Feature / Walking the line

The NHS must ensure that improvements in quality go hand in hand with better productivity. And, as Seamus Ward explains, some believe service line management holds a key role in delivering both.

Should the NHS persevere with service line management (SLM) and reporting in the current economic climate? Systems are not cheap and the service has a patchy history when it comes to implementing IT projects. The answer is a resounding yes, according to an HFMA/Monitor conference on SLM last month. Speakers at the event argued that SLM is much more than an IT project, but one that can help save lives and give trusts greater control over their spending.

Chairing the conference, King's Fund chief executive Chris Ham set the tone for the day - highlighting a story in that morning's Financial Times. It reported that Department of Health director-general of policy, strategy and finance Richard Douglas had told a meeting of NHS leaders that the service may have to save a further £20bn in the spending review period that falls after the current one ends in 2015.

Professor Ham said that if the story were true, SLM would gain even greater importance in providing the cost and quality information on which trusts could base decisions on efficiencies.
'It will be about reducing waste and delivering more. Many of the key decisions are taken by GPs, hospital doctors and others in direct contact with patients. This is why service line reporting and management are so important,' he said. 'SLM is a three-legged stool. Leadership is one leg, the second is IT producing real-time information and the third is incentives.'

While SLM is not required for foundation trust authorisation, Monitor encourages aspirant and authorised foundations to use the tool. 'A service-line management type approach is essential for boards to understand the economics of individual services in order to identify where value and quality to patients can be improved,' said the regulator.

Board responsibility
It continued: 'It is the responsibility of the board to ensure that organisations are  committed to delivering high-quality, efficient care which increasingly requires improving processes and changing the way services are delivered. To succeed and sustain this, boards must put clinical staff at the heart of the process and an SLM approach supports this. Through SLM, clinicians play a far more influential role, driving performance and making better use of resources to improve quality and patient care.'

Gill Gaskin, one of three medical directors at University College London Hospitals NHS Foundation Trust, pondered on the relevance of SLM in today's cash-constrained times. NHS organisations have tended to return to command and control when finances are tight, but SLM was about devolving responsibility to clinical business units. SLM had long been prioritised by improving NHS organisations.

Question of support
'We have 16 clinical service lines and service line management is fundamental to the way we do our clinical business,' she said. 'Are doctors willing to take the tough decisions? Who else would you want to make those decisions that have a significant impact on patient care? Do doctors have the capability? Of course they do. The crucial issue is how well they are supported, particularly by finance and operational managers.'

UCLH finance director Richard Alexander said SLM allowed him to step back. 'I couldn't be prouder of the fact that Gill and her fellow board medical directors present the financial information to the board. My role is in the background getting the framework right.'

The trust moved to preparing accounts on a service line basis a few years ago, though its PLICS remains separate. And when preparing business cases, it takes account of whether the proposed change will improve service line profitability, as well as more traditional measures such as net present value.

'We make a real effort to get 100% of income out to the divisions and service lines,' said Mr Alexander. 'There's nothing more incentivising for a clinician than to have the income from a research project they worked on or education they helped deliver where they can see it.'
Mr Alexander said the engagement and the data that is so much a part of SLM could help trusts in their quest to cut costs and raise quality. An in-year shortfall in a trust's cost improvement programme might traditionally be tackled by a blanket cut in staff numbers - but clinicians and managers working together can reduce the need for such measures.

A previous employer of his, Oracle, had been able to devolve responsibility down through the organisation, giving business units a lot of freedom within an overall command and control framework. 'Where SLM is going it has the potential to be that kind of framework,' he said. 'As finance people, we really want to let go. SLM, as it contributes to the overall financial framework and running of the trust, is the framework in which we can let go.'
University Hospitals Birmingham NHS Foundation Trust chief executi
ve Julie Moore said that while the NHS was often good at making measurements, it was not as good at taking action based on those figures. When it examined the quality of its services, the health service often chose 'soft' measures such as patient satisfaction as they are easy to measure. Even then, patient questionnaires returned to the trust could be as much as 18 months old, rendering the information useless.

Ms Moore insisted the NHS must gather feedback on both the quality of service provision (as measured by proxies such as patient satisfaction scores) and clinical care. The latter must be evidence-based and may need to be tailored to individual specialties. Using data at service line level is key to driving quality. Her trust had introduced purpose-built software providing real-time information that made a difference to patient care. 'The hospital mortality rate is about 3%, while 5% of hospital deaths are potentially preventable, so we are looking for a 0.15% difference in the best and the worst. This is like looking for a needle in a haystack so our strategy is to reduce errors to a minimum rather than monitoring mortality rates,' she told the conference.

One of the first clinical quality indicators her trust introduced measured the number of missed antibiotic doses. There was evidence that missed antibiotics had an adverse effect on patients and studies have shown 6%-20% of doses are missed. 'We see non-compliance in this as an error, so this forms part of our strategy of error reduction,' she added.

The trust's software supports point of care decision-making. Interventions and patient opinion (which can be input via bedside digital TVs) are recorded and fed back to staff.  Errors are reviewed at a number of levels.

The trust believes that as a result of this initiative, mortality within 30 days of primary procedure has fallen. 'We think it has such an effect on patient care that we would like to see it rolled out,' said Ms Moore. 'We have had 100 fewer deaths a year, which would mean about 10,000 fewer deaths across the country. We have often been accused of being "Big Brother" but our staff morale has increased, there has been a 25% reduction in sickness absence and we are oversubscribed for any job we advertise. Good staff really like it and say this was the way they were trained to give care.'
While impressed, delegates were concerned about the cost of implementing such a broad IT system. Ms Moore insisted: 'It costs less than you think and I'm convinced the system is an integral part of being financially stable.'

Clinical engagement is vital to the success of any SLM programme, but a number of speakers talked of the importance of ensuring clinical leaders have the required skills.

'UCLH have a programme to develop medical leaders and much of it is down to the close working relationships with their division or business unit finance manager. They spend a lot of time out with the clinicians, effectively coaching them through,' Dr Gaskin said.

Selection process
Alex Lewis, medical director for Central and North West London NHS Foundation Trust, said it had introduced a rigorous selection process for clinical and service directors. An assessment centre conducts psychometric tests to produce a long-list of candidates, followed by formal interviews. Then, clinical directors and service directors are matched in each of the trust's 11 service lines - ensuring the directors in each service line have complementary skills.

'Doctors are expected to lead, but they are never trained to manage. This has been one focus for our clinical director development,' he said. The result is that each service line has been able to develop its own business plan and, as the operating framework insists, clinical directors are responsible for delivering CIPs and quality impact assessments.

'The matching works well and our clinical staff have engaged across the board,' Mr Lewis added. 'We also run an innovations fund that allows clinicians to put in bids for money.'
With  a growing call for clinical engagement and quality and cost improvement, perhaps SLM is more relevant than ever.