Feature / Clinically driven financially aware

As a junior doctor, our general exposure to the world of NHS finance is minimal. For most clinicians (doctors, nurses, midwives and allied health professionals), the impression is that healthcare finance is all about cutting costs…. and it is the responsibility of senior managers.

Even then, it is presumed that only a basic understanding of ‘finance stuff’ is needed. It is not on the syllabus at undergraduate or postgraduate level and does not feature in our annual appraisal. Why should we learn and understand more about NHS finances?

What is often overlooked is that there is a financial implication to almost every decision a clinician makes. While the main focus of clinical staff should be providing the best clinical care possible for the individual patient, it is also important to appreciate that improving efficiency will release resources for other valuable treatments and investments. And this will improve the quality of care that can be provided to all patients.

The only way clinicians can provide the quality of care that they want is to understand the financial environment and engage with the ‘finance stuff’.

Clinical engagement in finance is not a new concept. In 2007, the Audit Commission published A prescription for partnership: engaging clinicians in financial management and more recently, in 2013 the Department of Health put it under the spotlight with NHS clinical and financial engagement best practice.

Unfortunately, while there are some good examples of close partnering between finance staff and clinicians, they are not widespread. The Department, as part of its annual reference cost survey, collects data on the perceived level of clinical and financial engagement in trusts. There are four categories, from level one, where engagement only occurs at boardroom level, to level four, where there is full collaboration and engagement across all specialities.

The latest survey data from 2014 shows that overall the degree of engagement has not improved significantly over the past four years. Surveys have shown that finance staff are very keen to have increased involvement of clinical staff. Why are clinical staff so reluctant?

As stated earlier, outside those with management or budgetary responsibilities, many clinicians do not see healthcare finance as part of their responsibility and therefore do not appreciate how important a role they play in NHS finances. Both those with and without management commitments, have to juggle competing commitments, and lack of time can limit how often clinicians can engage with finance colleagues.

How can we make things better? I believe that educating clinicians about finance is the key. But while there have been efforts in the past to do this, they have been targeted at those who already have management or budgetary responsibilities. By this stage, opportunities have already been lost and learning about finance takes time. If clinician education about healthcare finance was delivered while clinicians were progressing through their careers, this understanding of finance and willingness to engage with finance colleagues would allow ideas to be developed to improve efficiency and value.

Costing focus

One of the areas where this would have the greatest impact is costing, where coding and subsequent allocation of healthcare resource groups depend on good-quality information. Information in the notes about diagnostic results and diagnoses is often added by junior doctors, while data about surgical operations collected on operating theatre computer systems are completed by theatre staff.

A few years ago, I went to meet a member of the clinical coding team. I asked them what we as doctors could do to improve the accuracy of coding and that is when I started to realise how the terminology we use can affect the coding category. The details I would consider important were very different to those that were relevant to coding. Some knowledge about tariffs – in particular the current incentives and penalties such as CQUIN and best practice tariffs – would also enable better compliance in achieving these targets.

Junior doctors often order diagnostic tests for patients. Each test carries a significant cost. They should be ordered only after careful consideration, if it will affect the patient’s clinical care. There are two examples of this in my trust – University Hospitals of Leicester NHS Trust – in a busy 22-bed cardiac unit.

The first involved patient chest X-rays. These were routinely done after cardiac surgery. After careful investigation it was revealed that it was not needed routinely, only if there was a specific clinical indication. Changing practice reduced costs. It also reduced the workload for radiographers, allowing them to attend to other patients, reducing an opportunity cost. Most importantly, patients benefited from not being exposed to unnecessary radiation.

The second example involved blood tests. These were ordered for all patients on the unit, twice daily, as a routine. Again, investigation revealed this was not necessary unless clinically indicated, reducing costs, reducing clinical staff workloads and again, most importantly, reducing patient distress and improving the inpatient experience.

There are areas where clinical and financial engagement work well together. Locally at Leicester, we have departmental best value groups, where clinicians and colleagues from the procurement team meet to identify areas where efficiencies can be obtained through purchasing. This may be by identifying similar goods available at a better price, standardising the products across different hospital sites or by simply ensuring that purchase orders are placed through the correct route.

This is also the forum where requests for new products and equipment can be discussed and evaluated clinically and financially to ensure that they provide good value. It works well. Imagine if all clinicians were able to appreciate the value of the products they use.

Improvement exercise

In another example, a quality improvement exercise was carried out at a London hospital by junior doctors. Prescription charts were assessed to see if savings could be made by using similar cheaper or generic versions of the drugs prescribed. This identified a 26% cost saving for each patient, which could potentially result in total savings of £2.8m if it could be applied to the entire inpatient drug spend.

Education must be targeted. Most learning resources are aimed at finance professionals and may feel dry and irrelevant to clinicians. There are a few courses and e-learning packages, but these require clinicians to seek out and often pay to develop their knowledge. These clinicians are already on board and probably keen to engage with finance. It is outside of this cohort that efforts must be targeted.

The finance community can help develop the learning resources for clinicians. We need resources aimed at clinicians that are engaging, interesting and relevant. We also need teachers who are not only knowledgeable, but also enthusiastic about imparting the knowledge.

Work has already started, the future-focused finance close partnering group is developing learning resources and a team of finance educators – finance professionals trained to teach locally. Health Education East Midlands now has a finance component as part of its leadership and management course, which all junior doctors attend. But much more needs to be done.

There are pockets of good practice, but financial awareness needs to be ubiquitous throughout the NHS. Once the clinicians have been educated, finance professionals need to maintain that engagement and learn about what we do – spend time on a ward, come on a ward round, visit an operating theatre and understand better what we do. Only once we all have some understanding of each other’s worlds can we truly engage at the level required to take the NHS forward and provide the highest quality care for our patients.

• Akeeban Maheswaran is a junior doctor specialising in anaesthetics (ST6) at the University Hospitals of Leicester