8 Balancing act: supporting finance leaders to deliver on short- and long-term priorities
• launching new models of care within horizon 2 (for example virtual wards, frailty same day emergency care (SDEC) • designing a fundamentally new model of care for horizon 3 (for example single point of access (SPOA) and integrated neighbourhood teams). We heard from many finance leaders that while change was happening in their systems, to really impact the future of financial sustainability of their services, a rebalancing of these timescales and types of work was required. The starting points differed across the country. Many feel trapped in the short-term, with no headroom to think about important long-term elements. Others reported lots of discussion on ‘bigger picture’ ideas but lacked confidence on the benefits realisation timelines and current foundational ways of working. When thinking about larger scale transformation in horizons 2 or 3, one of the overriding themes was how to break out of the cycle of current performance churn and find time for those long-term important elements. It can currently feel like there are always fires to fight, and the more that senior leaders end up firefighting the less time there is available to prevent future fires. This is of course also true outside of the finance function. Participants were keen to explore how best to support and empower their teams, and once enabled then encourage and expect them to resolve what’s within their remit, rather than feeling the need to escalate. When discussing application of the horizon model, the following two key requirements were discussed. • The key to these horizons is not to think of them as entirely sequential , but rather to work with operational and clinical colleagues to understand the opportunities and time to deliver within each. A single work element may progress from horizon 1 to 2 to 3, or you may decide to jump directly to horizon 2 as improving the current model has limited returns. Conversely you may improve in horizon 1 and decide the further (more disruptive) transformation in horizon 2 or 3 is not required after all. • The horizons model informs an organisational/ system-wide view of improvement with finance teams helping to navigate the relative paybacks and expected values of working in these different horizons. If you zoom out to look across your efforts, there will be a mix of horizons across your improvement agenda. Having a shared view of improvement (and expected improvement trajectories) across finance, transformation, and operations can prove incredibly valuable.
Applying the horizon model Resonating with many of those involved in this work, one roundtable participant commented. ‘It’s not just do we have financial headroom, it’s do we have the time to stop and think?’ The role of finance leaders beyond the traditional boundaries is a key factor. This cultural understanding forms a helpful start point to determine the most impactful improvement approach (as per the three horizons) for each improvement outcome within an organisation/system. It helps to define which horizon is the most appropriate start point and the improvement journey over time in order to stretch each opportunity sufficiently, building a comprehensive improvement portfolio that balances short- and medium-term service delivery requirements. For example, those organisations with a history of large cost improvement programme (CIP) delivery should focus on more allocative efficiency gains (such as more activity in horizon 2 and 3), while those that have a lesser track record of CIP delivery and have more ‘brilliant basics’ opportunities should have the balance of productive and allocative efficiency (such as more activity within horizon 1, supplemented by key focus areas in horizon 2 and 3). When considering current performance and savings plans, many leaders reflected that they operate more in ‘horizon 0’: surviving an annual churn, with many non-recurrent savings, uncertain sustainability, or shifting pressures into future years. Key questions include: • Do we have the right balance of ‘fix today’ versus ‘change tomorrow’? • Do we know our organisation well enough to know which horizon is the appropriate starting point for each individual service? • Which opportunities do we want to focus on to maximise value over time? • Are we connecting our improvement ambition across horizons to maximise impact over time? For example: • urgent and emergency care (UEC) efficiency gains in horizon 1 (for example reduced length of stay via ‘brilliant basics’)
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