Feature / Value judgement

Clinicians, managers and finance leaders all agree that NHS professionals need to take a rounded view of the value delivered by services, rather than considering quality and cost in isolation. Steve Brown reports

Managerial and clinical leaders, including the HFMA, have issued a clarion call for all stakeholders in the NHS to unite around the delivery of greater value in health services. 

The association joined with the Academy of Medical Royal Colleges (AOMRC), Faculty of Medical Leadership and Management and NHS Confederation in April to publish Two sides of the same coin: balancing quality and finance to deliver greater value. The briefing contained hard-hitting messages for local organisations and their leaders, regulators, politicians and the public. All have a role to play in meeting the current challenges facing the NHS.

The briefing was informed by a roundtable discussion involving clinicians, finance leaders and managers at the end of last year. Its key conclusion was, as the briefing name makes clear, that quality and finance are two sides of the same coin. Clinical decisions commit resources and financial decisions have an impact on services.

As one roundtable delegate put it: ‘To consider costs without regard for quality is unthinkable; to consider quality without regard for costs is unsustainable.’

Instead, the single focus across the whole healthcare system needs to be on value, the briefing argues. That is value defined in terms of quality (including outcomes and patient experience) and cost. This means ensuring barriers to the delivery of value are removed and replaced with enablers.

Managers and clinical leaders identify three aspects of the value agenda:

• Value within an organisation
• Value in the whole healthcare system
• Value across public services.

To maximise value, these must be aligned.

Organisational value

There is a recognition within organisations that high-quality care costs less and improves outcomes, so a focus on quality makes complete sense within the current difficult  economic environment. But this may not be enough in some health economies. ‘We should recognise that quality improvements alone may not deliver the cost savings most organisations need,’ the briefing says. ‘In many cases, the financial rewards can be a long way off or else reaped in another part of the system.’

There needs to be far greater transparency and debate around the issue – some of which has implications for how the system is regulated – but organisations should be focused on spending ‘95% of their resources in the best way, rather than finding ways of saving 5%’.

Bringing clinical and financial colleagues closer together is essential to getting better value. The briefing itself is an act of engagement given the representative bodies involved. It is not the first time the HFMA has banged the clinical-financial engagement drum, having produced earlier joint statements with the AOMRC and worked closely with Department of Health national adviser for clinical and financial engagement Dr Mahmood Adil. But there is a feeling the context has changed and there is greater consensus around the need for service

transformation to meet the demographic and financial challenges ahead.

There needs to be better understanding of each other’s business – a point underlined by last year’s HFMA president Tony Whitfield in his theme for 2013 ‘Knowing the business’ – so that decisions can balance quality and finance issues. Finance and clinical leaders need to give a clear direction of travel on this joint approach, making it clear that neither quality nor finance holds the trump card.

Taking collective responsibility for finance quality and operational performance requires finance directors to trust medical and nursing directors to develop cost-sensitive plans and identify potential savings, while clinicians need to work with finance directors to ‘create the right environment to make long-term plans that maintain and improve services’.

Professor Terence Stephenson, chairman of AOMRC, says delivering the best possible care should always be what the NHS is about, but adds: ‘We cannot separate the need to continually drive up the quality of care while at the same time recognising the cost of care.’

Paul Briddock, HFMA director of policy and technical, agrees. ‘It is vital that clinicians, managers and finance staff work together to ensure that the maximum value possible is gained from every pound spent in the NHS.’

He adds that this engagement needs to happen across organisational boundaries. ‘NHS boards need to work in partnership to agree how to spend resources to the best effect, rather than individual organisations making cost savings in isolation,’ he says.

Whole system approach

This ‘beyond our borders’ approach is a key part of achieving value across the whole healthcare system. The briefing suggests that commissioners have a key coordinating role and that all organisations need to find ways to share benefits and risks, recognising that savings for a commissioner may not mean savings for a provider and vice versa. So clinical-financial collaboration needs to be broader than just one organisation.

Organisations also need the right regulatory environment. Regulation should provide ‘constructive challenge’ but not obstruct organisations in delivering change. Roundtable delegates said that even if organisations buy into the quality and finance agenda, regulatory and advisory bodies can often ‘reinforce a divide’. Many organisations report that they still feel they are forced to choose between being ‘hit for the quality or hit for the finances’.

The briefing calls for regulatory bodies to confine themselves to a focus on outcomes and leave local health economies to design services to deliver these outcomes. Beyond the regulatory framework and culture, other system levers will be needed – pricing, say, should support the redesign of models of care.

Across public services

The briefing also identifies a higher level aspect to the value agenda. ‘The public understands that NHS resources are predetermined by the government each year,’ it says. ‘What is less understood is that demand for NHS care, as with most public services, is always likely to exceed what is affordable and is determined in the main by public behaviour and expectations.’

The NHS finds itself ‘trapped between patients who want more care and want that care to be better than ever and the Treasury, nominally representing the taxpayer, which wants public spending constrained at a time of economic pressure’.

The four bodies call for an ‘open debate’ on quality and finance in the NHS, involving patients and taxpayers (themselves actual or potential patients). The debate should address what patients need and expect from their care, whether current resources allow for this and how much people are willing to pay for a public healthcare system. ‘The debate needs to happen now, nationally and in more detail at a local level,’ the briefing says. ‘The public needs to understand the tough decisions that are required [to balance finance and quality].’

Politicians are also challenged to change their behaviours, with the NHS widely recognised as a popular political football. The briefing suggests the notion of a protected NHS budget creates the impression that quality is also being automatically protected, ignoring the impact of growing demand. ‘Politicians must be honest about the financial settlement in the NHS so it is clear to the public what can be realistically achieved with limited funds,’ it says. And it calls for all political parties to clarify their plans for NHS funding in the long term as part of their campaigns for next year’s general election.

NHS Confederation chief executive Rob Webster says NHS boards need a ‘national climate of support and system alignment’. ‘Only then will we be able to transform care to ensure patients receive high-quality services now and in the future,’ he says. ‘The alternative is a continuation of an unsustainable set of services, kicked around like a political football while patients and staff suffer.’