93risks rated very high to extreme15 or more out of 25, on the boards’ own scoring
30sit at the very top of the scalethirteen about money, five about buildings, equipment or IT — none about staffing
19boards carry at least oneincluding all three commissioners
Money and buildings top the scale. No workforce risk is rated that high — although seventeen sit just below the line, and staffing runs through the boards’ own explanations of their money risks.
The 93 very high to extreme risks, by subject
The pale bar is the count at 15 or more out of 25; the red is the share their boards rate at the very top of the scale. Subjects are ours, assigned from each boardSubject is read from the risk’s title and description.rsquo;s own title and description.
The increased focus on the challenging system financial position, availability of resources and our need to increase productivity in 2025-26 makes it imperative to mitigate any potential impact to the quality and safety of commissioned services.
Significant headcount reductions and new ways of working, may disrupt strategic commissioning functions, destabilise workforce morale, and impede delivery of transformation priorities.
Digital Systems Sustainability — operational risk that the Trust's digital infrastructure (1000+ applications, ageing hardware, EPR readiness, asset management, clinical safety governance) cannot reliably support the delivery of safe, efficient services.
Every risk a board rated 20 out of 25 — the top of the scale30 risks · 13 boards
| Board | Ref | Risk, as the board words it |
|---|---|---|
| Alder Hey Children's | AH-3.4 | Financial targets, NHS regime change, capital commitments |
| Bolton | BFT-SR9 | Delivering Financial Sustainability |
| East Lancashire Hospitals | ELHT-BAF1 | Integrated Care / Partnerships / System Working |
| East Lancashire Hospitals | ELHT-BAF2 | Quality and Safety |
| East Lancashire Hospitals | ELHT-BAF5 | Financial Sustainability |
| Greater Manchester Mental Health | GMMH-PR1 | Safe Care |
| Greater Manchester Mental Health | GMMH-PR3 | Financial Sustainability |
| Lancashire and South Cumbria | LSCFT-PR4 | Failure to deliver a resilient digital infrastructure |
| Lancashire and South Cumbria | LSCFT-PR6 | Failure to deliver adequate patient flow |
| Manchester University | MFT-001791 | Implications of national restrictions on capital resource |
| Manchester University | MFT-005092 | Delivering financial sustainability in the medium term |
| NHS Cheshire & Merseyside ICB | P13 | Inability to achieve financial sustainability and productivity |
| NHS Cheshire & Merseyside ICB | P14 | Failure to meet national performance / access standards |
| NHS Cheshire & Merseyside ICB | P4 | Quality and safety failures in commissioned services |
| NHS Greater Manchester ICB | SR2 | Health and care services becoming unsafe and unstable |
| NHS Greater Manchester ICB | SR7 | ICS in-year and medium-term financial sustainability |
| NHS Lancashire and South Cumbria ICB | BAF-004 | Sustainable Finances |
| NHS Lancashire and South Cumbria ICB | ICB026 | ICB ability to meet its statutory SEND responsibilities |
| NHS Lancashire and South Cumbria ICB | ICB029 | Neurodevelopment pathways across Lancashire and South Cumbria |
| NHS Lancashire and South Cumbria ICB | ICB037 | Ability of the ICB to effectively identify and respond to quality and safety concerns for Primary Care |
| NHS Lancashire and South Cumbria ICB | ICB039 (NEW) | Court of Protection Deprivation of Liberty (CoPDoL) applications not completed in accordance with expected timeframes and court orders |
| Northern Care Alliance | BAF1 | Digital Systems Sustainability |
| Northern Care Alliance | BAF10 | Capital Investment |
| Northern Care Alliance | BAF11 | Financial Delivery |
| Northern Care Alliance | BAF12 | Cash Position |
| Northern Care Alliance | BAF2 | Cyber Security |
| Stockport | PR7.2 | Failure to maintain suitability of premises and environments |
| Tameside and Glossop Integrated Care | TG-PR7.2 | Failure to maintain suitability of premises and environments |
| Wirral University Teaching Hospital | Risk 1 | Failure to effectively manage unscheduled care demand |
| Wirral University Teaching Hospital | Risk 6 | Fail to manage our finances effectively and deliver value for money |
Where money and staffing meet
33 of those risks name both a financial and a workforce driver, across 13 boards. The boards’ own words link the two; no causal claim is made.
Read the ones rated at the top of the scale12 entries scored 20
Bolton Delivering Financial Sustainabilityscore 20
The risk, in the board’s words
If the Trust does not deliver its Financial Plan, then it will fail to meet its financial objectives, which could negatively affect the Trust's long-term financial sustainability.
Its stated financial driver
Verbatim issues: 'Bridging the financial gap, noting the scale of the challenge'; 'Cost control and managing inflation effects'; 'Shortage of revenue and capital funding'; 'Meeting NHS England Productivity requirements'; 'Working within GM ICB (jointly responsible and reliant on others results)'.
Its stated workforce driver
Verbatim: 'WTE Headcount reductions' named as a KPI. 'Annual bank / agency spend' named as a measure.
East Lancashire Hospitals Integrated Care / Partnerships / System Workingscore 20
The risk, in the board’s words
The strategies and partnership arrangements across the Integrated Care System (ICS) do not deliver the anticipated benefits for our communities and fail to support the financial recovery of the Trust, including exit from NHS Oversight Framework Segment 4 (Recovery Support Programme).
Its stated financial driver
Verbatim: 'fail to support the financial recovery of the Trust' is named in the risk wording itself. ICB commissioning intentions for 2025/26 still under discussion as of December 2025.
Its stated workforce driver
PMO resourcing gaps acknowledged — 'Some resourcing gaps identified and working with RSP to find additional personnel in the PMO team'.
East Lancashire Hospitals Quality and Safetyscore 20
The risk, in the board’s words
The Trust is unable to fully deliver on safe, personal and effective care in line with legislative and regulatory requirements.
Its stated financial driver
Patient Safety Incident Response Framework (PSIRF) implementation; pathology service mutual aid + outsourcing; Cerner upgrade implemented September 2025.
Its stated workforce driver
Verbatim: 'Fragility and availability of the medical workforce'. Pathology Biomedical Scientist and Medical Laboratory Assistant vacancies named.
East Lancashire Hospitals Financial Sustainabilityscore 20
The risk, in the board’s words
The Trust is unable to deliver its agreed financial recovery plan.
Its stated financial driver
Verbatim: 'Inadequate funding for the services commissioned'; 'No signed Contract for 2025-26' (resolved September 2025 to £691m); 'The financial plan will not be met in 2025-26 with a further risk that Deficit Support Funding is withdrawn and overall impact on cash position'. Cash support requested December 2025.
Its stated workforce driver
Vacancy Control Panel in place at divisional and Trust level, being strengthened with weekly process. Variable Pay Panel chaired by CPO meeting daily for bank/agency spend decisions.
Greater Manchester Mental Health Safe Carescore 20
The risk, in the board’s words
There is a risk that, as a result of the threats shown below, we may have incidents of patient harm which the foundation trust is directly able to avoid, which would lead to poor clinical outcomes, poor patient experience and risk further reputational harm or regulatory oversight.
Its stated financial driver
Inpatient Safer Staffing investment cited; capital plan referenced for clinical environments.
Its stated workforce driver
Threat #2 verbatim: 'If we do not have the correct professional skill mix adjusted to caseload/patient need there is a risk that we will be unable to deliver quality care'. Actions include safer staffing establishment review (community), Psychological Services establishment review, and Medical establishment review.
Greater Manchester Mental Health Financial Sustainabilityscore 20
The risk, in the board’s words
If we do not deliver the Trust's annual financial plan and longer-term financial strategy, then we will fail to meet our statutory duties and be unable to deliver improvements and sustainable services.
Its stated financial driver
£32.5m Added Value Programme efficiency requirement for 2025/26, of which £31.5m is recurrent. Trust held c£70m system-wide on Local Spot and Out-of-Area Placements in 2024/25.
Its stated workforce driver
Verbatim from financial-sustainability threats: 'High levels of vacancies and impact on operational, clinical and financial sustainability.' Action: 'Monitor performance against the target that we have included in our planning submission. People and Culture committee will own key actions.'
Lancashire and South Cumbria Failure to deliver adequate patient flowscore 20
The risk, in the board’s words
Failure to deliver adequate patient flow due to insufficient capacity, workforce challenges and delays in discharge leading to prolonged wait times, reduced access to services impacting quality and safety of patient care.
Its stated financial driver
Verbatim: 'significant impact (financial) on out of area placements impacting the Trust's strategic priorities'. OAPs (Out-of-Area Placements) reduction trajectory in place.
Its stated workforce driver
Verbatim: 'insufficient capacity, workforce challenges and delays in discharge'.
Manchester University Delivering financial sustainability in the medium termscore 20
The risk, in the board’s words
If we are unable to achieve our value for patients target, generate sufficient income or manage cost pressures then we would be unable to deliver financial sustainability in the medium term resulting in insufficient cash to meet expenditure obligations and regulatory intervention.
Its stated financial driver
Value for patients target shortfall; insufficient income generation; cost pressures unmanaged.
Its stated workforce driver
VfP delivery interdependent with WTE reductions per Finance Board Committee observation.
NHS Cheshire & Merseyside ICB Quality and safety failures in commissioned servicesscore 20
The risk, in the board’s words
There is a risk that commissioned services will not consistently deliver high-quality, safe, and equitable care, undermining our statutory duty to improve population health and reduce inequalities. This risk is heightened as we shift resources from hospital to community and redesign care pathways to deliver the 10-Year Plan's ambitions for neighbourhood health, digital enablement, and prevention.
Its stated financial driver
The increased focus on the challenging system financial position, availability of resources and our need to increase productivity in 2025-26 makes it imperative to mitigate any potential impact to the quality and safety of commissioned services.
Its stated workforce driver
Reduction in workforce capability and capacity due to organisational changes and organisational vacancies increases risk of gaps across central and place functions.
NHS Greater Manchester ICB Health and care services becoming unsafe and unstablescore 20
The risk, in the board’s words
There is a risk that key health and care services become unsafe and unstable due to growing and changing demand, pressures faced by other sectors and workforce, estates and technology gaps. This will result in poorer health outcomes for the GM population and a reduction in quality of care and patient safety and an inability to deliver operational delivery standards.
Its stated financial driver
Financial constraints is a contributory factor along with industrial action.
Its stated workforce driver
Further development of the function is required to respond to the ICB reform requirements including oversight arrangements.
Northern Care Alliance Digital Systems Sustainabilityscore 20
The risk, in the board’s words
Digital Systems Sustainability — operational risk that the Trust's digital infrastructure (1000+ applications, ageing hardware, EPR readiness, asset management, clinical safety governance) cannot reliably support the delivery of safe, efficient services.
Its stated financial driver
Multi-year investment plan aligned to infrastructure and application roadmap (named as a Gap in Control).
Its stated workforce driver
Lack of clinical digital resources (NMAHP & Medical) to support delivery of transformation programmes (named as a Gap in Control).
Northern Care Alliance Financial Deliveryscore 20
The risk, in the board’s words
IF we don't develop robust multi-year cost saving plans, including identification and delivery of safe and sustainable cost improvements THEN we will not deliver our agreed financial plan.
Its stated financial driver
ID of safe sustainable cost improvements (SCO) (Op Risk 10820, scored 20); Diagnostic and Pharmacy Recurrent CIP (Op Risk 6594, scored 20); Oldham Financial plan and CIP (Op Risk 8590, scored 20).
Its stated workforce driver
Pay Award Unfunded year-to-date £1.8m; Industrial action £3.5m offset by £4.7m income; Activity-related pressures including medical staffing (temp staffing) £14.2m.
What this covers
Board assurance frameworks held for 22 boards (162 scored risks). Boards whose register we do not hold are simply not counted. Scores are the boards’ own, on the 5 × 5 likelihood-by-impact scale; ‘very high to extreme’ is 15 or more.