The annual NHS Confederation conference begins today, and two documents help set the scene.

The first is the latest BMJ data briefing by the Kings Fund's iridescent chief economist Professor John Appleby.

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Appleby rightly points out that the UK's prolonged lack of economic growth is contributing to a highly uncertain financial future beyond 2015 for the NHS, when a new 'Nicholson Challenge Two: This Time It's Personal' period is mooted. Other departments which have had real-terms cuts will be higher up the pecking order for any spare cash.

The plan for a further £50 bilion of efficiency and productivity gains by the NHS in the five years beyond 2015 looks, Appleby adds, "on a historical assessment ... frankly undoable. If we assume no real funding growth (inputs) and the need to improve outputs (the activity of the NHS adjusted for the quality of those outputs) by around 5% a year to match the Wanless “challenge” for a better NHS, by 2018 this is equivalent to an improvement in productivity of around £49bn at 2010 prices.

"But while the NHS has produced more with more inputs, it has rarely made a positive productivity increase in a year in excess of 1%—let alone 5% each year for eight years".

He continues, "there is something to be said for having a ”stretching” target ... it can get minds focused on the task and, even if not achieved in full, may produce better results than would less testing goals. But giving the NHS a challenge of this magnitude would risk setting it up to fail. If the productivity policy goal is already just this side of credible, stretching it another four years surely must have crossed the line ... maybe it’s time for some realism.

"Even if the NHS achieves half the challenge over the next eight years it will have produced something quite unprecedented. Perhaps that’s the best that can be hoped for".

Serious problems already, more ahead
Meanwhile, a Picker Institute survey of the NHS Confederation's members reveals serious concerns about the impact of the current efficiency and productivity challenge.

28 per cent described the current financial position as “the worst they had ever experienced”. An additional 46 per cent said the position was “very serious” while five per cent thought it was “better”.

Providers felt the pressure most strongly. Seventy six per cent of respondents from providers said the pressure was “the worst they had ever experienced” or “very serious”. This compared to 64 per cent of respondents from commissioning PCTs.

53 per cent said financial pressures facing their organisation were worse or significantly worse than 12 months ago. Just 11 per cent thought they had improved or significantly improved. And some 85 per cent expect financial pressure to increase over the next 12 months.

It's affecting patient care
Asked which areas of patient care had been most affected by the financial pressures on their organisations over the past 12 months, 42 per cent said experience of
patients, 35 per cent said waiting times and 17 per cent said the availability of treatments and drugs. Just over a third, 34 per cent, said care of patients was not affected.

Asked to predict the areas of patient care that would be most affected over the next 12 months, respondents highlighted the same issues in greater numbers. Sixty three per cent said patients‟ experience would be most affected, 49 per cent said waiting times and 30 per cent said availability of treatment or drugs. The proportion feeling no care would be affected fell to 15 per cent.

Asked about the outlook for the quality of care across the NHS as a whole over the next 12 months, 47 per cent predicted a decline, 15 per cent thought it would improve and 38 per cent felt it would stay the same.

Foundation trusts were slightly more likely to believe quality would improve.

The social care factor
66% of respondents said that cuts in local authority spending had impacted on their services over the past 12 months - a further 18 per cent said they may have done.

Of those who felt there had been an impact from the cuts, 92 per cent said there were more delayed discharges from hospital, 87 per cent said there was greater demand for community services, 76 per cent pointed to more demand for mental health services, 57 per cent said there were more acute admissions to hospital, 55 per cent said there were more A&E attendances and 50 per cent said there were more emergency readmissions.

Those polled were clear that demands on the NHS will increase over the next decade. The commonly cited challenges were care of the elderly (42%) and pressure on finances (42%). These were followed by increased demand (33%), growth of long-term conditions (32%) and managing the expectations of patients and the public (32%).