Alumni story / Finance and medicine – a clash of worlds?

As central government seeks to exert greater and greater control to rein in expenditure on health, financial managers will find themselves caught between meeting the bottom line and addressing the needs of patients as articulated by local clinicians. However, if we are to do the best with what we have for our patients it is essential that we work together closely, marrying cost and outcome data to achieve maximum value and ethical allocation of resource across the system for our population.

To understand why tensions can arise we have to look at history. It was impossible to estimate how much the NHS would cost in advance of its inception and spending on health quickly rose above expectation. Savings such as those gained on the closure of old institutions for tuberculosis and mental health were not enough to keep pace with funding rapid innovation in surgery and pharmaceuticals. Aneurin Bevan himself said: ‘We shall never have all we need’ and  that ‘expectations will always exceed capacity. The service must always be changing, growing and improving – it must always appear inadequate.’

Growing complexity and expenditure within the NHS led to the increasing importance and power of the role of professional management. Under pressure from the centre, managers exerted more authoritarian control, while clinicians were losing autonomy. Financial managers were under pressure to meet the needs of their local population within their budget and bending to political agendas on priorities. Clinicians, however, remained more concerned with meeting the needs of the individual patients with whom they were interacting face-to-face on a daily basis. It is easy to see why these two perspectives often came into conflict.

When we do not work together, we can both make the wrong decisions. Financial managers may seek to make cuts in the wrong places, failing to recognise the impact on patients. Equally, the clinical focus may become too narrow, failing to see the bigger picture and the opportunity costs of some of their clinical decision making. When the relationship breaks down completely, mutual suspicion, scapegoating and poor decision making result with disastrous consequences as we have seen time and again.

This is not an insurmountable problem. Clinicians and financial managers in the NHS are united in their dedication to the service and much of the negativity comes from the same emotional reaction to extreme pressures within the system.

So what can we do? We must spend more time together. Language is important. Words like ‘efficiency’, ‘cost improvement’ and ‘performance’ may provoke a cool response from a clinician who may interpret that safety and outcomes are being ignored. If we spend time together defining our common purpose, building trust and understanding our jargon and data, we can begin to make real inroads into achieving value – defined in terms of quality and cost – across the whole system for the benefit of patients. We should empathise with each other’s pressures, compromise and solve problems together towards that common purpose.

Financial managers cannot turn a blind eye to the patient experience and the needs of individuals any more than clinicians can wash their hands of the financial implications of their actions and the needs of the whole population. We can and should do this together to sustain the NHS, perhaps even influencing the political agenda along the way.

A clash of worlds? No, a meeting of minds!

Dr Sally Lewis
Assistant medical director (value-based care)
Aneurin Bevan University Health Board