The future is bright

With the NHS in the throes of winter, the focus is, rightly, on patients and delivering care as safely as possible. But the stark images of patients in makeshift wards or corridors, or hearing their elective surgery has been postponed, has prompted further calls for a long-term review of the health and social care system. New HFMA president Alex Gild (pictured) is one of those highlighting the need for a strategic, long-term review.

Contributing to the debate on the future of health and social care is one of the workstreams that will flow from the theme for his year as HFMA president, Our NHS, your HFMA, brighter together.

There are two interlinked elements of his theme. In a nutshell, it is about working with colleagues across the four nations and partners in the NHS and beyond, and supporting HFMA members in the day-to-day and strategic challenges they face. ‘Brighter together means focusing across our teams, partner organisations and systems with a common aim to improve patient care and experience,’ he says. ‘If we are not all pulling together to improve services in our local areas then we are not doing the right thing for patients.’

Mr Gild, chief financial officer at Berkshire Healthcare NHS Foundation Trust, explains that Our NHS, your HFMA is about supporting members. ‘It’s about our network and the benefits the HFMA can bring. The association is seeking to help set the agenda, reflecting new partnerships and priorities in the NHS but also reflecting on the needs of its members. Negatives are always being highlighted by the media and some commentators but we must reflect on the fantastic work that is done for patients, both by frontline clinical services and by our support services, including finance. The work under my theme  aims to help us understand how we can best support and help improve clinical services.’

With the 70th anniversary of the establishment of the NHS this year, Mr Gild wants to create the headroom for the association and others to look forward 30 years to what the NHS might look like on its centenary. The HFMA NHS at 100 programme will focus on a number of subjects – perhaps areas such as the future role of the NHS finance professional or the impact of technology. ‘We want to project the NHS forward, realistically informed by the current operational and financial pressures, to do some strategic thinking and development of options,’ Mr Gild says.

He adds the partnership work could include other professional bodies, such as CIPFA, NHS Improvement and NHS England, together with HFMA partner associations in Australia and US. ‘It’s about carving out the headspace to do it – balancing the day-to-day pressures so we can do some work on the future outlook for the NHS. But it is challenging to do this when the service is under such pressure.’

This chimes with recent calls for a royal commission or cross-party work on the future of the NHS. ‘That would call for some cross-party alignment and support for an analysis and review of what services are provided and how they are funded. And if this work went ahead, the HFMA with others is well placed to support it,’ Mr Gild says.

‘There has never been a better time to use the capacity and expertise of HFMA’s network to get the right people around the table, including our geographical network – across all four UK nations and our colleagues overseas, all facing similar challenges – to look at what the future holds and how the NHS might change to meet it. The HFMA has a role in looking forward to alternatives to the current model.’

He adds: ‘We have got to bring social care and public health into this discussion, being so closely aligned with health services and because of the impact those services have on populations within the emerging partnership and planning remits of STPs and ACSs.’

Supportive role

The association could support wider efforts to examine difficult subjects, such as new approaches to funding. ‘The HFMA and other bodies are saying we are ready to do this work – let’s do it together and make the offer with others to scope the work,’ he says.

During his inaugural speech at the HFMA conference in December, Mr Gild struck a positive note, saying he was optimistic – a word rarely associated with health and care in recent years. What are his grounds for optimism?

‘I think there’s been a positive shift in operational and leadership relationships and understanding of one another’s contribution in the health and social care system,’ he says. ‘If you take the two exemplar accountable care systems [ACSs] that are developing in my trust’s local area [Frimley and Berkshire West], we have around the table local authorities, primary care and other health partners working together to innovate and improve the health and care of the population. Joint visions are being forged, goals aligned and it’s been a significant shift in quite a short space of time. Relationships are strong – I know that it is different in other places, but these relationships are a fundamental condition to system working and in our ACSs we can see collaboration for change and that’s good for everyone, especially patients.

‘The challenge for all systems with constrained resources is to prioritise initiatives that have the greatest health outcome impact for our local populations, using evidence wherever possible. This has been difficult to achieve so far but we know what we need to do.’

Health funding continues to be protected and, though less than the service had hoped for, the additional funds announced in the November Budget are welcome. Mr Gild adds: ‘As our STP and ACS systems develop across the NHS we are seeing a helpful shift in intention and action from NHS Improvement and NHS England in aligning their approach to supporting and enabling our systems, such as offering capacity and expertise where it is needed in the developing ACSs. Aligning approaches to system oversight and regulation is also critical and encouragingly we hear that will happen.’

While the wider system aligns, he says there are significant opportunities providers could consider as a route to sustaining long-term operational improvement, alongside traditional cost savings activity. ‘NHS Improvement’s backing of quality improvement through lean management and transformation is an example. This should not be seen as a top-down regulator initiative; it’s evidence based and aimed at helping trusts empower frontline clinical staff to identify continuous improvement opportunities and reduce waste.

‘The cultural impacts of innovation and engagement are also a major benefit. I’m really encouraged about this from NHS Improvement. It also naturally focuses our corporate services to align with clinical teams in the delivery of improvement. I recommend colleagues look at the QI support offers available and the learning from others. QI programmes designed to engage the workforce and sustain improvement gains over the long term are in my view an antidote to some of the pressures providers face’

He acknowledges the financial and operational position is extremely tight across all sectors, but he believes the response must be all encompassing from a partnership perspective. In recent weeks the strain of winter pressures has been evident with A&E performance falling and elective care postponed (albeit with the support of NHS England) – it is evident part of the solution will come from collaboration between health and care organisations, including ACSs.

‘We need to do something fundamentally different over the next few years,’ he says. ‘We will not get to the solutions to the current issues straight away, but in the new approaches being modelled we have collaboration and developing relationships in the system. The service will benefit as they develop. There is extreme operational pressure at the moment and the NHS is being resilient, to a point. It is important to progress the system work.’

Berkshire Healthcare NHS Foundation Trust provides mental health and community physical healthcare and he is the first HFMA president from a provider of these services, and from the HFMA South Central Branch. How does he feel about the outlook for his sectors? ‘It’s good to see the engagement, interest and understanding of mental healthcare developing within systems as these services provide part of the answer to keeping our populations well and out of hospital. It has been a bit of a battle for mental health services to be able to articulate the impact of services among health and care partners, and the public in terms of what services do for patients, but that is changing,’ he says.

The Five-year forward view for mental health was a big step forward. ‘The economic evidence for investing in mental health services is provided clearly in that analysis. This comes back to my point about evidence-based decision making, particularly in relation to system investment decisions. With the immediate pressures in other sectors, particularly acute, it can be challenging for finance directors to make the longer-term economic case for investment in mental health. But increased capacity in mental health, community, primary and social care is vital if out-of-hospital and prevention ambitions are to be achieved.’

He insists it is important to go back to the clinical, economic or existing service improvement evidence, for example from vanguards, to make the case for investment in the right services.

Mr Gild highlights an evidence-based example of the integrated care decision-making hubs that are being developed in the Frimley ACS. These hubs draw in and integrate the skills and expertise of community partners in supporting patients away from hospital. The evidence for the proposed investment in the East Berkshire hubs came from North East Hampshire vanguard and Surrey Heath outcomes. ‘We need to keep looking for the evidence together. We must not be defensive about solutions invented elsewhere – if a new service improves integration and care experience for patients at scale, and we can deploy it at lower cost than the current model, we need to prioritise it,’ he says.

Though the bigger picture for the NHS is important, the HFMA’s engagement with and services offered to its members are also a priority for Mr Gild. He pays tribute to his immediate predecessor, Mark Orchard, and his work to engage members. During his year as president, Mr Orchard visited every branch, linking with and understanding the needs of members. Membership increased by 7% over the year. ‘Mark connected with the membership and he can be very proud of what he has achieved,’ Mr Gild says.

‘I want to want to build on our support to members to help them work together and more collaboratively in their teams, in their organisations and their partners to build the resilience we will continue to need; to recognise that everyone’s bright ideas are important, no matter what level they are in an organisation; and keeping us focused on why we are here – for patients.’

Collaborative work

He highlights the importance of the association’s joint project with NHS Improvement to develop improvement practitioners. ‘This is a great opportunity for finance to get alongside clinicians and learn improvement techniques, and then apply them.’ He also plans to support finance staff with a series of free events organised at branch level. ‘These will be about things like collaborative skills, building resilience and understanding how to manage through change.’

And there will be a focus on supporting current finance directors and CFOs. Mr Gild says: ‘Many of us in finance leadership positions have operated or developed into these roles from a different place and time for the NHS. What’s expected and required from us as finance leaders now is to move away from thinking just about your own organisation to system working for the benefit of patients. A change in mindset and skillsets are needed at a time when our services face huge challenges. It requires a step change in finance leaders’ skills and contribution.’

While softer skills, such as communication, are important, technical knowledge is also needed. ‘We must know how to plan and prioritise investment at a system level and manage risk and upside in a system, on the back of transformation, rather than just in our own organisations; to support and encourage the identification of opportunities; and enable collective decision making in the system. All this is needed while also maintaining leadership contribution, oversight and grip within our own organisations. This is a stretching context for finance leaders and so I have asked the HFMA to design a pilot personal development programme to support existing finance directors and chief finance officers.’

As with so many of his peers, working hours are long and he likes to spend his spare time with his wife and two children. He also enjoys walking and travelling. The coming months will be tough, both personally as he juggles the demands of the presidency and his day-to-day work, and for the NHS, but he remains optimistic that the future is brighter, together.