System finance: the art of influence

02 March 2020 Steve Brown

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The move to system working presents big challenges for NHS bodies in England to work together to make best use of resources across a broader footprint. It also brings new challenges for finance professionals as they step into system finance roles that, under current structures, rely on influencing skills to ensure system goals are delivered.

Su RollasonSu Rollason (pictured) has spent 15 years at the University Hospitals Coventry and Warwickshire NHS Trust (UHCW), becoming director of finance and strategy in 2015 and then chief finance officer at the start of 2018.

However, last October, she expanded her remit by also taking on the system finance lead role for the Coventry and Warwickshire Health and Care Partnership, the recently adopted name for the area’s sustainability and transformation partnership.

Both are major roles. UHCW is an acute and tertiary provider that on its own delivers services for more than a million patients from two main sites with income of £700m. The system role – with system allocations totalling close to £1.4bn in 2018/19 – means supporting an ambitious five-year plan, while delivering scaleable savings that mean the whole system stays within its financial envelope.

The system role needs different skill sets than the trust role – or at least better developed influencing abilities. ‘It is really all around influencing,’ says Ms Rollason. ‘I don’t have control over any of the organisations in the system. I can’t tell a finance director or chief executive not to do something because it isn’t system coherent. I have to influence them to make that decision for themselves. The lack of direct control is the big difference.’

And there are a lot of people to influence – four providers, three clinical commissioning groups and two local authorities make up the partnership. And influencing these organisations means regular discussions with chairs, chief executives, accountable officers and all the finance directors, particularly as monthly finance figures come in.

These discussions centre on the need to think system-wide and beyond the immediate impact on any individual organisation, while recognising the organisationally focused lines of accountability that still exist. ‘The volume of discussions is itself challenging,’ she says. ‘But it is also a huge opportunity personally to exert influence and make a difference.’

The strategic system plan, an early draft of which appeared in partnership board papers last year, builds on the initial STP plan published in 2016. Over the past four years, moves to a population health management approach have been underpinned by place-based and asset-based joint strategic needs assessments.

The art of influenceGood progress has been made on urgent and emergency care, with about 6,000 more patients on average seen across the system within four hours each month compared with 2016. And in mental health, there has been increased access to psychological therapies.

Health and wellbeing have also improved, with a reduction in smoking prevalence among adults across Coventry and a reduction in the under-75 mortality rate from cancer.

The new plan will look to push on with these priorities, with service development focused on four areas: Coventry, Rugby, North Warwickshire and South Warwickshire. With A&E attendances and emergency admissions to hospital rising nationally, the Coventry and Warwickshire system will target a 50% reduction in the growth of such activity.

But Ms Rollason says this won’t translate – at least not immediately – into stripping out provider capacity. ‘It is about stopping the high levels of growth that commissioners have had to pay for and taking that to a level that is within their allocations,’ she says.

Frailty pathway

The frailty pathway will be another focus, with the establishment of an acute frailty service and development of the out-of-hospital model. Part of this will look to address community providers’ workforce problems. ‘We want to see if, as a system, we can use our total resource in a different way and build a more flexible workforce,’ says Ms Rollason. This could involve joint appointments with staff working across different providers and settings.

One of the system’s key service improvement schemes will involve the musculoskeletal (MSK) services. This was identified as a system priority in a 2018 clinical strategy that aimed to reduce unwarranted variation across the system. Data has also shown the system’s commissioners spend more than comparable commissioners on MSK elective activity. New MSK hubs will provide a first point of contact, primarily with a physiotherapist rather than a consultant, giving faster access to treatment and making better use of consultants’ time.

Moving beyond a simple organisational focus presents different challenges in terms of how you view issues – whether from the point of view of the place or system or from a commissioning or provision perspective.

Each area has a different mix of deprivation and challenges in terms of the age and needs of the population. Their financial positions also vary as a starting point for system working.

‘There are different dynamics across the system,’ says Ms Rollason. ‘It becomes even more complicated if you start to think about the moves to a single or strategic commissioner and provider.’ This also presents significant opportunities, she adds, and the ability to transform services on a greater scale.

There are other dynamics at play too. South Warwickshire NHS Foundation Trust and George Eliot Hospital NHS Trust work together as a part of a foundation group with Wye Valley NHS Trust – which is outside the Coventry and Warwickshire system. The group shares a single chief executive.

System finances are arguably the single biggest issue that needs to be addressed in moving to an integrated care system – the national timetable suggests this needs to be in place in just over a year. The system is forecasting a circa £34m deficit for the current year, £50m off its £16.5m surplus control total. Stripping out current contributions from the Provider Sustainability Fund and non-recurrent funds, the system has an underlying deficit of around £100m to address.

Delivering the strategic system plan, including reducing growth in activity and remodelling patient pathways, will be key to closing these financial gaps.

In practical terms, Ms Rollason has to split her time between system and organisational work. Notionally, she spends two days a week on system activities, though in practice she has to work flexibly across both roles – largely dictated by the availability of other senior officers across the system.

She says she relies on her deputy at UHCW, Antony Hobbs, who has stepped up to fill some of her duties, but there has been no formal backfilling. One new finance officer supports system work and works with a virtual team across all organisations, with each organisation nominating a finance contact to provide information and figures as needed.

Ms Rollason acknowledges that the clear move to a ‘system by default’ approach, as laid out in the planning guidance, supports the attempts locally to work more collectively. However, she points out: ‘You still have to remember that these are all statutory autonomous organisations and we can’t underestimate the challenge of bringing them all together.

‘It is becoming better as accountability is aligned at the system level by the regulators NHS England and NHS Improvement. But this doesn’t change overnight – especially not for governing bodies and boards. The non-executives need to be brought on this journey, as well as the chief executives and accountable officers – they were all appointed to specific boards but we are now asking them to think about the system as well.’

A key change for 2020/21 is a move to aligned contracts across the whole system. While these are already operating in some places, other areas have retained contracts based largely on the national tariff. The switch aims to acknowledge providers’ clear role in managing demand alongside commissioners. ‘It’s about more than just the money,’ says Ms Rollason. ‘This is about the performance objectives, the capacity providers are putting on to deal with demand, and what transformation programmes we are jointly signing up to. It is about putting it all together.’

She points to a huge focus on the financial challenge facing the whole system by the chief executives and chairs of each organisation. Finance directors from across the system meet fortnightly and there is greatly enhanced transparency about each organisation’s financial position. ‘We held a joint financial development session recently with all finance directors and their deputies. We went through the system financial position in detail, with a specific session on the barriers that mean we don’t operate as a system at times.’

Financial MoU

This ‘all part of the same team’ approach is underpinned by a locally developed financial memorandum of understanding, which supplements the new financial management agreement required to accompany contracts. This memorandum sets out the values and parameters that all organisations are signed up to. Ms Rollason says she is lucky to have the support of finance director colleagues around the system. ‘Without this backing, there is no way I could do this role,’ she says.

She recognises the need to be objective and transparent in all her actions, which she believes is reflected in how she is trusted. But she has to walk a line. ‘I do have a system role, but I still have to represent my organisation. If anything, there’s a danger I overcompensate – something I have to think about daily.’

Increasing numbers of finance professionals must find such a balance as the move towards integrated care systems continues.

Supporting documents
The art of influence