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CIPFA Chief Executive Rob Whiteman set the context at the first meeting of the Health and Integration Board. It provided a chance to press on further with the aim which CIPFA has had since his arrival in 2013: to re-engage with health after becoming too heavily local government oriented; and to do so by carrying through a governance review associated with culture change so that the charity, membership and business aspects of CIPFA are unified. The three areas of focus are policy, membership and commerce. The boards are intended to advise on the state of the nation, what thought leadership to advance, how best to support members, and what products might we develop (typically in partnership) for health and social care to facilitate the commercially successful delivery of CIPFA's charitable aims.
CIPFA’s Head of Health and Integration, Jane Payling, introduced the health and integration business plan for 2016, which looks to segment the market into the following groups: health providers/health commissioners/regulators/local government care commissioners. It aims to help those groups with the strategic imperatives of balancing books, achieving long-term financial sustainability, delivering transformation and integration, and dealing with staff shortages.
She had four questions for the Board:
It was agreed that they make sense now, though it might be possible longer term to look more thematically. Other points mentioned were the need to avoid concentrating on illness rather than health and to beware of concentrating on organisational needs, when action on the whole system is what counts. What does it mean in governance terms, for example, to manage a health provider trust in surplus next door to one in a major deficit? How should you take account of the whole system factors? The Board also stressed the value of following users of care on their journey through the system. Also, could health learn from social care’s approach to decision support, procurement and managing markets?
Planning guidance due out on 20 September will emphasise systems working, not just organisational control; helping people to think in those broad terms is critical. Implicit in that is the current over-emphasis on short-termism: can we weave in the ‘three gaps’ identified in the Five Year Forward View (the health and wellbeing gap, the care and quality gap, and the funding and efficiency gap)? Support is also needed in reconciling the Carter Review to sustainability, and to focus in that on workforce as well as money.
The broader imperative around wellbeing in the NHS finance community was mentioned. Future-Focused Finance is about to issue tools around the question of the ‘pipeline’ – how to develop the right staff? The need for whole system thinking was identified as organisation based thinking tends to omit people on the periphery, or working at the interface.
The Board also stressed the importance of playing the wider determinants of health such as housing, employment and benefits into the total support. Another increasingly important question is: how do you get non-finance staff engaged to look after budgets, the more so as finance staff numbers reduce.
Clinicians and social workers ‘didn’t come into this world to manage budgets’, so a need to support their development was identified which links to a partnering stream of FFF. HFMA, it was felt, does in health a lot of what CIPFA does in local government. Competition makes little sense and it makes more sense to work in partnership. However, there are things which CIPFA do which HFMA doesn’t cover, CIPFA, for example, is better placed than HFMA to ‘speak the truth to power’ (eg recent stance on the pressures generated by how NHS control totals are being treated) and to work closely with local government on integration.
The Board agreed there was scope for adapting existing approaches for the health market, eg the FM Model’s main market has been in central government and abroad. Products around financial resilience and counter fraud might also be adaptable? Access to capital in NHS is problematic, so that might be helped by facilitating the conversations with local authorities on how to access capital using their greater flexibility.
The Board was supportive of the project to develop tools for the assessment of revenue investments, which it was felt would fill a gap for finance directors. There’s a need for training on the gateways people need to go through and how to cost a pathway? The starting point should be value to patients, not just cash. Financial management in GP consortia was also seen as a potential product.
The Board also suggested that CIPPFA should view employing organisations as "members", and act as "the home of people working in finance", not just of people sitting CIPPFA exams. "We’re going to help you support your students" is a key offer.
The Board’s Terms of Reference were agreed, being consistent with the discussion. It was suggested that a third sector representative should be sought for the Board.
CIPFA’s Director of Public Affairs, Drew Cullen, explained that CIPFA had been successful in raising its public and press profile in health, based on well-researched content, but also sought to bring about the right sort of changes. He indicated a desire, which the Board supported, to shape the broader agenda and engage with stakeholders more effectively in the key areas of integration, fiscal resilience and the effects of Brexit.
The Board discussed their perspectives on the Better Care Fund (BCF) in the light of the end of first year CIPFA-HFMA survey. The consensus was that any reduction in apparent agitation at the problems caused by the BCF was likely attributable more to the acceptance of its marginality as to the more stable long-term position given to it by the December 2015 announcements.
Interesting debate on BCF was on ‘who bears the risk?’ It was suggested that a tussle lies ahead between HMT and DH on how BCF is funded, with pressure to subsume it within locally retained business rates, which might well prove problematic. The BCF was seen as likely to lose any relevance as the requirement for full integration takes shape. As currently set up, it had failed to follow the principle that ‘form should follow function’ – rather, you were set financial targets and had to concentrate on passing the checkpoint at the expense of the originating purpose, which was now lost. The local partners had challenged all this when the BCF came out, it was said, but had now mellowed and went with the flow. Perhaps we had tried to make more of it than it had largely proved to be, ie just a mechanism for the transfer of funds.
In a fuller discussion of the project to assess long-term revenue investments in public health, the Board indicated that it would like to act as a reference group for the work. The generic nature of the intended tool was emphasised: so, for example, it could be applied not just to ‘traditional public health concerns’ such as tackling obesity, but to such early intervention as taking action to reduce loneliness. A distinction between ‘total benefits’ v ‘realisable benefits’ should be emphasised – ie emphasis is on both cash and the quality of life.