Feature / Meeting of minds

Collaboration between clinicians and finance managers can have a major impact on improving quality and decreasing costs. Dr Mahmood Adil champions a team approach.

Clinical engagement has always been important – more so now, while historic levels of spending growth cannot be sustained in the NHS and we have to deliver more care of higher quality with fewer resources.

Finance managers have an important role in this efficiency drive but they cannot do it alone. It is clinicians – doctors, nurses and allied health professionals – who commit NHS resources and they need more understanding of the financial consequences of their actions by working closely with financial colleagues.

A number of recent developments have highlighted the importance of clinical engagement. These include the unprecedented joint statement in February 2009 from the Academy of Medical Royal Colleges (AOMRC), Audit Commission, Department of Health, HFMA, NHS Institute and Royal College of Nursing, which called for clinicians to take more control of NHS money to help improve the quality of care. Subsequently, the AOMRC and Audit Commission jointly published A guide to finance for hospital doctors in July 2009 (see www.aomrc.org.uk).

Enhancing leadership

The AOMRC and the NHS Institute have been working together on the ‘Enhancing engagement in medical leadership’ project.

As part of this project, a Medical leadership competency framework has been produced, which includes a resource management competency. And in 2009, the Department published Acute health clinical costing standards now being maintained by the HFMA. These standards represent the service’s commitment to continuous improvement in patient level information and costing, leading to a high level of consistency in the costing methods used by hospitals.

It is encouraging to read the HFMA consultation response to the white paper, which insists financial management is not just about the finance function. It also says bringing together responsibility for clinical decisions and financial consequences through GP consortia is a good thing, provided clinicians are willing and able to take both on board without compromising one or the other.

Clinicians and finance staff usually hear different music and dance to different tunes. These can take the form of patient outcomes versus bottom line, or disease management versus episode costs. An average accountant might have to google ‘decubitus ulcer’ (bed sore) to participate in discussions about reducing harm rates. By the same token, the typical clinical leader may glaze over at the mention of productivity measures and costing. But if we can help these two professionals talk about how to improve these two data points, it could be the start of a valuable partnership. A mutual respect for data and how it guides decision making is one of the common grounds between finance and clinicians.

Finance directors cannot design pathways, but they can help clinicians to play that role by informing them of the financial implications of their plans to improve quality. QIPP (quality, innovation, productivity and prevention) expects clinicians to take account of the financial implications of their clinical quality improvement decisions, so they have to engage proactively with their finance colleagues to achieve both cost and quality outcomes. 

If we want clinicians to engage with finance, we need to make information as accessible as possible. Patient level costing has proved itself more meaningful to clinicians than average healthcare resource group costings. Data on individual components and costs of a patient’s episode of care helps clinicians understand variation and, through redesigning pathways centred on patient need, eliminate unnecessary use of resources (see table, previous page).

As a minimum, all doctors should know how money flows round the NHS and how their organisation receives income to treat patients. This is not about turning doctors into accountants; it is about enabling them to make best use of NHS resources for patients.

On the flipside, we need to encourage finance professionals to learn the business of clinical care delivery. Of course, they do not need to prepare to do surgery but to learn the processes and standards of care, how care is delivered and by whom, to provide the best and relevant information to clinical colleagues.

In the past, financial management was often seen as the preserve of the finance department, but this approach will not stand up to today’s expectations. Finance directors can do a quick litmus test by asking how much time their staff spend directly working with clinicians or in staff meetings to learn and truly understand the ongoing care planning process. Are they part of the teams dealing with any quality improvement initiative in their trusts?

Many levers are available to pave the way for collaborative working, including the NHS white paper; QIPP; patient level costing (PLC) and service line management (SLM).

SLM has great potential to improve clinical contribution to strategic decision making and, importantly, to obtain the acceptance of clinicians and key stakeholders in the process.  Department initiatives such as payment by results and best practice tariff will also help the relevant professionals to align quality and cost.

Collaborative working could be improved by:

• Enabling joint teams to work on shared cost and quality improvement projects
• Developing frontline resource steward champions from clinical and finance teams
• Pairing schemes that formally team up finance and clinical staff (at operational and strategic levels) to conduct detailed service line and patient pathway analysis; identify clinical improvement strategies; and work together to create single productivity report to be understood and used by both teams
• Updating royal colleges’ curricula and examinations to encompass cost and quality
• Enabling specialist registrars (consultants to be) to have three-month attachments with finance departments during their training
• Providing dedicated presentations slots at each other’s national conferences.

American examples

We can also look across the Atlantic to find examples of good practice where chief finance officers and clinical leaders have worked together to build high-quality services in a cost-efficient manner.

The Institute of Healthcare Improvement (IHI) in Boston is promoting ways to narrow the gulf between business and quality outcomes in the US healthcare system. At a 2009 IHI forum, the Cincinnati Children Hospital’s chief financial officer and a professor of surgery presented an excellent example that resulted in positive impact on the hospital bottom line – by making the pursuit of quality and continuous clinical improvement a core business strategy throughout their team work.

NHS North West’s advancing quality pay for performance programme has been developed in partnership with US Premier. It has shown that joined up work between clinical and financial colleagues leads to positive results.

Healthcare finance staff and clinicians may speak different professional languages, and at times may get on each other's nerves, but go beneath the surface and we will find that finance and clinical staff have the same goal: caring. They are interdependent on each other and must synchronise their intellectual rhythm to the changing needs of the time – alignment of the quality and cost agendas to provide the best cost-effective care in the NHS.

Reducing human suffering motivates us to improve quality in our hospitals. Efficient use of resources and good-quality services go hand in hand. Clinicians and finance colleagues cannot do this individually but must collaborate to achieve this common goal.