Feature / Fully engaged

When NHS trusts get into financial difficulty and enter turnaround, they often recruit external consultants and perhaps an experienced turnaround director. But before developing and implementing a turnaround plan, many trusts – such as Brighton and Sussex University Hospitals NHS Trust – also seek the involvement of senior clinicians.

Facing a forecast deficit of £14m in 2005/06, the south coast trust turned to its clinicians – one of which, Phil Thomas, is still actively involved in the trust’s financial management.

A consultant urologist, Mr Thomas became the trust’s first clinical chief of finance in 2008 and his engagement with finance was acknowledged at the 2010 HFMA Awards, when he won the Working with finance – Clinician of the Year Award.

The path to his current role began when he was appointed the trust’s clinical director of cancer and then, following a reorganisation, clinical director of the surgical division. At this time, the trust was financially challenged and placed in turnaround. Taking up an invitation to contribute to the turnaround efforts, Mr Thomas became the turnaround team’s clinical adviser – supporting patient flows and medical workforce productivity workstreams.

The trust is now out of turnaround, has turned in a surplus in the past three financial years and has repaid its working capital loan.

Mr Thomas’s contribution to the trust’s financial management was recognised in 2008 with a new title – clinical chief of finance. This is a management board position, with the management board sitting beneath the board of directors in the trust’s structure. In his role he adds a clinical point of view to projects to help deliver the trust’s current £40m, two-year efficiency programme.

He also chairs the trust’s business case and investment group. Following a recent change this group now reviews revenue investment plans as well as those for capital investment.

Difficult decisions

This can mean difficult decisions, including reducing activity. For example, Mr Thomas

was the trust’s lead clinician in a local health economy group that reorganised the care pathways in musculoskeletal (MSK) services, such as orthopaedics and rheumatology.

This aims to place more of the care in community clinics, reducing the number of new referrals to the trust.

‘One of the many issues we faced was the significant financial challenge of the lost outpatient activity and the fact that it left a lot of embedded fixed costs, which I think we have still not reconciled completely,’ he says. ‘We had to disentangle both the clinical aspects of service redesign and the financial consequences of that. The pathway has changed significantly and hopefully the health economy will see financial benefits from that.’

Indeed, the trust projected a £4m reduction in income following the pathway redesign, although commissioners have mitigated this

to some extent.

Mr Thomas is involved in six sessions of clinical activity a week, and the rest of his

10 notional half days are dedicated to management. Maintaining his clinical work

is vital – it adds credibility with his clinical colleagues and ensures he retains first-hand knowledge of how policies are affecting the front line.

He believes that having a clinical chief of finance means decisions are more evidence-based and are driven by clinicians. ‘I hope the financial decisions we make will help improve the quality of care. A clinician can often recognise opportunities that people from a non-clinical background would not necessarily see, though that is becoming less so now as quite a lot of the finance team are becoming more “operational”,’ says Mr Thomas.

He adds:  ‘I don’t think we have yet managed to persuade a significant proportion of the workforce that managing the finances well is an important priority.’

Service line reporting and management (SLR/ SLM) can be used as a lever to gain clinicians’ interest. But he acknowledges that engagement through SLM is patchy.

‘Some clinicians have already done a lot on their own accord. Others are more sceptical and don’t want a conversation about money. They are more challenging to get to, but improving the quality of data is critical as it can be easy to brush off evidence if they believe the data is inadequate.’

Service line influence

However, with SLR dashboards also showing quality, safety and other performance measures, Mr Thomas believes the initiative can have a role in engaging clinicians in management and finance. No doctor will

want to be bottom of the pile on these measures, he says.

Mr Thomas is leading the trust’s SLR implementation. While many believe SLM must be underpinned by a patient level information and costing system (PLICS) in order to identify a greater number of efficiency opportunities, he feels it may not be necessary for PLICS to cover all activity. ‘I think we will do PLICS. Probably the next step is to look at specialties with a focus on particular care pathways or procedures,’ he says.

‘I can understand how if you choose a particular pathway, such as knee replacement or heart failure, you can uncover variation and opportunities to influence practice. But if I looked at my own specialty and tried to describe every patient in PLICS, I would get

lost in the data. I think it should be a bit like

clinical audit, where we audit aspects of it by taking samples.’

Mr Thomas is currently involved in the trust’s work on readmissions, following the new policy announced in the 2011/12 operating framework. Like other trusts, Brighton is modelling the financial risk associated with the readmission penalties and the steps it can take to mitigate this risk. Providers will wish to influence which community services should receive investment, he says.

Clinicians’ views are important and can help shape new step-down services, increasing the quality of the service, reducing readmissions and saving the trust money.

Mr Thomas is clearly an asset to the

Brighton trust, but does he believe other trusts could replicate his role with their own clinical chief of finance?

‘I think it’s down to the individual. If a person is interested, then yes, absolutely, it’s really valuable,’ he says. ‘Other organisations may find a clinical director with an interest in running a divisional specialty with a focus on finance. That’s fine too. You have to tailor it to the individual and their interests.

‘But if I were looking at succession planning – and, to be clear, I’m not planning to step down any time soon – it would be difficult to find someone interested in doing what I do. I don’t think these skills are well developed in tomorrow’s consultants – they could learn these prior to their appointment as consultants or soon after. We have to identify individuals and grow them.’

But while this new wave of finance-literate, finance-enthused consultants is under development, Mr Thomas remains a beacon for the fully engaged clinician.