Grace under pressure

01 March 2021 Steve Brown

Login to access this content

One day stands out. Portsmouth Hospitals University NHS Trust has had a year like no other – along with hospitals across the country – as it responded to the Covid-19 pandemic. But for Mark Orchard, the trust’s chief financial officer, Saturday 2 January is particularly memorable. ‘It was the most operationally demanding day of my career,’ he says.orchard_conf_206_landscape

Portsmouth is a big acute trust with some 8,000 staff and 1,200 beds, nearly half of which were filled with Covid-positive patients at the height of the second wave of the pandemic at the beginning of the year.

The city had become something of a hotspot for the virus, with infection rates well above the national average, and this had increased the pressure on acute services rapidly. The nearly 40 intensive care unit beds occupied were less than the peak of 59 that would be reached later in the month, but nearly double the trust’s normal capacity.

On 2 January, Mr Orchard was the trust’s gold command executive on call and the numbers of Covid patients presenting at the hospital were beyond the levels that had to this point reliably been predicted by the modelling.

‘The pressure was intense, and the numbers were growing,’ he says. He spent more than 15 hours on site and, while the day was full of incident and decisions that needed to be taken, he remembers one challenge in particular from an extremely busy 24 hours.

‘Three out of four patients who were presenting were already Covid-positive and that put a lot of pressure on our front door and on our red pathway,’ he says. ‘We had empty beds becoming available, but we couldn’t turn them around quickly enough – despite deploying extra scrub teams. We were also short of staff and couldn’t open up our internal surge and escalation capacity.’

The ambulance trust was also experiencing huge demand and, in a series of escalation calls, it was pressing to be able to hand over patients and get its vehicles back on the road.

The trust had the space to take patients off the ambulances more quickly, but not the staff. So, the suggestion was made to open up the trust’s surge capacity to take six ambulances’ worth of patients, manned by one ambulance crew and overseen by one senior nurse.

It was not a new idea. ‘This had been mooted by the ambulance trust over the years for times of extreme pressure, but it had never been agreed,’ says Mr Orchard. However, in the space of a few hours, the new arrangement was put in place, involving agreement with the trust medical director and emergency department consultant and negotiation with the ambulance trust.

It was a good solution, rapidly put into action, and it created some much needed breathing space for the emergency team, while releasing ambulance crews back to the streets. But it was not enough to relieve the pressure.

More was needed. The trust’s silver command managers were getting increasingly vocal in calls for an opportunity to reset by diverting ambulances for a period to a neighbouring trust. Mr Orchard says, in his experience, this is difficult to put in place at any time. But during a pandemic, when the whole country is facing sustained pressure, it becomes even more challenging.

The trust’s nearest neighbour – University Hospital Southampton NHS Foundation Trust – was faced with its own significant pressures and was unable to help. However, Hampshire Hospitals NHS Foundation Trust, which has hospitals in Winchester and Basingstoke, indicated it might be able to do something.

Putting this into action took a further two hours of discussion and checks, plus a group call involving the ambulance trust, the Winchester and Basingstoke site directors and their trust’s executive on call. ‘So you end up with eight or nine people on a call to agree the parameters around this ambulance divert,’ Mr Orchard remembers.

‘It was about four o’clock in the afternoon at this point and we agreed that all our trauma activity would go to Basingstoke and all of our confirmed Covid-negative patients would go to Winchester for a period that would be under review, but would likely last until 10pm,’ he says. ‘This was later extended until the following morning.

‘Of course, this meant a greater proportion of our patients were Covid-positive, but it gave us the breathing space we needed and allowed us to focus on them.’orchard_portsmouth 2_landscape

He says both the ambulance trust and Portsmouth’s acute neighbour were brilliant on the day and it is a great example of how working across the system has been enhanced during the pandemic – something the trust is committed to as part of its Working together five-year strategy.

Pressure has subsequently reduced across the country since the January peak, and Portsmouth is no different. By mid-February, it was treating 255 patients with a Covid-19 diagnosis. While this was still above its peak level in spring last year, it represents a 50% reduction on its more recent January peak. And the rate of infection in the community is also heading in the right direction.

For the trust, this means the focus can return to the reintroduction of services that had to be paused. Waiting lists have grown across the country as non-Covid capacity has decreased and there are likely to be further increases in list sizes as pent-up demand finally turns into referrals. Mr Orchard says the trust is now working on how it can return to more of its normal levels of activity, although he acknowledges that full recovery for the NHS will be measured in years not months.

Staff are also a major consideration in the return to more normal service delivery alongside reducing Covid activity. He pays tribute to the efforts made by all the trust’s staff in getting to this point and recognises that it is not realistic to expect them to continue to work at the same levels of intensity, whether that is on Covid or recovery work.

‘We know that many of our staff have been working in difficult and often unusual situations to their usual work or even place of work,’ he says. ‘So our recovery plans will be carefully balanced against the need for everyone to take time off and rest. Their wellbeing is incredibly important to us and we will do everything we can to ensure this is done in a balanced and sensible way.’

Mr Orchard has spent a lot of time focused on Covid-related issues during the year. Not only was he part of the gold command executive team, but he spent more than six months as the trust’s emergency accountable officer, ahead of the appointment of a new substantive chief operating officer. And more recently, he was executive lead for staff testing, overseeing the roll-out of lateral flow testing for asymptomatic staff. But the chief finance role remains vital.

Financial recovery

The trust has made significant strides forward financially over recent years, and Mr Orchard is determined to keep up the momentum. It broke even in 2019/20 – in fact, recording a small surplus – after years of deficits, culminating in a deficit of nearly £38m in 2018/19. The 2019/20 break-even position was achieved with national support of £17.5m through the Provider Sustainability Fund, suggesting an underlying deficit of the same amount.

In January last year, the Care Quality Commission rated the trust as ‘good’ on use of resources, highlighting a low cost per weighted activity unit, good work on procurement and reducing agency staffing costs. (The ‘good’ rating came alongside an overall CQC rating of ‘good’, moving the trust from its previous status of ‘requires improvement’.)

The use of resources report noted that the trust was delivering against its financial recovery plan. And Mr Orchard says not reporting a deficit is such a motivating state to be in – for the whole trust – that he is determined to continue making progress.

However, the Covid pandemic has completely changed the context for this financial improvement journey. ‘This year has been a tale of two halves on the financial front,’ he says. ‘For the first six months, along with all providers, we were reimbursed for the full costs of what we needed to meet the pandemic. For the second half of the year we were operating within an envelope again.’

This envelope included the continuing block contract income from the first six months, but stripped out the retrospective top-ups for unexpected Covid costs. And the trust’s phase three plan also took into account the level of recovery that was expected at the time, although this did not account for such a high second wave of the virus. The result was a forecast £9m deficit, which needs to be seen in the context of its full-year financial improvement trajectory deficit target of £15m.

But the trust immediately set about trying to improve this position, recognising the importance of having a sustainable run rate for when the sector moves out of the current block contracting arrangements (which have subsequently been extended until the end of June).

‘We immediately started to develop a recovery plan for getting back to break-even by the end of the year, so we could exit the year in good shape,’ Mr Orchard says.

Additional costs

This was not a traditional cost improvement programme – clinical teams were rightly completely focused on meeting frontline demands – but it followed similar principles of weekly tracking across divisional run rates, non-recurrent opportunities and investments that had to be delayed because of the new surge.

Nearly £4m of the phase three forecast £9m deficit was the assumed cost of carrying forward holiday entitlement for staff, recognising that many staff have simply not felt able to take leave while the service has been under such pressure.

‘By month 8 and reaffirmed in month 9, we had reduced our overall forecast deficit to £4.3m, which putting aside the annual leave issue, puts us really close to operational break-even,’ says Mr Orchard.

The second surge has led to staff once again forgoing leave, and the cost of carrying forward this increased leave entitlement has been reassessed at £6.4m. In addition to this, the trust has allowed a further £1.5m to offer a wellbeing day to its staff – including staff at the trust’s private finance initiative partner and its associated military hospital – as a reward next year.

However, taking into account commitments from the centre to cover providers’ non-NHS income losses – a large part of which relates to private patient income and car parking – and, more recently, to cover an element of the annual leave costs, Mr Orchard remains focused on delivering break-even.

The underlying deficit will still be there when normal activity and funding rules return, but Mr Orchard believes the trust is in a good position to continue its improvement journey. After years of high spending on agency staff, this year the trust spent some five months without booking a single agency nurse shift – the result of a sustained international recruitment drive that meant the trust was actually over-established heading into the pandemic.

And a new two-year financial strategy aims to maximise resource, while eliminating waste.  In the first year, the strategy will focus on optimising use of the workforce, eliminating waste and simplifying information and processes.

Mr Orchard’s role as chief finance officer is supported by five teams covering financial services, estates, commercial services, procurement and charities. All have put in a significant shift over the last year. Procurement has been at the heart of keeping personal protective equipment flowing freely, while also ensuring equipment and supplies are in place to meet escalation capacity plans.

At times, the estates and facilities team has focused almost completely on site visitor and security controls, while at the same time ensuring vital utilities such as oxygen remain on stream.

Meanwhile, some finance staff have been formally redeployed or volunteered to support the front line – for example, helping with patient meal times or administering the vaccination hub.

But alongside these activities, the 60-strong finance team has also used the past year to review and redesign processes and reports. The trust will move to reporting the monthly finance position on the first working day of each month from April – following support from Leeds Teaching Hospitals NHS Trust – and it has eliminated business-critical supplier payment delays.

‘This has been supported by cash advances this year, but we’ve also used the time to redesign all our processes so we are confident we can maintain and eliminate delays on any non-NHS invoices,’ he says. New lead indicators have also been established to help teams more quickly understand their key metrics.

It is not a year anyone in the NHS will want repeated and significant challenges still lie ahead, both with continuing Covid-19 treatment and the further recovery of services. Mr Orchard says it has been undeniably exhausting and heart-breaking, given the toll the pandemic has taken on individuals and their families. ‘But I’ve also loved being as close to the frontline as I’m ever going to be as an accountant and being part of the amazing response by the whole NHS.’


    In conversationorchard_HFMATalk landscape

    A mini-series of podcasts, part of the HFMAtalk podcast launched in January 2020, aims to focus in on some of the key figures in healthcare finance. Hosted by former HFMA president and chief financial officer at Portsmouth Hospitals University NHS Trust Mark Orchard, HFMAtalk in conversation with… will feature current and former healthcare finance leaders, exploring their careers, motivations, experiences and lessons learnt. Keep your eyes on HFMAtalk podcasts for news about the first episode.


Supporting documents
20-23_mar21_orchard final