Feature / On the right track

Lara Sonola and Catherine Foot from the King’s Fund discuss recent research into how NHS trusts are using service line management to deliver improvements in quality and productivity

The NHS has a long history of supporting and encouraging senior clinicians to work with managers to improve quality and productivity by using detailed information about the activity, cost and performance of their services.

Service line reporting (SLR) and service line management (SLM) are increasingly used as approaches to achieve this. In SLR and SLM, the hospital is divided into discrete clinical areas or service lines. 

SLR systems provide data on performance, activity, clinical quality and staffing used at service line level. In SLM, each service line is led by a clinician, often alongside a manager, with explicit decision-making authority devolved to the service-line level.

By devolving management decisions to service lines, hospitals operating with an SLM structure aim to foster clinical leadership and encourage greater staff engagement in the delivery and planning of services.

To find out how organisations have been interpreting and implementing the SLM approach, the King’s Fund recently conducted a series of semi-structured interviews in seven NHS trusts with varying levels of experience of SLM. We interviewed chief executives, directors of finance, medical directors, service-line leads and support staff in a range of clinical areas. 

The study and report suggest some lessons and tips for improving the implementation of SLM for organisations looking to introduce or develop further their SLM approach.

Impact of SLM

SLM was often viewed by interviewees as central to their trust’s overall management strategy with ‘managers and clinicians working closely together to be clear about what we deliver and the financial implications of delivering or not delivering it’.

Most saw SLM as a form of devolved decision-making, with some viewing service lines as ‘mini foundation trusts’. 

Several trusts had taken this analogy a stage further and were in the process of developing compliance frameworks or accreditation processes to give service lines greater freedom and responsibility.

Overall, however, progress in devolving decision-making was variable, with some trusts feeling that increased buy-in at board level was needed for  greater control to be ceded to the service line level. For example, although the ability for service lines to retain their own surpluses is often touted as a benefit of the SLM approach, none of the trusts had completely devolved budgetary control to service lines.

Trusts that were implementing SLM effectively found the SLM approach helped clinical teams develop a deeper understanding of the costs faced by a service, including using data to understand and address clinical variation such as variations in length of stay.

Adopting the SLM approach has led to service changes in some trusts. Typically these were the trusts that had been working with SLR and SLM approaches the longest. Overall, however, the current impact of SLM is fairly limited. In some trusts, examples of concrete impacts are few, or small-scale, with little evidence yet that SLR data is being used systematically. For most trusts, the size of the impacts reported vary markedly between service lines, depending on the presence or lack of clinical and managerial champions of SLM leading the service lines.

SLR and SLM are often seen as a responsibility of finance directors within organisations, but it should not be seen as solely a finance initiative. Understanding the wider range of factors that affect SLM implementation is important to secure buy-in across departments and to ensure that it becomes part of the overall management strategy of the organisation.

Implementation lessons

The research highlighted four key areas where lessons can be identified from trusts’ experience in implementing SLM (see checklist above). The first is around the role of the board. Realising the benefits of SLM requires skilful implementation and the board plays a critical role. It needs to show clear and consistent leadership by relinquishing control and delegating decision-making rights to clinical teams. This might also mean shifting its focus from daily operational matters to a more strategic role overseeing and co-ordinating across services.

One board member described the changes within her executive team: ‘It takes their role away from performance management and more into… enabling [service-line leads] to do those things themselves. It is a fundamental change and can be quite difficult to balance.’

Clinical engagement

A further area relates to clinical engagement. It is critical that clinicians are engaged in the process of implementing SLM from the outset.  Providing support, training and mentorship will help clinicians to take on and succeed in leadership and management roles. And involving them in the development of performance reports makes it more likely that the data collected will be accurate and clinically appropriate.

It is also crucial to outline the aims, objectives and goals of SLM to avoid creating unrealistic expectations and prevent disillusionment setting in.

A senior clinician in one trust warned: ‘It is hard to keep extended groups of people interested in the process unless they can see what the outcomes will be.’

Trusts should also be aware that differing organisational cultures will affect the capacity or willingness of staff to introduce aspects of the SLM approach and it is important to recognise and respond to these.

Data also needs to be used effectively. Gathering and using information on performance for SLR is an ongoing process and organisations can promote the effective use of data in several ways. Developing a clear understanding of available data sources and introducing a rapid and transparent method to correct inaccurate data will reduce unnecessary data collection, improve reliability and allay concerns about data quality. 

As service lines differ in the time, value and ease of data collection, some will not have access to sufficiently detailed information to create full SLR reports. One manager said: ‘With services based on block contracts… you have to divvy up and make do’. 

To accommodate these differences, clinical divisions should retain responsibility for determining the appropriate level of reporting. The information generated from SLR should then be filtered and tailored to its audience to ensure that people see what they need to know, presented in an understandable format. 

Patient-level costing builds a bottom-up picture of the costs and overheads associated with an individual patient journey, enabling teams to make detailed comparisons of their services.  But organisations using patient-level costing should consider how this approach fits with SLR to ensure they do not place an additional burden on clinical teams and support staff.

Finally, organisations should not underestimate the time, expertise and training needed to implement SLM. Clinical teams need to work closely with finance and informatics staff who generate and interpret data, as well as providing ongoing support and training. 

More broadly, allocating a dedicated project management resource can help to manage and resolve competing demands and develop staff champions. 

Executives have a particular role in ensuring that new and existing staff are aware of the SLM programme and its progress to mitigate the impact of staff turnover on its effective implementation.