HFMA president: a clear focus on opportunity

It’s almost become a cliché, when a new HFMA president takes office, that they will spend a year leading an embattled NHS finance profession doing its best to balance the books, while their organisations face ever-increasing demand as they try to find time to transform services. This year will see the new money promised in the five-year financial settlement begin to flow, but in England the NHS long-term plan and planning guidance for 2019/20 expects the extra funding will produce quick results – for example, reducing the number of deficit trusts by 50%. The outlook may appear challenging, but new HFMA president Bill Gregory sees reason for optimism.

‘The long-term plan is a welcome reset after a challenging and difficult time, which has lasted five years or more both for the NHS and finance professionals,’ he says.

‘I am quite pleased about the emphasis on outcomes rather than getting hung up about the structures. Reorganising might enable us to reorientate our thinking, but it won’t solve our problems – we have to achieve that reorientation in other ways.’

Mr Gregory, chief finance officer and deputy chief executive of Lancashire Care NHS Foundation Trust, also backs the move to blended payments in urgent and emergency care, and the scrapping of the marginal rate emergency tariff and 30-day readmission rules.

‘I found the focus on reducing unnecessary outpatient appointments fascinating. That’s fertile ground for value-based healthcare because I suspect many of us have been to a hospital appointment and thought, “Why was that not done in the local GP surgery or by phone?”. The real prize will be gained when replacing the current outpatients system with alternatives – the question will be, are the alternatives more efficient and what will the outcomes be? This is good territory for value.’

Public health data could be used to plan services in the future. ‘That really resonates with value and using data alongside financial information to work out the best thing to do.’

He adds that more work is needed on the role the NHS will play in decisions on spending the public health grant – the long-term plan said government and the NHS would consider giving the health service a greater role in commissioning sexual healthcare, health visitors and school nurses. Mr Gregory believes this must be handled carefully as it could become contentious, especially given the financial pressures on council social care. ‘It’s an area where there is the potential for disintegration rather than integration,’ he adds.

Equally, he sounds a note of caution about the clinical commissioning group allocations for 2019/20. ‘There was some excitement about the size of some CCG allocations, but we need to be cautious. There is some differential compared with the current year, but there have been changes to the allocations, the market forces factor has changed, and these will affect the system differentials.’

Changes to the allocation of the provider sustainability fund, including the transfer of £1bn from the fund into urgent and emergency care prices, have also affected the new allocations. ‘Quite a bit of any increase will be due to sustainability funding, which will come through allocations, as well as funding around pay awards. When integrated care systems (ICSs) do their plans, it will be important to see the underlying growth in resources. I suspect they will probably not be as big as the headline figures,’ Mr Gregory adds. ‘The move to get providers collectively back in balance within two years is a positive step, but we will still need to understand how that will work.’

National bodies have dubbed 2019/20 a transitional year, and Mr Gregory is looking forward to playing his part as HFMA president. ‘It’s a real privilege to be a trustee and also president of the association. It gives me an opportunity to put something back in, particularly after a number of years of benefiting from the networking and the personal and professional development offered by the HFMA to its members. It feels the right thing to do, and an honour to be asked.’

He continues: ‘I am most looking forward to getting out there and visiting the branches. I have been a trustee for about three years, so I have a fair understanding of the mechanism of head office. I’ve met some branch chairs who have come to trustee meetings, but apart from the North West Branch events, I’ve not really been able to get out to the branches. I want to get a sense of what people are thinking around the new long-term plan for England. It will also be an opportunity to meet the finance leaders of the future.’

UK-wide awareness

Though, naturally, a lot of attention this year will be paid to the long-term plan for England, Mr Gregory is keen to ensure voices from the three devolved nations are heard. ‘All the other nations have integrated systems of varying structure, but are still facing similar service challenges and pressures to those being experienced by the English system. I am sure that we in England have a lot to learn from integration in Scotland, Wales and Northern Ireland. Having integrated systems does not resolve all the problems. But it does give you a more joined-up way of looking at the problems and finding solutions.

‘The devolved nations have a big part to play in the English system learning from what’s happened there. But, as the English system evolves, there will be learning for the devolved nations as well. I think the four-nation focus is a real strength of the HFMA and it’s really important we continue with that.’

Mr Gregory’s theme for the year is Value the opportunity. It has three elements – influencing the agenda; focusing on value to improve patient care; and professional development.

Though the long-term plan for the NHS in England has been published, Mr Gregory believes the HFMA can continue to influence how it develops. He points to unanswered questions – on control totals or the use of public health grant, for example. The association is talking to NHS England and NHS Improvement about how it can help work through outstanding issues.

‘The long-term plan sets out a useful direction of travel and, together with the one-year planning guidance, is clearly a step in the right direction,’ he says.

But 2019/20 will be a transitional year and there are questions around areas such as additional funding, control totals and nuances in the tariff.

‘There is still quite a lot to be worked out, not least the issues around ICSs becoming the level of local planning in the NHS. This work includes hammering out the detail of the operation of system control totals. There are still some things that need to be fine tuned for 2019/20.’

There are other questions, he adds. ‘How does the NHS influence how the public health grant is spent and how do you deal with competition in an integrated environment? The things that would stop us making progress have been addressed for 2019/20, but in the longer term some things need to be clarified.’

The long-term plan does not deal with capital – instead, saying capital funding will be dealt with in the forthcoming spending review. Mr Gregory points out that, in the meantime, the NHS has a major maintenance backlog.

The HFMA influencing agenda will not be restricted to the NHS long-term plan. Some workshop events, initially created under 2018 president Alex Gild’s theme, Brighter together, will be held this year and focus on system working and integration.

‘One of the things to focus on in this area is the information we need to operate more effectively as systems,’ Mr Gregory says.

Value-based care

The second element of his theme seeks to improve patient care by increasing the focus on value-based healthcare. The NHS long-term plan’s vision of system working could create new opportunities for the HFMA value work, which is carried out by the Healthcare Costing for Value Institute. ‘The long-term plan vision almost cries out for value-based healthcare techniques and tools,’ he says. ‘When you are moving from working at an organisation level to working as a system, it potentially becomes easier to talk about the whole pathway. The time has come for the work the institute has been doing and will be developing.

‘For example, outpatients with cardiac outpatient appointments are quite often on six- or 12-month recalls to see their cardiologist. That happens for good clinical reasons, but could it be done differently? Could primary care be supported to do it? It would shift funds around the system, but you would also have to ensure that the outcomes, at the very least, do not deteriorate. Hopefully, outcomes for patients and patient experience will be better.’

In his speech to the HFMA conference in December, Mr Gregory mentioned the institute working with Matthew Cripps and his team at NHS England on programme budgeting. The current programme budgeting tool allows, for example, comparison of costs across disease groups by CCG.

Returning to this theme, he says: ‘There are lots of issues around the programme budgeting tool, not least of which is the fact that how it gets deployed on the ground varies across the country. NHS England is keen to make it a more useful tool and the institute is working with Matthew Cripps and his team on that.’

Mr Gregory is looking forward to the institute/Future-Focused Finance value summit in May. ‘The theme of the summit is how finance professionals and clinicians are working together to use value to solve problems – it’s an opportunity for institute members to showcase work they are doing.’

Development focus

Professional development is the third element of Mr Gregory’s theme and the HFMA qualifications will be central to this. ‘At conference I mentioned that most of us will be members of professional accountancy bodies, which gives us the licence to practise as accountants. But the HFMA provides us with sector-relevant development and expertise in healthcare. I think the higher-level qualifications will be valuable to individuals keen to further their career or change roles within the sector.

‘They will help introduce them to wider issues and are already beginning to mark out individuals seeking new opportunities.’

The association’s introductory level qualifications could provide a step-up for those new to NHS finance or hoping to develop their career through an apprenticeship. ‘The next step with the qualifications is how we can harness the power of the apprenticeship funding,’ says Mr Gregory. ‘Could we make sure we are offering something that’s relevant to people who are not yet qualified? The ideal solution would be a programme that accesses the resources of the apprenticeship scheme and also offers the option to progress to gaining a full professional qualification.’

Mr Gregory wants the association to continue to develop its offering to current and future finance professionals, supporting their career development and helping shape the policy environment in which they work. For the HFMA and its members, he believes, opportunity knocks.