The financial year just gone has not been the easiest for acute services, with tough targets, population changes and possible structural shifts all putting pressure on trusts.

The compliance agenda has ratcheted up (18 weeks and infection control). Population changes have put additional pressure on maternity and children's services. Uncertainty over the shape of acute services in the capital (in the wake of Lord Darzi's Healthcare for London) raises strategic questions about who does what where, which needs planning alongside operational delivery. And then for King's and our south east London partners there is the emerging academic health science centre question, about which HSJ recently reported.

Let's start with the money. Like the majority of acute trusts and almost all foundation trusts, we achieved our target surplus. In fact, we exceeded it by a significant amount, once the additional expense needed to deliver on 18 weeks became clear. Commensurately, our liquidity has improved and thus our risk rating. With this flexibility we can withstand the odd blip in the payment process and plan for the transitional costs of investment without disrupting the overall running of the trust.

We have big investment requirements in areas of growing demand such as cancer and critical care. What is interesting is how in the wider organisation the accumulation of money is seen as perfectly compatible with the continuing need for cost improvement programmes. The foundation trust environment has taught the provider side of the NHS a whole lot about managing money.

Delivery of 18-week milestones has been closer to the wire. As I write, the checks continue, but it looks like we are there. We have built innovations into this: new musculoskeletal pathways and telephone outpatient consultations, for instance. But an uncomfortably large amount has been down to sheer hard work. Some of that has been about efficiency improvement such as extra operations per list. But a fair chunk has involved weekend operating or use of the independent sector. The commitment of many clinical colleagues has been extraordinary. While we salute it we know we cannot sustain it.

Our deputy chief executive and change leaders' team have put down the foundations for the rest of this year, which should reach fruition in the coming months. This has included a couple of workshops for care groups and commissioners where progress, including breakthroughs and best practice, is shared. I sometimes refer to these as the 18-week equivalent of bring and buy sales.

My impression is that the need to use all available space for 18-week patients has bumped up against the bit of spare room that sometimes comes in handy for the accident and emergency target. We have more than made the target here and for the most part our rather unusual categorisation system for acute medicine withstood some significant variation in demand. This is important because it seems to be variation rather than demand overall that has challenged providers. Interestingly, we spent a fair bit of the last winter with outliers from other care groups in medical beds - there's a novelty.

Nevertheless, there are lessons in managing contingency more effectively in the new year. We must look to innovate further with our commissioning colleagues. A little less heroism, a little more system.

The service under most challenge at King's just now is obstetrics and maternity, where demand has grown by nearly a quarter in the last three years. There seem to be two drivers: the growth in population of a reproductive age and the expression of choice by women who would historically have gone elsewhere. We invest in midwives and obstetricians and have little difficulty recruiting, but we are running out of space. Our response? To acquire real estate around the corner so we can clear space for a birth centre.

Infection control remains high profile and, like many, we have driven MRSA firmly down. C difficile is also heading in the right direction, although not always in a straight line. We decided to call in the Department of Health team for a third party view. It had few significant points to make, which was both a compliment and a disappointment (one always hopes for the magic bullet insight). The solution here has been governance, data, responsibility and accountability. In other words, hard work by committed people.

But as in many areas of risk, the journey never ends. We're only as good as our last lapse and however good we think we are, our patients (and governors) are quick to point out the odd omission. But it is reassuring to note our patients' opinion of us gets steadily better. We mirror the national patient survey with our own monthly version, set our own challenging benchmarks and now serially exceed them, albeit with plenty more to do.

While all that goes on, we remember King's is a leading university hospital. It probably wasn't in the original job description for the medical and strategy directors and me, but we find ourselves driving the university hard, raising money for key academic programmes and pushing clinical divisions to set out the research and development components of their strategies. We will see a£62m investment in a research and experimental medicine facilities campus in the next two to three years in which the foundation trust board is a genuine stakeholder.

Bedding in our National Institute for Health Research-funded centre for patient safety and service quality and our partner role in the biomedical research centres based at Guy's and St Thomas' and South London and the Maudsley foundation trusts sets King's up as a dynamic partner in the academic health science centre.

It is one of the best things that could happen for the health of local people and for the competitiveness of UK health services internationally.