The NHS enters 2025/26 under the most demanding financial expectations in over a decade. To achieve a balanced plan, local systems must deliver a record 7.1% efficiency gain and reduce workforce headcount by 2%.

Yet this is not simply a numbers game. Amid ongoing recovery demands, rising care complexity, and long-standing workforce pressures, the risk is clear: cost control measures that outpace clinical resilience will degrade care quality.

This blog explores the tightrope NHS leaders must walk between efficiency and safety, and how new safeguards, particularly Quality Impact Assessments (QIAs), must be operationalised to protect patients.

 

 

The Financial Ask: Historic in Scale and Scope

The revised 2025/26 financial plans submitted by all 42 ICSs require:

• Over £2.2 billion in central deficit support funding.
• A national average of 7.1% efficiency savings.
• Workforce contraction, including substantive, bank, and agency roles.
• Deep cuts to agency reliance, enforced via monthly reporting and performance monitoring.

Many systems are already over plan. As of Month 2, the year-to-date overspend sits at £110 million, concentrated in a few systems with large efficiency gaps and workforce variances.

Strategic Takeaway:

The margin for error is small. Systems must be rigorous in planning, agile in delivery, and unwavering in safeguarding quality.

Introducing Quality Impact Assessments: Guardrails for Safety

To prevent unintended harm, NHSE now mandates that all major cost-saving initiatives undergo a Quality Impact Assessment (QIA). Key features include:

• Clinical sign-off by the Chief Medical Officer and Chief Nursing Officer.
• Board-level oversight and visibility of all high-risk changes.
• Consideration of patient safety, access, outcomes, and experience.

QIAs are not just a governance formality. They are a vital check to ensure:

• Risks are identified and mitigated early.
• Evidence and intelligence inform decisions.
• Efficiency does not come at the expense of care standards.

Strategic Takeaway:

Providers and ICSs must embed QIA governance into all transformation and cost-saving programmes. Quality is a shared leadership duty.

Workforce: Reductions Without Erosion

Headcount Pressures

Workforce size is set to contract for the first time in years. The headline asks include:

• 2% reduction in overall staffing levels.
• Agency reductions enforced by planning assumptions and ICB monitoring.
• Suspension or repurposing of certain roles to meet headcount targets.

Emerging Risks

• Burnout and attrition risk exacerbated by unfilled rotas.
• Loss of skill mix and leadership continuity.
• Fragility in smaller providers and specialist services.

Skill Mix and Morale: The Unseen Cost

Workforce data reveals a concerning trend. According to NHS Digital, over 170,000 NHS staff voluntarily resigned in the year to September 2023, a 28% increase over five years. The Nursing and Midwifery Council (NMC) reported over 27,000 nurses left the register in 2022-23, while 4% of doctors leave the GMC register annually.

This is not just a numerical challenge. As experienced staff exit, the dilution of expertise compromises complex care delivery, mentorship, and clinical leadership continuity. The Health Foundation and The King’s Fund have both highlighted how workforce attrition correlates with increased patient safety incidents, longer waiting times, and deteriorating staff morale.

Strategic Takeaway:

Financial decisions must be workforce-informed. Overcutting risks losing essential capacity, institutional knowledge, and care quality foundations.

Operational Pressures: A Triple Demand Curve

NHS leaders must reconcile workforce reductions and cost efficiencies while also:

• Recovering elective backlogs.
• Meeting urgent care access targets.
• Expanding access to mental health, diagnostics, and community care.

Each of these imperatives places upward pressure on workforce, infrastructure, and spending.

Strategic Takeaway:

System plans must account for demand elasticity. Without adaptive delivery models, pressure will outstrip capacity.

What Leaders Must Do Now

1. Integrate QIA into All Financial Plans

• Make QIA a standard step in budget setting and transformation programmes.
• Ensure sign-off is not retrospective.
• Monitor downstream impacts through governance dashboards.

2. Redesign Workforce, Don’t Just Reduce It

• Prioritise redeployment over redundancy.
• Invest in retention strategies: flexibility, support, progression.
• Protect skill mix integrity, especially in specialist and leadership roles.

3. Focus on High-Yield Productivity Gains

• Invest in digital tools that save clinician time.
• Rationalise admin and back-office functions, not frontline care.
• Scale standardisation where variation adds cost without value.

Final Word from Altin Biba, MBA, AMBA Chief Executive of ProMedical

The NHS faces an impossible equation if cost savings undermine the very quality the service was built to protect. Yet, the solution is not austerity, it is strategic leadership. Systems that treat efficiency as a blunt instrument will erode their capacity, capability, and credibility.

At ProMedical, we understand that transformation is not about cutting, it is about creating: smarter care models, safer workforce designs, and sustainable productivity gains that do not compromise patient outcomes.

This is the leadership test of our time: to deliver a health system that is financially resilient without losing its clinical soul. For those ready to lead that change with intent and intelligence, we are ready to stand with you.

References

• NHS Financial Performance Update, July 2025
• NHS England Board Meeting Minutes, July 2025
• NHSE Integrated Operational Performance Report, July 2025
• Department of Health & Social Care Spending Review 2025
• NHS England Guidance on Quality Impact Assessments (QIA), 2025
• Health Foundation – Efficiency vs Safety Commentary
• NHS Digital – NHS Workforce Statistics, 2023
• NMC Annual Data Report, 2023
• GMC State of Medical Education and Practice, 2024
• The King’s Fund – Workforce Trends Analysis