1. HEALTH MATTERS
Autumn 2016

2. CONTENTS
INTRODUCTION3
NEW MODELS OF CARE 4
BRIDGING THE GAP BETWEEN CONTRACT AWARD AND
BUSINESS AS USUAL 7
IMPROVEMENT AND SAVINGS – TEMPORARY STAFFING 10
THE CHANGING ROLE OF THE FINANCE FUNCTION 13
WHISTLEBLOWING – THE IMPORTANCE OF GETTING
IT RIGHT, FIRST TIME, EVERY TIME 16
2

3. INTRODUCTION
Welcome to RSM’s Autumn edition of its quarterly Health Matters
publication. The NHS is now half way through the financial year and
its financial pressures continue. Recent weeks have seen public
announcements of significant deterioration in financial positions
of a number of providers and commissioners, and this is before we
get into the key period for delivery of most cost improvement plans
which in our experience have historically under delivered.
The next three months offer some key deadlines for the NHS in looking to provide
medium and long term solutions. October sees the submission of STP strategic
plans and December finalised two year organisational level operational plans.
Whilst both plans are interlinked and cover much more than just finances, the
importance of delivering both organisational and local system control totals is
made fundamentally clear.
In this edition of Health Matters we have looked to provide RSM’s thoughts on a
number of key areas to support the financial challenges the NHS faces, including
articles on:
• the importance of get the most from your procurement teams;
• our thoughts on dealing with the constant temporary staffing pressure;
• the importance of tax planning in any new models of care; and
• a case study highlighting the work we have done with Kings College Hospital
NHS Foundation Trust to develop their finance team to meet the challenges
the Trust is now facing.
I hope you find the contents of this edition of Health Matters of interest. As always
please do contact me or your usual RSM contact if you would like to discuss any
of the matters raised in this edition. Alternatively, if you’re planning to attend the
NHS Providers conference in November come along to our stand where we will be
delighted to talk through the wider services RSM can offer.
Best wishes
Tim Merritt
Head of Healthcare

4. NEW MODELS OF CARE
Tax controls and identifying new saving areas
Vanguards and Sustainability and Transformation plans (‘STPs’) are helping to
promote working across organisational boundaries to build consensus for the
transformation, redesign and delivery of community healthcare.
However, the recent collapse of the £750M UnitingCare Partnership (‘UCP’)
contract was a high profile event, with parliament commenting that they are
astonished that a project approved by Monitor, the NHS strategic projects team and
NHS England all failed to identify any potential VAT problems.
As a brief background, UCP was set-up as a consortium between Cambridgeshire
and Peterborough NHS Foundation Trust plus Cambridge University Hospitals NHS
Foundation Trust and, following an open bidding process, was the awarded provider
of older people’s healthcare and adult community services.
AfailuretoaccountforunplannedVATcostswasasignificantcontributortothe
contract’searlydemiseandinquiriescommissionedbyboththeNAOandNHSEngland
havenowprovideddetailedanalysisofshortcomingsandofferedanumberofsensible
recommendationsforothernewmodelsofcarebeingplannedacrosstheNHS.
So what are the lessons learnt and could these inhibit other co-design and joint
working projects that are being progressed?
New legal entities can often be created by the NHS, local authorities and other
providers for reasons of risk, to pool resources or simply to provide more
cohesiveness for better co-ordinated care. The subtleties of legal partnerships
and the principles of agency are important areas and ones that can easily be
overlooked, creating risk, potential negative publicity or reputational damage for
the board. For example, whilst a legal agreement might assert that there is no
partnership intention, formal status can still be assessable by the actual working
conduct of the parties involved.
The UCP model (at a late stage in the procurement process) intentionally created
an LLP in between the CCG and both NHS providers. This ultimately altered the tax
status of the commissioning funds and the NHS provider’s business status. UCP, as
a non NHS body, was also excluded from benefiting from VAT refunds enjoyed by
the consortium members. The failure to factor these into their financial forecasts
was, ultimately, a significant oversight.
Thenewmodelsofcareprogrammehassignificantmeritstoitandthe‘VATinefficient’
UCPscenariomaywellhavebeenavoidedhadbettercontrolsbeeninplace.
4

5. On the flip side, it is also possible that VAT efficiencies could be
made by organisations working together especially when you
consider the very different VAT regimes that apply across the
various partners involved in our public care service delivery.
For example, GPs and GP Alliances generally have minimal to no
VAT recovery, an NHS body reclaims a proportion of their VAT
whereas local authorities often benefit from full VAT recovery.
As fingers have now been burnt will VAT efficient models still
be considered and driven forward? We think so. As the NHS is
under external pressure to make saving after saving, we are still
seeing both NHS Trusts and contractors push the boundaries on
what is acceptable. Often, clinical or procurement leads are left to
negotiate contracts without fully understanding the risks they
could be exposing the Trust to should tax assumptions not be
taken seriously enough or if they are not correctly quantified.
Ensuring there’s a rounded understanding of these factors
should never be underestimated and is a topic the board should
periodically visit. Given the sums involved, all flows of funds and
financials should be scrutinised and their correctness challenged
before commitment. This is easier said than done when you
consider the significant pressures on NHS personnel to effect
immediate change and hesitancy for engaging professional advice.
However, during this period of significant change and arguably
one of outright experimentation, if we are to avoid more multi-
million pound failures let us take one positive step forward and
put in place stronger controls and ownership; this may just help
avoid the NHS taking multiple steps backward.
5

6. Questions to consider
Do you have a tax strategy policy?
Is it in-line with your organisational policy?
Are your finance executives sufficiently involved in the set-up of new care models?
Do you consider all the various taxes from the outset?
What process map is followed against large commissions or engagements?
Does this involve comment on the tax impact (whether neutral, positive or negative)?
Is tax included in your audit plan and measured against your tax strategy?
How often are independent appraisals required?
Who is your senior accounting officer?
Dotheysignoff major operationalcontractsincludinganassessmentonthetaximpact?
Does your Cost Improvement Programme include VAT saving projects?
DoesprocurementunderstandtheVATbenefits/costswhenprocuringdifferentformsofcontracts?
Aretax savings/costsbeingmeasuredinyourorganisation?
6

7. MIND THE GAP!
Bridging the gap between contract award and business as usual
Lord Carter’s efficiency review of 2014 identified that the NHS would be able to make
a total of £5bn savings per annum in the years leading up to 2020/2021 if a number of
steps were taken to improve efficiencies across England and Wales.
With increased pressures on NHS Trusts to deliver, procurement functions are
under more scrutiny than ever to translate buying and sourcing activity into real and
sustainable benefits.
Some of the challenges faced within public procurement in the NHS are clear and
long-standing. Things are not getting simpler or easier; good procurement people are
scarce, time and money is tight and procurement officers have to compete for the
attention of equally stretched stakeholders. This means that most of the benefits
identified at the procurement stage may not be fully realised further down the
line simply because the resources needed to make this happen are not available. In
addition, procurement staff are under pressure to move on to the next exercise making
it difficult to focus on the work required to realise the benefits identified during the
procurement stage. To further compound this problem, the sole focus of some finance
and procurement departments on delivering against Cost Improvement Plan Savings
(‘CIPs’) targets has somewhat blurred the vision of some procurement departments
and executives within the NHS. This has sometimes perversely led to sub-optimal
outcomes, ultimately unsustainable results and unrealised or diminished benefits.
There seems to be a gap in the crucial period post contract award and prior to business
as usual which needs to be filled if organisations are fully to realise benefits.
The very resources that the NHS needs to achieve and maintain their CIP targets and
other objectives against the Carter review are the resources that it desperately lacks.
This calls for a more creative and innovative approach if departments are to achieve
lasting success against their objectives.
Notably, in our experience, the Trusts that deliver the sustainable outcomes are those
that are able to focus their resources on this gap between the contract award and
business as usual stages.
7

8. 1
Joined up working- Avoiding the collaboration gap
Good procurement functions are able to interrogate the market for value
for money solutions. However, these are not always readily adopted by
business managers, contract managers and clinicians because of gaps
in collaboration. The achievement of lasting success requires time and a
joint effort from all the relevant stakeholders from the outset. The Carter
report reinforces this sentiment by stating that; ‘we have learnt from our
conversations with Trusts that close engagement and collaboration are
essential and that this supportive approach needs to be maintained'.
We have identified the following three simple investments that can lead to improvements in bridging
this gap:
2
Keep key resources close- Filling the resource gap
It is important to keep the same team that were involved in the delivery of
the initial procurement exercise and use them to embed the change as these
are the people that know the requirements inside out. They are very often
the super users and voices of other users and they usually have the power
and influence, as well as understanding to manage and mitigate issues and
risks that may arise at the early stages of implementation. They are also
likely to be in a position to undertake the granular work required at the user
end to ensure that users adopt the new or changed product or service.
3
Introduce good governance- bridging the accountability gap
Trusts should consider appointing a Senior Responsible Officer (SRO) for key
categories of spend so that there is good governance around procurement
and accountability between procurement functions and their stakeholders
to ensure benefits are realised. Governance should be informed by high
level plans for sourcing and procurement. This would further strengthen
accountability and improve communication which can contribute to
achieving sustainable improvements in procurement.
How we can help?
As organisations seek to meet the challenges around procurement promoted by Carter both by
looking at current capabilities and outsourcing opportunities, this is the right time to undertake a
review of the Procurement Function effectiveness to determine what may be required to ‘bridge
the gap’ and help release the savings not previously reached.
8

9. 9

10. IMPROVEMENT AND SAVINGS – TEMPORARY STAFFING
Recent instruction from NHS Improvement Chief Executive Jim Mackey has focused the NHS’ attention on
reducing temporary and agency staffing and consolidating services, many of which are traditionally back
office. The NHS now faces a challenging time to bring about change, improve staff utilisation, increase
retention and shift from a reliance on bank or agency.
So what are the issues that create ‘high’ temporary staffing in hospital?
1 Recruitment
• While there are many different reasons for the use of temporary staffing, one of the most common ones is
that there just is not the supply of permanent staff out there. ie it’s an issue of supply and demand, and often
the demand exceeds the supply.
• The question then has to be asked: At a time when jobs in the UK have been at a premium, why are so many
people choosing to work as a temporary employee through an agency rather than as an employee?
Retention
• Hospitals are the training ground for health professionals, as there is only so much you can learn in the
classroom or lecture theatre. This will always be the case as people retire and move on, and is the natural
order of all organisations worldwide. However some hospitals seem to do more than their fair share of
training as they train staff who then move on to get a job somewhere else or become locums or temps.
• Sometimes the wages are just better with your neighbours (especially if you live on the border of the London
weighting zone).
• For some the job as permanent employee is too hard or comes with too much pressure, which is one of the
reasons why many nurses approaching retirement choose temporary work as a more flexible option.
• For some temping is simply easier and more flexible for their lifestyle, making it easier to have that important
home and work life balance.
Funding (and timings)
• Short term initiatives and uncertainty of length of funds for specific projects – mean organisations are risk
averse to taking on permanent staffing.
• Temporary staff brought in by the Trust to help deliver one off change or improvement initiatives.
2
3
10

11. Quality – ‘throwing staff at it’
• Poor CQC ratings or KEOGH or waiting lists or… you name it there is always an issue, now or just around
the corner that extra resource will help solve (sadly this usually comes with a cost that can’t always be
recovered). Then when things improve, costs and temp staffing are reduced … until the next issue and so on.
Custom and practice for staff management
• More common than you think one of the answers is ‘that’s the way we always do it’ when it comes to
planning staffing levels, rostering and balancing out holidays and rotas.
• Temporary staff have been around for so long that they are like permanent staff members anyway.
Demographics / age / brain drain
• Simply put, some places are just more appealing to work than others:
• an out of town run down building away from any facilities or a nice new hospital site where there are lots
of thing going on;
• the commute; or
• the dread ‘parking’ situation at some hospitals.
The reality is that for each hospital, it will be a combination of these and other factors that drive the high levels
temporary staffing.
4
5
6
11

12. So what can you do?
Option A has often been the ostrich approach – hospital staff sticking their head in the sand and
waiting, until the issue goes away or money is available. Unfortunately it does not look like extra
funds are arriving soon. So Trusts have to tackle this one head on.
However there is light at the end of the tunnel and there are several things that can be done to
improve the situation; there is no one size fits all magic wand to fixing this, but some of the areas
to look at are highlighted below:
1 Tackling Entrenched behaviours
• Trust wide – one approach across the Trust
• Clinical areas and wards – diving into the problem areas individually
Procurement and third party relationships
• Contracts – taking a commercial and operational look at how temporary staff
are procured (after all this is like any other purchase with opportunities to
consolidate and drive down costs both locally and through national initiatives)
Staff
• Retention – looking at why people join in the first place, why they leave, and
working to make being a permanent employee the best options. Working
with other Trusts in the area to take a more global approach to staffing, and so
remove some of the reasons to move elsewhere.
• Temporary staffing governance and control – Looking at setting up capacity
planning across all areas where there is high usage of temporary staff,
implementing a governance structure to drive down costs and improve
staffing quality.
• Recruitment – working on the roles and levels needed, including taking a non-
traditional view of what type of staff are needed where and matching this more
closely to what is available in the market. Add to this there are lots of qualified
staff across the EU and countries further afield that see the UK health sector
as an appealing market, notwithstanding Brexit.
Clinical quality
• Service improvement – the improvement in service often drives out the
inefficiencies and therefore the need for higher staffing level
2
3
4
At a time of stretched capacity it can be difficult both to see what needs to be done and to
implement change. Consideration should be given to a diagnostic, investigating the issues above
and providing a clear signpost based on internal data and available benchmarks as to where the
best opportunities may lie to reduce temporary staffing costs without jeopardising safety.
12

13. 4
5
6
THE CHANGING ROLE OF THE FINANCE FUNCTION
Trusts are faced with ever increasing financial challenges and consequent demands being placed
on their finance departments with pressures emanating both internally and externally. Delivering
the traditional transactional processing service alone is no longer sufficient, but transformational
improvement to deliver faster, more insightful management information and decision support while
simultaneously reducing costs in line with the national drive to reduce back office function costs has
been a struggle. To achieve this objective, efficiency and effectiveness improvements must succeed
together.
Approach to transformational improvement
The starting point of transformation improvement commences with a review and assessment of
current practices. Achieving this is accomplished by:
1. conducting a time activity analysis of finance resources;
2. surveying internal stakeholders, capturing their view on both the ‘As-is’ state and the desired
‘To-be’ state of services delivered by finance; and
3. facilitating process workshops to fully understand the ‘As-is’ state pain points that exist in the
current Finance Operating Model. A review of a Finance Operating Model covers the below six
specific areas.
• People
• Technology enablement
• Organisation
• Financial close, consolidation and reporting
• Transactional processes
• Compliance
Key considerations – 10 questions to ask yourself
• Is the cost of the Finance Function greater than 1 per cent of Trust turnover?
• Does transactional processing account for more than 30 per cent of resource time?
• IstheITlandscapefragmented,comprisingmultipleandoutofdatenon-integratedITsystems?
• Is there heavy reliance on spreadsheets and manual data manipulation?
• Is there a proliferation of paper based documentation and physical approvals?
• Are there variations in the ways of working, driving non standardised processes between
departments and within teams?
• Is management information not available until more than 8-10 days after month end?
• Is management information insightful and forward looking providing clear signposting of
decision making actions?
• Is management information appropriately detailed and flexible to meet user needs both
internally and externally?

14. 14

15. CASE STUDY - KINGS COLLEGE HOSPITAL
Kings College Hospital (KCH) with an annual income of over £1bn continues to face significant financial
challenges. The Trust has been under significant scrutiny from the Regulator, with particular emphasis on
the financial performance. As a result, the Trust restructured the operational management of the Trust
with significant implications on the back office functions including finance. The finance department had
received criticism from external and internal sources and whilst it was clear that there were very capable
individuals within the department a high proportion of transactional non-value adding work was impeding
the team from delivering a world class service to the Trust. Working with RSM’s Finance Consulting team
a fundamental root and branch review of the department operating model was undertaken.
The review commenced with assessing the perceptions from
internal stakeholders in receipt of finance services delivered
by the department. This entailed issuing a questionnaire
which sought to understand the ‘As-is’ state and the
desired ‘To-be’ state. The outcome from this clearly showed
that stakeholders wanted more transformational support
and improvements in reporting whilst maintaining the
department’s perceived leanness.
To achieve the dual objective of releasing finance department
resource for transformational support and maintaining
current investment levels it was important for the
department to consider what it currently did and how/where
it adds value. The team mapped the current resources against
current activities to understand the current resource drivers.
This identified that 75 per cent of the current resource was
spending time undertaking transactional activities and
therefore if the department was to deliver stakeholders’
needs, this type of activity needed to be reduced significantly
to release resource to improve the value delivered by the
department. Through facilitated workshops with process
staff at all levels, the team mapped the core transactional
processes end-to-end as well as the systems landscape,
capturing current inefficiency and ineffectiveness pain points
which were driving the resource demands.
Against each pain point, the team produced a prioritised and
time bound improvements roadmap to enable the Trust to
deliver its ‘To-be’ state Finance Operating Model. Proposed
recommendations were used to design clear, standardised
‘To-be’ state process blueprints for Purchase to Pay, Order
to Cash and the month end close processes. A reconfigured
department structure was also proposed to improve span
of control. The reconfiguration also included the creation
of a centralised business partnering sub department with
resource aligned to the restructured divisions of the Trust as
well as external requirements.
Finally, the team presented a statement of system
functionality requirements to drive efficiency and governance
benefits to the Trust.
Reallocation of
resource time from
transactional processing
to more productive value
add analysis and business
partnering decision support
while eliminating excessive
hours being worked.
1
Delivery of flash
reporting on day three and
final budget statements /
finance pack presentation on
day five, outperforming the
NHS benchmark.
2
Standardised flexible
reporting meeting
the needs of users and
providing forward looking
insightful management
information for informed
decision making.
3
Overall benefits from the review
15

16. WHISTLEBLOWING – THE IMPORTANCE OF
GETTING IT RIGHT, FIRST TIME, EVERY TIME
Whistleblowinghasbeenunderthespotlightinrecentyearsfollowing
theFrancisReport,whichledtoanumberofrecommendations,inpartto
seekimprovementstoorganisationalculture,supportforthosewhoraise
concernsandareminderfororganisationstoreviewtheirownprocedures
toensuretheyareknown,accessibleandoperatingeffectively.
So why do organisations still sometimes get it wrong?
Well, there are several factors relevant to this point, not typically because of
intentional failure to follow policy, but often down to:
• lack of understanding of the processes in handling information;
• lack of understanding of the importance in maintaining confidentiality; and
• failing to meet obligations placed upon management within organisations to
identify and investigate whistleblowing independently and on a timely basis.
Examining each point enables a better understanding of where the symptoms
often arise from, with some key lessons to take note of so you can ensure that your
systems are robust.
Lack of understanding in handling information
Part of the challenge that organisations face, is not just identifying cases which fall
under the whistleblowing procedure, but also in identifying what can be a disclosure
which covers many aspects, such as complaints or grievances entwined with
a potential disclosure. Part of the skill required is to assess the referral, identify
swiftly whether it is a disclosure under the procedure, or something that should
be dealt with under another internal procedure, such as a grievance procedure
or similar. These are two distinct processes, and often we see matters being
progressed as whistleblowing which are not appropriate for this process.
It is important to communicate where possible, with the referrer (if known)
to advise them of your receipt of the referral and the procedure that it will be
progressed under. Remember, it is for the investigation to determine the terms of
reference for any investigation and not for the referrer to dictate the terms or the
basis of an investigation proceeding. It is important to establish these parameters
at the outset, to manage expectations.
16

17. Lackofunderstandingoftheimportanceofmaintainingconfidentiality
Thiscanbeabighurdletogetover,asmanyindividualsmaynotwish
toreportconcernsunlesstheyaretreatedinasupportivemanner,
wheretheirconfidentialityisrespected.LineManagersinparticular
areanimportantelementwherebytheymaybetherecipientofsuch
informationinitially,whereitisnecessarythattheyunderstandthe
importanceofhandlinginformationinconfidenceandnotexposingthe
referrertoanypossibledetriment.
UnderthePublicInterestDisclosureAct1998(PIDA)thereareseveral
factorswhichorganisationsmustbealerttowhichplacealegalduty
uponthemtocomplywith.Oneofthesefocussesaroundtheprotection
affordedtowhistle-blowersiftheyhavemadeaqualifyingand
protecteddisclosure.Whistthisarticledoesnotgointodetailonwhat
constitutesaqualifyingandprotecteddisclosure,theActisveryclear
inthatemployeesareprotectedfromsufferinganydetrimentonthe
groundsofhavingmadeaprotecteddisclosure.Thisincludesdismissal,
ifaprotecteddisclosureisthereasonfordismissal.Gettingthiswrong
canbeverycostly,ascompensationpayableattribunalisuncapped.
Thisisinadditiontothereputationaldamageandharmtoyourculture
thatwouldfollowasaresult.
Failing to meet obligations placed upon management within
organisations to identify and investigate whistleblowing
independently and on a timely basis
To inspire confidence in a process, it is important that referrals are
investigated as quickly, but thoroughly as possible. Acknowledging
and thanking the referrer (where possible) allows engagement and
reassures the referrer that they are being taken seriously and the
matter is being looked into. Whilst it is a simple thing and promises
as to updates or outcome may not be provided, a simple thank you
and acknowledgement of the referral can be reassuring to a person,
especially when they may have had to pluck up the courage to refer
the matter in the first place.
We see that matters often become contentious or difficult with
referrers when there is no action taken or things do not appear to
be taken seriously or treated with priority. I have a certain level of
sympathy as these matters typically get passed to a manager, often
within another department or site to investigate, on top of the day
job when they may have had very little, or any investigative training
on dealing with such matters, or what techniques to use. It is then
where things can start to spiral, a loss of confidence in the process
or a belief that matters are not being taken seriously can lead to
difficult relationships developing and a widespread disillusionment in
the process across the organisation. The consequences of this one
incident can be far reaching if handled incorrectly.
Handling whistleblowing effectively is a specialist skill, which is
something that you only have to get wrong once to diminish staff
confidence in management; despite the level of work you may have
done to develop your procedures. It could also cost you financially
and impact negatively on your reputation.
17

18. Culture – Do you assess the culture in your organisation?
• Engage with your workforce by using anonymous secure surveys or mailboxes
to seek feedback to inform your view.
Review – Does your Board review the level of incidents? Do you get none?
• Consider whether this is down to inadequate reporting procedures and as such
matters are not being flagged up.
Reporting accessibility and responsiveness - Are your reporting mechanisms clear
and accessible? Where a response is required do they respond swiftly?
• Consider whether you communicate the different reporting lines clearly and
triangulate what is received, to ensure that incidents don’t get reported through
incorrect channels or missed altogether.
Professionalism and skills – Do your staff have a clear understanding of how to deal
with whistleblowing?
• Provide training so they have the tools to do this effectively, including handling
information securely, escalation procedures and investigative techniques.
Strategic position – Do you have a whistleblowing champion in your organisation,
who fully understands the regime as the point of contact for advice and guidance?
• This person should be suitably senior with access to the board with a degree
of independence, to issue a positive message as to the stance that you take in
tackling these matters.
1
2
3
4
5
5 key areas to consider
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CONTRIBUTORS:
Tim Merritt
Head of Healthcare
T +44 (0)1908 687 800
tim.merritt@rsmuk.com
Nick Atkinson
Internal Audit Partner
T +44 (0)7730 300 307
nick.atkinson@rsmuk.com
Pelle Langli
Consulting Partner
T +44 (0)7703 539 130
pelle.langli@rsmuk.com
Scott Harwood
Tax Director
T +44 (0)7855 846 419
scott.harwood@rsmuk.com
David Foley
Fraud Risk Services Director
T +44 (0)7721 977 523
david.foley@rsmuk.com
Steve Uttley
Associate Director
T +44 (0)7800 617 223
steve.uttley@rsmuk.com
Patricia Nweke
Managing Consultant – Procurement and Contracts Advisory
T +44 (0)7737 638 514
patricia.nweke@rsmuk.com