Feature / Delivering quality

Quality was the central focus of a joint HFMA/ACCA/CIPFA health finance conference in Scotland in October. Ian Waugh reports

An American tourist arrives at St Paul’s Cathedral and notices a red phone on the wall of the entrance. ‘Why is this here?’ enquires the tourist. It is a hotline to G but it costs £1m per minute replies the bishop. Curious though he was, he declines the kind offer and carries on his journey northwards and reaches York Cathedral and notices an identical red phone on the wall. The bishop there too confirms that it is indeed a hotline and costs £100,000 per minute. Again the tourist, exercising remarkable self-control declines the kind offer and continues on his journey north until he reaches Dunfermline Abbey. Here again, he enquires of the minister the purpose of the red phone on the wall. Although it is a hotline it now only costs 5p a minute, which prompts the tourist to ask how this could possibly be so. The minister replies indignantly: ‘Well it is a local call my son’.

So started a tour-de-force on ‘quality and cost’ by Jason Leitch, clinical director in the Scottish government’s Quality Unit at the first joint HFMA/ACCA/CIPFA health finance conference held in Dunfermline, Scotland in October.

In many respects the conference did also provide an ideal ‘hotline’ to chief executive and director of finance panellists for the many finance staff who work in health boards and social care. They were able to put questions on how integrated working between health and local authorities would work in practice.

Mr Leitch reminded the delegates of the very varied health outcomes enjoyed, or not enjoyed, by the Scottish population, citing Milngavie and Possilpark in Glasgow as a case in point. Average life expectancy of the population differs by 15 years, greater than any other UK city. 

Although the past is not always a guide to the future, it was also often the case that you come out of hospital with something rather nastier than when you went in. Cue the NHS Scotland quality strategy, which has been making determined efforts to reduce healthcare acquired infections. And on the evidence of recent statistics on C.difficile and the ‘patient safety programme’ in Scotland it is now succeeding.

Mr Leitch believed that the ethos was succinctly summed up by the oft-cited quote: ‘Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction and skilful execution; it represents the wise choice of many alternatives.’ He went on to describe the strategy’s quality outcomes and the Institute of Healthcare Improvement’s ‘triple aim’ centred around objectives linked to the improvement of health in the population, enhanced experience of care and greater control over the per capita cost. Combined with a strategy to combat waste and greater innovation, the dividend for accountants is greater budget savings.

Lesley McClay, chief operating officer for NHS Tayside, was able to build upon Mr Leitch’s learned teachings in her presentation on a real-life approach to delivering the triple aim in her health board. Her experience of dealing with major variations in performance metrics between hospitals only 20 miles apart drove her to seek out the root causes for the variations and go on to begin to train and empower key individuals.

She also used every piece in her armoury to accurately forecast activity and plan for greater capacity. She confirmed that the continuous reduction in waste, the elimination of harm and focus on variation served her well in this endeavour.

During the question and answer session, delegates heard of examples of innovation to improve quality from around the world with a prediction that a single locus for person centred care for patients with co-morbidities in acute settings would require physicians rotating around the patient rather than, is often the case, the other way around. The Change Fund in Scotland, although relatively new, was being applied to managing pressures, preventative healthcare, integration and joint working in the health and social care system. There are clear roles for finance and IT professionals in helping to deliver in these areas.

‘Don’t waste a good crisis,’ was John Matheson’s jovial mantra during a lively session on his vision for the finance function. As director of finance in the Scottish government’s Health and Social Care Directorate, Mr Matheson is well-placed to see ‘the big picture’ and to see where the talent that clearly exists in finance is best deployed.

In moving towards ‘business partnering’, he reinforced the message that behaviours are just as important as technical competence and clinicians and accountants need to apply the quality strategy in those terms. This approach provided a neat juxtaposition with Jeff Ace’s presentation on how finance can ‘add value’. Earlier in his career Mr Ace had been a director of finance before becoming chief executive of Dumfries and Galloway Health Board. Old and new techniques and disciplines need to converge and organisations need to integrate in a more seamless way if the goal of adding value is to be achieved, he said.

Professional groups in health need to become well versed in promoting change and improvement methodologies or risk being left behind. He told delegates that greater outward focus would be a key attribute in delivering this vision, adding that funding schemes used in the National Housing Trust and tax incremental financing models had been achieved on the back of innovative financial thinking. Learning from the application of statistical analysis, health intelligence and health economics also lies behind attempts at rationalisation of vascular and trauma centres in England, he said.

The afternoon session was given over to the reporting of pilot work on integration in Highland with Nick Kenton and Derek Yule providing case studies from health and local authority backgrounds. They gave other examples of changing the locus of care to the patient rather than moving the patient to the deliverer’s locus.

In one case, an outbreak of norovirus had been efficiently and effectively handled by a hospital locum attending a care home rather than automatically admitting clients to an acute setting. Streamlining managerial roles, the budget and the process had also reduced the bureaucracy associated with many activities including planning for patient discharge. Quick wins in early years, older persons and disabled clients had all been achievable under the pilot although many more practical examples of overcoming years of working in silos were reported. Not least, property ownership, insurance arrangements, VAT, pensions, employment terms and conditions, IT systems for procurement and payroll all demand enormous flexibility.

Delegate questions served to highlight a number of other practical issues around addressing the equal pay agenda; implementing new lines of accountability across professional groups; modelling new care pathways, forecasting activity and aligning budgets where health and local authority roles are swapped over.

In contrast to rural Highland, Paul James and Lynn Brown from Greater Glasgow and Clyde highlighted a somewhat different set of urban problems centred on early intervention in 0-5 year olds, vulnerable elderly and those with long–term health conditions in areas of inner city deprivation. Many of the difficulties encountered have been around cultural differences between organisations.

A major difference between health boards and local authorities is that the latter all have democratically elected members. The NHS provides universal health support whereas local authority assistance is more targeted. Local authorities have prudential borrowing and are allowed to keep financial reserves whereas health boards cannot.  These dichotomies themselves will require new approaches to partnership working and the next year will be spent looking at partnership and body corporate models of organisational structure and the associated delegated functions, budgetary and accountable officer arrangements.

To round off the event, delegates were reminded of the role of ethics in this brave new world by Angela Scott, head of CIPFA in Scotland. An important aspect of the integration agenda is the degree of change that can leave accountants very exposed to misrepresentation unless there is sufficient, relevant and reliable evidence to support an opinion or an assurance. The professional attributes of integrity, objectivity, professional competence and due care, confidentiality and professional behaviour have never been more relevant in maintaining the status of the profession through these periods of change.

For those working in the public sphere, one can add the principles of public life [Nolan et al] and in the government sphere the civil service management code to these tenets of best behaviour. Two pieces of advice Ms Scott gave to those in the front line were to be mindful of, and declare, any conflicts of interest and to be honest about the competencies required to fill new roles.

Continuing professional development (CPD) was a theme I picked up on in my closing address. The 2003 consultant contract embodies the consultant’s job plan for which there are programmed hours to maintain clinical skills. If the accountancy profession is to deliver public sector reform and with its reputation enhanced, there is a clear need for a vision of the finance function with quality at its heart and the professional skills to match. In agreeing employment contracts, employers would do well to heed the example of the CPD offered to those in the clinical profession and treat all members of professional bodies on a level playing field.

As delegates headed off from the HFMA/ACCA/CIPFA health finance conference they could reflect on the day’s events and be reminded that, to slightly misquote Aristotle, ‘the accountancy family as a whole is greater than the sum of its parts’.   

Ian Waugh is head of capital planning at the Scottish government’s Health and Social Care Directorate and a member of the conference steering group