Feature / Terms of engagement

Healthcare Finance asked representatives from the clinical and financial communities for their views of the importance of getting the two groups better engaged

Answering the questions

[MA] Dr Mahmood Adil is national QIPP adviser for clinical and financial engagement at the Department of Health and has 22 years of clinical, public health and management experience in the NHS and the USA.

[ST] Suzanne Tracey is president of the HFMA and director of finance and business development at Royal Devon and Exeter NHS Foundation Trust.

Why is clinical engagement important? And is it more important in the current financial environment?

[MA] Clinical and financial engagement is vital and perhaps the key to improving value given the current financial challenges. Cost reduction without maintaining or improving outcomes may lead to false savings and have a detrimental impact on the delivery of effective care.

[ST] Clinical engagement has always played an important part in the delivery of safe and cost-effective services. But it becomes even more important in the current financial environment as we shift from a period of substantial growth to what feels like significant constriction. If we are going to make the right decisions for patients we have to work together as one team.  

Is the distinction between frontline and back office helpful?

[MA] It is a functional distinction and at times it does help to understand the role of individuals and teams in a healthcare setting. By understanding their roles better, we can support them appropriately to improve outcomes. However classifications such as frontline/back office, strategic/operational or clinical/managerial are arbitrary in terms of assessing the importance of different roles.

All these players have a role in running an effective and efficient NHS. In terms of healthcare, we need to think about teams that require combinations of different skills.

[ST] The distinction between frontline and back office is really unhelpful. To successfully address the efficiency agenda we need all parties around the table bringing their skills, knowledge and experience into play to ensure the right outcomes for patients.  

A recent HFMA survey of clinical and financial engagement (see page 23) found a perception of existing good engagement, albeit with some room for improvement. Do you recognise this?

[MA] In visits to trusts around the country I have seen examples of excellent practice as well as no real engagement. The survey may have provoked a response from more actively engaged organisations. However, we need to build this engagement at scale, which means spreading excellent practice and finding room for improvement where it has already become the norm.   

[ST] Yes. My current organisation has a long held belief about the very positive benefits of good clinical and financial engagement and has created opportunities for this to take place.  Recently, as well as the usual meetings, I have been invited along to the medical staffing committee more frequently to provide information on the financial environment and the implications for our trust. It is clear clinicians are keen to understand so that they can be effective in the decisions they take. 
 

Few would argue with the concept of good clinical-financial engagement. But is there a danger that clinicians and managers only pay lip service to good engagement, and fail to put it into (sufficient) practice?

[ST] I don’t think there is anyone who knowingly pays lip service to good engagement but I think there is a danger then when things become pressured, the time to engage becomes tight and there is a risk that staff can retrench back into their departmental silos to get on with the job in hand. 

We therefore need to keep the importance of engagement at the forefront of our minds and understand that, while the planning may take a bit longer, we are more likely to get there first time with a much better outcome.

At what levels within an organisation does engagement need to take place?

[MA] In an acute trust there are several different possible levels: senior management/strategic (for example, board executives); mid-management/tactical (for example, clinical directors); and frontline/operational (for example, matrons, consultants and junior doctors).

We need engagement at all levels. In my experience, I have seen good engagement between medical director and finance director, but it is often at these other levels where we need to orchestrate more engagement to achieve QIPP goals. 

[ST] Engagement needs to take place at every level in the organisation from the ward and departmental teams right up to the board – everybody has a role to play in ensuring that safe, quality and affordable care is provided for our patients. The challenge for finance professionals is to ensure the key messages are understandable at all levels – that we avoid the use of jargon and technical language and make our messages clear and concise.  

Are there specific areas where the benefits of engagement will be maximised? 

[ST] I think engagement on any level helps the different parties to gain a better understanding of all the factors and therefore this alone moves the current agenda forward.

However, I think the work around deep dives on service line reports is really exciting. The deep dives tend to provide a distinct area of work that teams can get their teeth into and we have seen some real changes in practice as a result, including changes to patients care protocols, standardisation of clinical products and improvements in clinical coding and data quality – all of which have improved clinical safety and cost.


What does good engagement look like?

[MA] When you meet the teams involved [in good engagement] you realise that not only do their organisations have good structures and processes, but most importantly finance and clinical staff work together from the outset.

Mid-level or frontline staff from both groups are involved, pooling their knowledge and skills to establish a business case for quality. The real litmus test of good engagement is whether it leads to real results – we don’t just need good engagement; we need effective engagement.
 

Do clinicians and finance understand each other’s language and know each other’s business? If not, how could this be addressed?

[MA] Clinicians and finance managers do use different languages in fulfilling their roles. However, a mutual respect for evidence is a common trait and we need do our best to promote this locally and nationally.

There have been national attempts to ‘dejargonise’ some of the language – the Audit Commission’s A guide to finance for hospital doctors,  for example. But we also need to consider short and focused ‘medicine for managers’ guides to support greater clinical awareness among finance staff.

[ST] I think this is improving due to the level of engagement to date. It would be highly unusual to encounter a clinician who doesn’t understand the basic financial concepts or a member of the finance team who doesn’t understand an outline of the service being delivered. We must be clear how much understanding is required and to keep things simple in terms of reaching the required level. 

Some of the initiatives taken forward between the HFMA and the royal colleges have certainly helped improve our respective understanding. 

Locally my trust has run service line management workshops that we have encouraged all members of the service line teams (both clinical and non-clinical) to attend together.  I also encourage my finance team to attend the lectures that clinicians put on for our foundation trust members on clinical subjects.    

How important is reliable data?

[MA] Both professional groups are data/evidence savvy. Any tools that can measure and show variation in cost and quality data will provide common ground for improvement. Patient level costing provides an important opportunity to deliver reliable and consistent data based on clinical costing standards. However if we are to reap the QIPP benefits across the whole service, it needs to be implemented and used by clinical and finance teams throughout the NHS.

[ST] Reliable accurate information is crucial to support this process – without this we are liable to lose buy-in.  Service line reporting has greatly improved

the accuracy of both financial and non-financial information and in particular organisations that have invested in developing patient level costing systems are reaping the benefits because they can provide information at a level that clinical teams can practically relate to.   

 

What do you see as the barriers to greater engagement? For example, is there a danger that QIPP will be seen as simple cost cutting and drive clinicians away?

[MA] It would be wrong to view QIPP as a cost-cutting measure. However, QIPP does expect clinicians to take account of the financial implications of their clinical quality improvement decisions, which means they have to engage proactively with their finance colleagues. So QIPP should really be seen as a driver of greater engagement.

[ST] There is an initial danger that QIPP is seen as solely a cost cutting exercise, but that is the challenge for finance teams – to ensure that clinical colleagues are fully aware of the task ahead, that there is no cavalry coming over the horizon, and that we need to make the best decisions we can for patient care within the resources we have available. What is different this time is the need for us to own the problem and provide the solutions locally in our own organisations.

Engagement survey results

The introduction of clear consequences and incentives for the non-delivery or achievement of quality and cost improvement targets would make the single biggest different to clinical engagement in NHS trusts and foundation trusts, according to an HFMA survey of senior finance managers, writes Steve Brown.

The 50 finance managers taking part in the clinical-financial engagement survey (mostly finance directors) also backed wider adoption of service line management and greater use of patient level costing as ways of bringing together the clinical and financial communities.

The survey was conducted in September and run in association with Dr Mahmood Adil, national QIPP adviser for clinical and financial engagement at the Department of Health. The survey, which involved one fifth of the 251 NHS provider trusts, found overwhelming support for the need for engagement between clinicians and finance colleagues.

The directors suggested there was already a good platform of engagement on which to build. The survey described different levels of engagement, from 1 (limited engagement) to 4 (engagement routine across the organisation) and more than a quarter of the sample claimed to be at the top level. Another half believed they were just shy of this level, with joined-up working the norm in at least one speciality and plans to roll this out.

Finance directors were asked to rate clinicians’ understanding of NHS finance. In general 65% of respondents thought their consultants had a good or excellent grasp of finance, with 46% also thinking nurses had a similar level of understanding. However there was less confidence in junior doctors, where nearly 90% of finance managers thought understanding was only average or poor.

More than two-thirds of respondents thought finance staff’s understanding of clinical care was good or excellent, mirroring consultants’ financial awareness.

Virtually all organisations said that savings schemes were evaluated for their impact on patient safety and quality. One finance director said: ‘Finance managers are integral to project teams driving service improvement and innovation for example pathway redesign, length of stay reductions, hospital at night.’

One in five finance managers said their clinicians were fully involved in the costing process, for example refining cost apportionment and allocation approaches. However in the majority of cases (75%), clinicians were only partially involved.

The variability of cost and income data was identified as the main barrier to greater engagement.

HFMA members can download the full survey results and results of other HFMA surveys,​ here.