Flourishing relationships - finance staff and clinicians - the challenges and solutions

This paper examines the challenges that need to be overcome for the relationship between finance staff and clinicians to flourish and critically appraises the techniques that can be used.

Challenges that need to be overcome

1.      A strategic disconnect

Cost and quality improvement (QI) programmes are often viewed as separate if not competing entities rather than strategies of equal priority and complimentary intent within NHS organisations. The hypothesis that ‘quality improvement reduces costs’ remains debatable, ‘there is some evidence to show that quality improvements can both improve quality and release resources’ (Neath, et al., 2012, p. 1); and though some cases are effective and report savings; the evidence is weak (Llewellyn, et al., 2016). These initiatives carry costs which may exceed savings, and this is complicated by cost-benefits being spread over time and between stakeholders. There are also several contextual factors (e.g. contractual arrangements) that influence potential savings from QI initiatives  (Øvretveit, 2009). The need for further research to address this strategic disconnect is a challenge in itself as it would need to address and understand the limitations of  QI sustainability as well as initial and recurring costs of QI initiatives.

2.      Whose business is it anyway?

Blunt and Bardsley stress the importance of clinical engagement in the costing process (Blunt & Bardsley, 2012, p. 25) to ensure that the information generated is used in a meaningful way to deliver improvements for patients and service users; however, less than a fifth of NHS trusts (n=44/239) embodied attributes of collaborative working between clinical and finance teams as the norm across all clinical specialties/ directorates with finance managers routinely working as integral members of clinically led quality improvement teams with both professional groups sharing cost and quality data to improve outcomes. There is a decline in number of trusts at Level 4 engagement compared to 2012/13 and 2013/14 (Department of Health, 2015, p. 38) and this highlights the fact that majority of clinical and finance teams continue to work in silos with a lack of shared purpose and mutual accountability. There remains a disagreement over the ownership of patient level costing, which traditionally has been viewed as a finance function and is often treated as a ‘box ticking exercise’ by disengaged clinicians.

There is a gap in understanding the reasons for this clinical-financial disconnect; which are complex and range from innate behavioural differences stemming from professional training and perception of roles within an organisation; to varying perspectives, knowledge and attitudes of drivers, incentives, purpose, goals and function of healthcare (Future Focussed Finance, n.d.).  This disconnect of function and perception amongst finance teams (costing practitioners) and clinicians (important to remember that this group refers collectively to doctors, nurses, pharmacists and allied health practitioners, the inclusion of latter three professional groups are often overlooked as part of the collaborative process) is further exacerbated by a time and skill divide amongst these professionals who struggle to find protected time to collaborate in a productive environment because of insufficient capacity/ flexibility in existing job plans and the absence of formal mechanisms/forums to facilitate working  together. Due to their distinct and specialised professional roles, a further challenge is lack of basic financial awareness and skills amongst clinicians, and to a degree the lack of costing teams’ understanding of clinical context of applied costing.

3.      Methodology, tools and data

Clinical and finance teams both lack an understanding of QI methodology and its use in relation to deriving benefits from patient level costing. This is exemplified by the eight case studies included in the Patient level costing: case for change (NHS Improvement, 2016, pp. 23-37) which make little if any reference to QI methodology or tools of continuous improvement (e.g. run charts or statistical process charts) which are essential to understand and ensure the sustainability of changes made.

Another onerous challenge is the limited understanding of the interdepartmental dependencies within organisations – an improvement initiative delivering cost savings in one area may have an adverse effect on another. There is a need for a systems thinking approach of continuous improvement if patient level costing is to be used to support QI in healthcare systems.

The challenges described above are confounded by the lack of widespread adoption and use of benchmarking resources (Department of Health, 2016, p. 38) such as the National Benchmarker, Model Hospital and GIRFT (Getting It Right First Time) which allow teams to understand variation in relation to national/regional/peer performance.

Last but not least is the challenge of data, which needs to be of a good enough quality that it can be used to support QI initiatives whilst acknowledging that imperfect data should not be disregarded; but used to overcome challenges of imperfect clinical-finance relationships to avoid the vicious cycle of poor quality data secondary to poor clinical engagement (Chapman and Kern, 2010, p. 94). Untimely and infrequent production and review of actionable costing data and the inability of costing systems to produce information relevant to tailored role-based views are important challenges that need to be overcome to ensure that costing information is generated and used appropriately to deliver improvements in healthcare.

Solutions to overcome these challenges

1.      Developing ‘soft skills’

A ‘back to basics’ approach to understand how healthcare professionals interact (Academy of Medical Royal Colleges and NHS Confederation, 2014) is imperative to nurturing engagement between clinical and finance teams. This will only be possible by establishing an enabling culture which prioritises a whole system approach of value based healthcare using continuous improvement methodology (Department of Health, 2013). This needs to be facilitated by leaders able to collaborate across professional, geographical and organisational boundaries through compassionate and inclusive leadership skills (National Improvement and Leadership Development Board, 2016). A supportive culture and leadership embodying these values with a clear statement of direction needs to be embedded within all levels of organisations to create ‘norming’ and subsequent ‘performing’ teams wherein people share a common focus, communicate and reflect effectively and become more efficient (Tuckman, 1965). For this to happen; teams need to overcome an uncertainty of their roles and negotiate a degree of conflict and power sharing during the ‘forming’ and ‘storming’ stages of team development.

Overcoming professional boundaries, establishing trust and encouraging open reflective conversations for clinical and finance staff to work cohesively can be facilitated via peer support from the Future-Focused Finance network and by learning from organisations with Level 4 engagement. Periodic (and not one-off) use of resources  for organisations to assess culture and behaviours;  process and tools; and benefits and outcomes (Department of Health, 2013, pp. 16-18), along with toolkits to assess the status of clinical-finance relationships (The King's Fund & Future-Focussed Finance, n.d.), and the Sustainability Model to assess ‘staff’, ‘process’ and ‘organisation’ factors required to implement and sustain improvement initiatives (Lynne, et al., 2017) can play a supportive role for trusts to improve engagement. The potential subjectiveness of these toolkits needs to be backed by tangible evidence to support the assessments made and should consider the recommendations made by Trusts which have already used these resources (The Chartered Institute of Public Finance and Accountancy, 2015).

2.      Creating capacity and capability

To overcome the challenge of limited time to interact with finance colleagues, clinicians from all professional backgrounds and at different levels of training need to be provided with protected time, opportunities and incentives to engage. This could be through recruitment of clinical-costing practitioners, junior clinical costing fellows, inclusion of ‘costing’ in consultant job plans; and inspiration should be drawn from clinical engagement in digital health and informatics (Sood, 2017), (Wachter, 2016, pp. 38-42). Creating the clinical headspace needs to be complimented with appropriate costing knowledge for clinicians. This can be achieved through formal qualifications offered by HFMA (Healthcare Financial Management Association, n.d.) and by shadowing costing practitioners (which will require creating facilitative capacity within finance teams). Structured shadowing will mutually benefit costing practitioners too, by generating a better understanding of clinical context to applied costing. The opportunities to build on the ‘soft skills’ previously described can be further enhanced by clinical-finance partnerships participating as teams in QI development programmes like QSIR (NHS Improvement, 2016).

Additional recruitment, creating facilitative capacity and provision of training opportunities may be seen as additional costs for organisations to bear, but their benefits outweigh the costs, and this could be incentivised by reinvesting a portion of savings from cost reduction initiatives to support the capacity and capability requirements for relationships to flourish (Sears, 2012).

3.      Data governance

Information derived from patient level costing is an important key for clinical-finance partnerships to unlock the QI potential of value based healthcare and requires formal, structured and timely reviews of actionable good quality data tailored to suit clinical needs through use of clinical analytics systems (Mate, et al., 2017) whilst acknowledging the need for continuous review of ‘imperfect data’ to improve ‘imperfect relationships’ (Chartered Institute of Management Accountants, 2014, pp. 8-10). The use of granular patient level costing data can also be supplemented by using best practice formats for effective Service Line Reviews to recognise potential efficiency gains and realise service improvements (Foot, et al., 2012) (Department of Health, 2013). Adoption of clinical costing standards- in particular Standard 9 - the Materiality and Quality Score (MAQS) assessment tool is vital for organisations to build clinician trust in the process by creating a standardised and transparent mechanism to identify, monitor and resolve data quality issues (Healthcare Financial Management Association, 2016/17, pp. 52-53).

4.      Further research

Further research to understand the relationship intricacies between quality and cost improvement, peer review of costing-quality improvement case studies using QI methodology, further analysis of available toolkits and self-assessment tools, a better understanding of the factors causing variation in levels of engagement over time, as well as a better understanding of the ‘cost of inaction’ are required.

Conclusion

An optimistic outlook, a reflective view and a ‘back to basics’ approach inculcating system wide, strategic and inclusive leadership which nurtures cross professional collaboration beyond clinical-finance partnerships to refine tools, develop skills and create capacity through a method of structured continuous improvement is required for  relationships  between finance staff and clinicians to flourish.

References

Academy of Medical Royal Colleges and NHS Confederation, 2014. Decisions of Value, s.l.: AoMRC and NHS Confederation.

Blunt, I. & Bardsley, M., 2012. Use of patient-level costing to increase efficiency in NHS trusts, s.l.: Nuffield Trust.

Chapman CS and Kern A., 2010. Costing in the National Health Service: From reporting to managing. Chartered Institute of Management Accountants.

Chartered Institute of Management Accountants, 2014. Building Clinical Engagement with Costing How NHS Teams Are addressing key challenges, London: CIMA.

Christianson, J., Leatherman, S. & Sutherland, K., 2007. ). Financial incentives, healthcare providers and quality improvements. A review of the evidence, s.l.: The Health Foundation.

Department of Health, 2013. Effective Clinical and Financial Engagemet, A best practice guide for the NHS, s.l.: Department of Health.

Department of Health, 2015. Reference Costs 2014-15, s.l.: Department of Health.

Department of Health, 2016. Reference Costs 2015-16, s.l.: Department of Health.

Foot, C., Sonola, L., Maybin, J. & Chris, N., 2012. Service-line management, Can it improve quality and efficiency?, London: Kings Fund.

Future Focussed Finance, n.d. Crossing Professional Boundaries Toolkit. [Online]
Available at: https://www.futurefocusedfinance.nhs.uk/crossing-professional-boundaries-toolkit
[Accessed 27 December 2018].

Healthcare Financial Management Association, 2016/17. Acute health clinical costing standards, Bristol: Healthcare Financial Management Association.

Healthcare Financial Management Association, n.d. HFMA Qualifications. [Online]
Available at: https://www.hfma.org.uk/education-events/hfma-qualifications
[Accessed 3 January 2019].

Llewellyn, S. et al., 2016. Patient-level information and costing systems (PLICSs): a mixed-methods study of current practice and future potential for the NHS health economy. Health Services and Delivery Research, 4(31), p. 5.

Lynne, M., David, P. G. & Alyson, E., 2017. Sustainability Model and Guide. [Online]
Available at: https://improvement.nhs.uk/resources/Sustainability-model-and-guide/
[Accessed 3 January 2019].

Mate, K. S., Rakover, J., Cordiner, K. & Maskell, B., 2017. A Simple Way to Involve Frontline Clinicians in Managing Costs. Harvard Business Review, Issue October, pp. 2-7.

McCaffry, R., 2014. Building Clinical Engagement With Costing - how NHS teams are addressing key challenges, s.l.: Chartered Institute of Management Accountants.

National Improvement and Leadership Development Board, 2016. Developing People –Improving Care, A national framework for action on improvement and leadership development in NHS-funded services, s.l.: NHS Improvement.

Neath, A., Downham, N. & Mugglestone, M., 2012. Clinical-Financial Partnerships in the NHS- Why we need them to deliver the Cost and Quality challenge, s.l.: Institute for Innovation and Improvement.

NHS Improvement, 2016. Patient-level Costing: case for change, London: NHS Improvement.

NHS Improvement, 2016. Quality, service improvement and redesign (QSIR). [Online]
Available at: https://improvement.nhs.uk/resources/qsir-programme/
[Accessed 3 January 2019].

Øvretveit, J., 2009. Does improving quality save money? A review of evidence of which improvements to quality reduce costs to health service providers, London: The Health Foundation.

Sears, N. J., 2012. Managing margins through physician engagement. Healthcare Financial Management, Issue July, p. 45.

Sood, H., 2017. Clinical leaders need to go digital. [Blog]
Available at: https://www.england.nhs.uk/blog/clinical-leaders-need-to-go-digital/
[Accessed 3 January 2019].

The Chartered Institute of Public Finance and Accountancy, 2015. Sharing the Agenda: Increasing collaborative work between finance and clinical teams, Independent Evaluation of the King’s Fund Toolkit Pilot, London: CIPFA.

The King's Fund & Future-Focussed Finance, n.d. Crossing Professional Boundaries Toolkit. [Online]
Available at: https://www.futurefocusedfinance.nhs.uk/crossing-professional-boundaries-toolkit
[Accessed 27 December 2018].

Tuckman, B., 1965. Developmental sequence in small groups. Psychological Bulletin, 63(6), pp. 384-399.

Wachter, R. M., 2016. Making IT Work: Harnessing the Power of Health Information Technology to Improve Care in England, Report of the National Advisory Group on Health Information Technology in England, s.l.: s.n.