Feature / Close call

In many ways, engagement is what the Future-Focused Finance initiative is all about. Finance staff have engaged with the initiative in their droves and their enthusiasm is infectious. It has even launched the NHS finance community into the virtual world of social media – the busy FFF twitter feed has more than 2,000 followers.

Perhaps we shouldn’t be surprised by this. After all engagement, albeit between clinical and finance staff, is at the heart of the initiative.

Set up in 2014, FFF aims to ensure the finance function remains fit for purpose. The NHS needs to transform to meet its current challenges – a result of an ageing population, changes in disease patterns and restricted finances. And the finance function will need to transform along with it – providing the evidence for this broader transformation, identifying the opportunities to increase value and making its own contribution to improved efficiency.

The initiative has six specific work streams, arranged under three strategic themes of ‘Securing excellence’, ‘Knowing the business’ and ‘Fulfilling our potential’. Clinical engagement – or ‘Closer partnering’ to give it its formal title – is one of the work streams under the ‘Knowing the business’ theme. It is, appropriately, headed by Dr Sanjay Agrawal, consultant respiratory intensivist at University Hospitals of Leicester NHS Trust – the only clinician among the initiative’s six key senior responsible officers.

Better engagement between the key groups of finance and clinical staff is widely recognised as a fundamental building block for a transformed health service. This is hardly a new message, There have been many earlier attempts to put the issue in the spotlight, including reports and initiatives from the Audit Commission, the HFMA, the Department of Health and the Association of Medical Royal Colleges. But this time FFF wants to stay focused on providing practical help to improve engagement.

Dr Agrawal recognises there has been improved engagement in recent years – tracked in part by a crude self-assessment included in the Department’s annual reference costs survey. But he suggests this is often in pockets – for example, where trusts have pushed ahead with patient-level costing. And there is definitely room for improvement.

A survey conducted by Ipsos Mori for FFF last summer found that 50% of clinicians think they have a good understanding of finance issues. However this differs, depending on what aspect of finance you are talking about. Clinicians in general confess to having a poor understanding of procurement and equipment replacement, but feel more confident where their income comes from and managing costs to a budget. Similarly, nearly three in five finance staff think they have a good grasp of a patient’s journey. But this reduces if you look at specific patient outcomes.

Clinicians’ view of finance staff understanding of clinical issues is not as complimentary. ‘The bottom line is that finance people could know more about the clinical side of healthcare, and clinicians could do with consolidating and improving their financial knowhow,’ says Dr Agrawal.

‘Senior clinicians are often overseeing budgets of millions of pounds – and it is clinical decisions that commit these resources. Yet our survey shows that 50% of clinicians don’t really understand how finance works. It is a simple fact that better understanding of finance by clinicians will help the service improve value.’

Educator network

The FFF team has taken practical steps to support this goal, with the creation of a 130-strong network of finance educators.
The eventual intention is to have one in every NHS body including all commissioners and providers. This cohort of finance staff was provided with some training in presentation and the aim is that they will deliver financial training to clinicians and budget holders in their own organisations.

 ‘It is not an additional role – being a finance educator,’ says Pam Kaur, commercial finance manager at University Hospitals Coventry and Warwickshire NHS Trust and the FFF lead on the educator network. ‘This is already part of the day job. Finance managers should, and do, interact with clinical colleagues and managers on a daily basis. The aim is to demystify finance to create clinical value, make our interactions more effective and give the educators access to support, some national recognition and profile.’

 Just over a year since the network launched, Ms Kaur is convinced it is having an impact. ‘We get good feedback and overall I think we are being more effective,’ she says.

One of the key benefits is access to resources developed elsewhere across the network, free at the point of use – with training notes and slide sets all being shared so that people can avoid duplicating effort and pick up on tried and tested good practice.

‘We have to recognise that some people are more active than others in terms of providing financial training to budget holders and clinicians,’ says Ms Kaur. She is as keen to help people taking their first steps into formalised training as to help more experienced educators try new ideas. ‘The key this year is to keep the momentum going, spread the message and increase active participation in the educator network,’ she says.

These approaches can be underpinned with e-learning, which can fit in well with clinicians’ busy professional lives. The HFMA, for example, provides numerous general and specific e-learning modules on topics such as budgeting, costing and payment systems.

Dr Agrawal is clear that there needs to be a parallel process with clinicians helping to demystify clinical terminology and practice for finance staff, but he recognises that this may not be delivered through a national network of clinical educators. And he adds that there is no substitute for local engagement. FFF’s real campaign, he says, is to ‘promote localism’.

Finance staff will benefit from a basic grounding in clinical subject matter – what are the key conditions treated within a particular specialty? What do the different patient pathways look like? What are the standards and protocols in place?

He also wants teams engaging about problematic issues such as how you might change staffing arrangements to cover low-volume services at night or how different roles – such as advanced nurse practitioners – might help improve services and value.

 ‘We recognise that education on its own is not enough,’ says Dr Agrawal. ‘Education is pointless without a relationship. That’s how finance learns about clinical issues – by meeting regularly with clinicians.’

Face to face

The Ipsos Mori survey threw more light on this subject. Both clinicians and finance staff report that most interaction currently is by email or telephone, and both sides agree
that they would prefer the majority of interaction to be face to face.

But both clinicians and finance identify a number of obstacles to better working relationships. Both cite lack of time – although interestingly this is seen as a problem by more finance staff (75%) than clinicians (57%). Both also see the lack of robust data, particularly around costs and income, as an obstacle – even though better engagement is one of the ways this can be improved.

Here, too, the FFF team has provided support to underpin better teamworking across professional divides. It commissioned the King’s Fund to undertake work that would both reinforce the case for collaboration and identify the key components in successful relationships.

This work – styled as a toolkit for collaborative team work – identified seven factors known to improve team working (see box) and provides a questionnaire based on these factors for teams to self-assess their effectiveness.

The toolkit went through a pilot process involving 22 trusts and an evaluation of this process by CIPFA concluded it had been ‘a highly beneficial exercise’, with the toolkit adaptable to specific organisational needs.

Supporting improved mutual awareness of each other’s business and improving relationships are key work areas for the ‘Close partnering’ team. But Dr Agrawal also wants the better partnering to stretch to the general public. A series of patient focus groups confirmed suspicions that there is generally limited understanding about the health service in general and its funding in particular among the general public.

This may not be surprising, but Dr Agrawal says that improved understanding will be crucial to some of the changes likely to come in as part of the transformation agenda. This could see services relocated or provided in completely different ways. However, there is not a great track record on public understanding of NHS changes – with a common suspicion that changes are driven by financial rather than clinical factors.

There is clearly a financial imperative to looking for better delivery models, but the overarching driving force is the ability to deliver quality services that meet changing patient need in a sustainable way. So while better clinical-financial engagement may identify the opportunities for reform, this may count for nothing if the public are not brought along on the journey.

‘We can’t think this is somebody else’s responsibility,’ says Dr Agrawal. ‘The public are key stakeholders in this change process and we need to contribute to finding better ways to communicate any planned changes and the reasons for making them.’

There are big plans within the ‘Close partnering’ team for the year ahead. ‘We need to keep highlighting what is being done in some trusts and show it can be done in all trusts,’ says Dr Agrawal. ‘Clinicians are up for learning more about finance – our survey showed they are more interested than finance thinks they are.

‘We’ve made a good start with our research work and establishing our educators’ network – now we need to mature and grow it. At the moment they are more likely to be focused on basics, but we would hope this would develop into engaging with more detailed issues and introducing things like the best possible value toolkit [developed by the ‘Best possible value’ work stream and including the decision effectiveness framework] and NHS Improvement’s costing transformation programme. Why can’t the finance educators become agents for change and be skilled up for quality improvement techniques?’

These are ambitious plans, but Dr Agrawal insists the immediate focus is on ensuring the work stream can ‘walk before it runs’.

However, with the Finance Leadership Council – made up of the national system finance leaders – challenging the initiative to be ‘really purposeful’ in the year ahead, he is determined that ‘Close partnering’ will start to have a tangible impact.