Feature / The cry goes up for quality

Finance directors may be leading the efficiency drive, but some argue that they should also be the main advocates for quality. Seamus Ward reports

Whichever political party (or parties) forms the new government, NHS providers will live by two watchwords over the next few years – efficiency and quality. This twin-track campaign will go on long after the election, but who will lead the NHS to victory?

Finance clearly has a role in helping to ramp up efficiency and productivity, but there are some who believe finance directors should be their organisation’s quality champions – ensuring that improving quality and efficiency are elements of a single agenda, rather than separate initiatives.

The idea of appointing quality champions – board-level leaders who will help drive through improvements – sprang from the Darzi report. And while some believe finance directors have enough on their plates as the NHS faces up to years of austerity, and quality falls more readily within the ambit of a medical or nurse director, others believe finance can act as the fulcrum between quality and efficiency.

But regardless of whether finance directors become their trust’s quality lead or not, most agree that they will still have a key role to play.

You need only consider how the tariff is developing to see why standardised mortality ratios, patient-reported outcome measures and staff morale surveys are becoming more important to the modern finance director.

While they may not yet be as important as income and expenditure position or liquidity, financial performance depends increasingly on quality – through commissioning for quality and innovation (CQUIN) payments and best practice tariffs, for example.

At the HFMA annual conference last December, NHS England chief executive Sir David Nicholson warned that the financial challenge facing the service should not be used as an excuse to lower quality. He also said the NHS should think about the impact financial decisions have on the service as a whole.

The NHS Institute for Innovation and Improvement has called for finance directors to act as champions of quality improvement in partnership with other strategic leaders such as directors of nursing and medical directors; operating at the interface between clinical processes and management of resources.

Expanded role

Monitor policy director Robert Harris argues that the quality of clinical services must be part of a more expansive role for finance directors. He highlights the case of the Cincinnati Children’s Hospital in the USA, which put its chief financial officer at the helm of its quality initiative. He believes the message is that quality is as important as the hospital’s profit and loss.

‘It was a sign that getting the money right and the quality right are two sides of the same coin. You cannot neglect one and prioritise another – if you do focus on money, for example, quality is likely to slip.’

He is strongly in favour of finance directors becoming quality champions. ‘They have a view of the money and the monetary consequences of delivering high-quality services. There is plenty of research to show that high quality can lead to lower costs.’

Better quality is good not only for patients but also for trusts’ income – a reputation for good services is the best marketing tool in an NHS where money follows the patient.

Several months ago, Professor Harris brought together 60 finance directors to look at their trusts’ cost improvement programmes (CIPs). Many had common elements – reducing operating costs by 5%-10% for example. ‘We understand aggressive CIPs are required to meet the overall financial challenge the NHS is facing. But a number of trusts present hadn’t really considered the consequences of aggressive CIPs on staffing levels in certain high-dependency areas. This is one area where CFOs can look at the CIP numbers and then assess the impact on the overall quality of service. These two sets of considerations are interdependent not unrelated,’ he says.

Although the analysis of the CIPs took a high-level view, the seminar revealed that a small number of trusts had nurse-to-bed ratios lower than those at Mid Staffordshire NHS Foundation Trust – criticised by regulators for quality. Yet at the same time they planned to take out significant costs, including workforce, without considering the impact on skills mix and cover. This could be very serious.

Stephen Thornton, chief executive of the Health Foundation (which focuses in healthcare quality improvement) and a non-executive member of the Monitor board, echoes concern over CIPs that do not take account of their impact on clinical quality.

But he adds: ‘Increasingly, finance directors are taking the lead and ensuring there are proper processes in place for the assessment of cost improvement proposals and to give them a quality rating.’

Professor Harris says: ‘We are trying to get finance directors to think more expansively around the financial direction being taken and the impact on quality.’

This is embodied in the regulator’s strategic financial leadership programme. ‘This is absolutely not about teaching them finance; it’s about being quality champions and getting them to think more broadly about the business we are in and the drivers of that business.’

Salford Royal NHS Foundation Trust has placed great emphasis on quality improvement for years. Executive director of finance and deputy chief executive Tony Whitfield acknowledges it is a leading trust in this area, although it does not have all the answers.

The trust has not nominated a single director to be quality champion; they all are. For the past two years, the first third of every board meeting has been taken up discussing quality and quality improvement, including a verbatim account of a patient’s view of their treatment.

Mr Whitfield says this often provides a powerful and sobering account of what has been achieved and what has yet to be done to provide a high-quality patient journey.

Like his fellow directors, Mr Whitfield has a clinical patch to look after in addition to his specialty in finance – stroke care. ‘As a finance director, I can moan and groan about things when they go wrong, particularly if I think it’s going to cost money. But if you give people responsibility it’s tough. The finance director has to understand the clinical process; you’re no longer on the sidelines keeping the books.’

He adds: ‘A small example is when you ask people to wash their hands. For a nurse, this could mean 100 times a day, so we spent money on a product that cleans and protects their skin – it’s not the cheapest, but it costs nothing compared with keeping patients in hospital for another week or two as a consequence of getting an infection.’

Honest with patients

He believes being honest with patients is at the heart of what Salford is trying to achieve. Two years ago, the trust launched a quality initiative, which aims to reduce the harm hospitals inadvertently do to patients. In this context, harm does not refer to malicious intent or calamitous mistakes such as removing a wrong body part. Rather, Salford is trying to clamp down on healthcare-associated infections, pressure sores, procedures not performed properly or incorrectly administered medicines – issues that patients and their families trust healthcare providers to get right and which many hospitals simply dismiss as human error.

The trust measures quality using hospital standardised mortality ratio (SMR). Its quality improvement strategy, launched in 2008, aims to reduce harm events by 10,000 over three years, and save 1,000 lives.

‘SMR is a hard measure and it’s something we found we could sell to the clinical community in the trust. It’s about the service to the patient and doing right by them. It’s a noble cause and a by-product is that if you avoid harm to the patient, you will be able to treat them more cheaply,’ says Mr Whitfield.

‘Under the current tariff construct you are rewarded to a degree if you harm a patient – when things go wrong, the treatment is more complex.’

Mr Whitfield says anyone who is going to champion quality – be they a director of finance, medical director or chief executive – must believe what they are doing is right. He describes conversion to the cause almost as a religious experience.

He adds that Salford’s quality initiative is a work in progress and the trust’s finance team is trying to come up with a way of measuring the cost of harm and the benefits of harm reduction. ‘This is difficult because you can’t always make the causal link. But quality will be a major plank in our work as we see our way through the next five years. If quality goes out the window, the money will go out of control.’

Lorraine Bewes, director of finance and information at Chelsea and Westminster Hospital NHS Foundation Trust, says finance directors do have a role to play in quality improvement. But she is cautious about formally extending finance directors’ responsibilities at a time when public finances are being squeezed.

‘As a board director I have to take an interest in the wider business and the quality agenda,’ she says. It’s about enabling managers, providing them with a scorecard and holding them to account. It’s not about expanding our role, but you still have to get out and about and pay attention to quality.’

While all board members are jointly accountable, the finance director must act as a facilitator – ensuring those with direct responsibility for quality have the information they need. On Chelsea and Westminster’s board this responsibility is shared between the nurse and medical directors, and supported by the director of governance.

‘Its about your personal style and, more specifically, about the direction of travel, where more and more funding depends on quality,’ adds Ms Bewes. ‘So, for example, we are looking at our CQUIN income and how we can build in a mechanism that allows that money to be earned by and rewarded to specific divisions. This is an opportunity to incentivise staff. There should be an upside and we are trying to link that to the debate on efficiency.’

Not only are finance directors in a position to influence quality, but they also have the skills to do so. Ms Bewes argues that finance staff can also play a key role in benchmarking. They are data literate, so they can help clinicians and other managers develop a picture of what best practice looks like.

‘I have been impressed with the quality of finance directors in my three years at Monitor,’ says the Health Foundation’s Mr Thornton. ‘I have seen a continuing improvement in the quality of the finance function, not just in their ability to “do” finance but also in their ability and willingness to have a corporate overview. It would be wrong to stereotype finance directors as being the last to come to the party.’

Information centre

Professor Harris says finance directors have close links with service level management initiatives, which will provide much of the data to set the quality and efficiency agenda.

‘They sit at the heart of the spider’s web of information generated in providers. But the message is clear, if you only want to be a bean counter then arguably you have no place on the board where the demands are much greater,’ he says. ‘Good finance directors have a way of seeing through mountains of information and coming up with action points. They have particular skills around leveraging information and data to come up with clear recommendations. If I were an FD right now I would be seizing on the opportunity to champion quality in all its forms – patient safety, clinical outcomes and patient experience.’

Finance directors may not seem the obvious choice to champion quality in their trusts, but quality is now so closely allied to efficiency that their skills – as well as their role as senior board members with critical information at their fingertips – have put them right at the centre of the quality party.