The finance role in recovery

by Steve Bown

15 May 2020

The NHS may be past the initial peak in demand as a result of the Covid-19 pandemic. But what is the finance team’s role in supporting their organisations back to recovery? Wirral University Teaching Hospital NHS Foundation Trust’s chief finance officer Claire Wilson, along with finance leaders across the country, is starting to think this through.

The Wirral trust was arguably the first trust in the country to be impacted by the coronavirus as it provided quarantine facilities for around 100 British nationals brought back in January from Wuhan in China, where the virus first emerged.

Mrs Wilson (pictured) says, in some ways, this gave the trust a bit of a head start – mostly in terms of establishing its command and control structure early and starting to think through the implications for infection prevention and control (IPC). It also put the data capture processes in place to enable it to track Covid-related spending separately.Claire Wilson_204x307

However, following the trends seen by the rest of the country outside London, it was the middle of March before the trust admitted its first Covid-19 patient. That first patient recently returned home after spending seven weeks in hospital, including four weeks in intensive care. During that time the trust and the country have seen a surge in Covid-related demand, which hit its peak in mid-April.

The NHS is now in a second phase of the pandemic response, where the trust is preparing for increased non-Covid, non-elective activity and is exploring the potential of restarting elective care. At the same time, it needs to ensure that it continues to maintain services for Covid patients. ‘We are looking at the capacity we have available and how this will be impacted by introducing the distancing measures we need to minimise transmission of infection,’ says Mrs Wilson, adding that the finance role is then to turn this into a financial plan.

‘And then as a finance team we need to be looking beyond the next six to eight weeks and to the remainder of the financial year. What will the new normal look like as we go into winter still managing Covid, but alongside seasonal flu and other winter pressures?’

The key to building financial plans – and then setting and managing budgets – is understanding capacity. But this is not a straightforward question. While the NHS has historically operated at 90% occupancy and above, this cannot be maintained during and post-Covid. It is understood that occupancy levels of closer to 80% are being used for modelling purposes.

‘We are really conscious of the impact of IPC, we will not be able to fill beds in the same way as we did pre-Covid. We will need to build in greater segregation, which will take out capacity or change flow – so we really need to understand these new capacity constraints, the staffing models needed to support them and  what this means for our cost base.’

The regional hospital cells are co-ordinating capacity plans, asking trusts to calculate what they think their Covid and non-Covid demand will look like and what elective activity needs to be undertaken to meet the needs of prioritised patients.

Clinical and operational teams are starting to work through these demand estimates, supported by the finance team. But the NHS is in new territory. The Wirral trust currently only has 55% of its 840 beds occupied – with about 60% of these being Covid-related. But increasing activity is not as straightforward as simply reopening wards and services.

In addition to the isolation and distancing issues, there is personal protective equipment (PPE) to be considered. This would not have been seen as a planning constraint pre-Covid, but appropriate use of PPE is a critical part of the delivery of all healthcare now and more PPE will be needed as the service returns to a broader range of service delivery.

Staffing is another issue that needs to be factored in. Like all providers, the Wirral trust has seen an increase in staff absence, either because of staff infections or because they are self-isolating. This topped 20% at the peak, although it has subsequently come down to a still abnormally high 15%.

This means understanding what can be delivered with existing staffing numbers, using redeployment across the trust where possible, as well as understanding what temporary staffing might be needed to meet gaps in rotas. During the surge, staff holidays were restricted. While this is no longer the case on the Wirral – given the low overall levels of overall bed occupancy, staff are now being encouraged to take annual leave – it means a lot of annual leave will be pushed later into the year, which will have a knock-on impact on temporary staffing requirements.

Budgets for the first four months have been rolled forward from last year – matching the basis for the trust’s funding through block contracts. But as the service moves further into phase two, there is likely to be an increasing focus on value for money and affordability. The cost base in the three different phases of the response will be completely different, Mrs Wilson says.

A further focus will be harnessing the impact of innovation and new patient pathways. One of the positive developments to come out of the crisis has been the rapid deployment of technology to support virtual consultations. ‘We implemented virtual outpatients in about a week, when we had previously planned to do it over two years,’ she says.

The national changes to discharge processes have also  been really helpful. ‘There has been a major focus with our community and social care partners to support accelerated discharge processes and this is working really well,’ she says. ‘It’s clearer now than ever before how unnecessary extended stays in hospital are not good for patients.’

Even so it has been a dramatic increase in pace. ‘We need to build on that good start,’ says Mrs Wilson. ‘From a finance point of view, we need to understand what capacity and resource that releases. Some of it will have a positive impact on productivity and we need to capture that. And we need to look again at our system transformation programmes to see how we can harness and further develop these positive changes.’

With the finance team largely working from home, Mrs Wilson says she is having to think about how she can support the team’s development. While many aspects of home working have been positive, it also provides some challenges. ‘We are trying to think of ways to strengthen team relationships and the cohesiveness of the team in a world where they cannot be physically brought together – you can’t set aside an away day in the same way that we might have done before,’ she says.

She is also thinking about how finance teams can continue to develop working relationships with operational team members and clinicians. ‘We’ve been promoting clinical engagement as important in the NHS for a number of years,’ she says. ‘You need to be out there understanding how the service operates. You can’t do that effectively over emails and the odd Microsoft Teams meeting. We need to think about how we approach this differently.’

Covid-19 means changes for the NHS for a long while to come and the service may not ever return to what it previously saw as business as usual. It will have to adopt new working practices – running Covid-related services in parallel with normal activity – and it will have to do this with a heightened awareness of infection control.

For finance teams there will also be challenges as they look to capture the financial implications of these changes and return to a greater focus on budgets and financial control. With home working and changes in the financial framework, they too may well be working back to a new normal.