contributed to the majority of operational surpluses in 2022/23, are being outstripped by inflationary cost pressures and, reflecting the workforce pressures, a higher spend on agency/locum/bank staff to keep services running.

Eleven of the 24 IJBs that overspent needed additional contributions from their NHS and council partners. NHS boards and councils face significant financial challenges themselves and IJBs cannot continue to rely on their partners being able to find additional money to support them during the year. IJBs need to agree budgets that are realistic and transparent and to have strategies in place to manage in-year risks.

In 2023/24, IJBs also used more of their reserves than they had planned. Total reserves held by IJBs reduced by 40 per cent (in real terms). Contingency reserves have almost halved, limiting IJBs ability to address future financial deficits. Of the 24 IJBs that overspent, 16 made unplanned use of reserves. Aberdeenshire IJB used all its reserves in 2023/24, and four others used all their contingency reserves. Nine IJBs in total now do not hold any contingency reserves. This puts additional pressure on these IJBs in setting an achievable budget this year; there is no more financial flexibility and increases the risks for these authorities. This is very concerning.

The majority, 79 per cent, of IJBs total planned savings were achieved. However, this varied from seven IJBs achieving all their planned savings through to three achieving less than half their target. Around half of planned savings were from one-off, non-recurring savings, such as unfilled staff vacancies. This doesn’t support achieving a better position for future years, as these non-recurring savings will be carried forward and will also need to be found to balance future budgets.

The projected financial position is set to worsen. The projected funding gap for 2024/25 has increased from £357 million (2023/24) to £457 million in 2024/25. IJBs have been reacting to short-term pressures rather than pursuing longer-term transformation of services to meet the financial pressures. IJBs need to be working collaboratively with each other and with their NHS and council partners to find ways to transform services so that they are affordable. This needs to also look at how money is being spent across the services so that there is investment in prevention and early intervention, with the aim of slowing the ever-increasing demand for services, the cost of more complex care and, improving the experience and outcomes for people. Medium and long-term financial planning is important for planning transformational change and should provide the foundation for budgeting. It is now clear that potential changes to the delivery model through a National Care Service are not going to take place, but transformation must happen. IJBs and their partners must act now to improve financial sustainability.

We recognise none of this is easy, but our communities are relying on the boards to make the difficult decisions that will not only sustain vital services now and into the future but find ways to improve them and the outcomes for Scotland’s people.