Quality versus Finance – Do the grey suits run the NHS? by @katylew38

Having been motivated by the inspirational weekly blogs I decided to put pen to paper with much trepidation as to whether the ramblings of an accountant would even vaguely interest the usual readerships of the weekly instalments. I’m not saying I was born an accountant, but my aptitude for maths was identified at an early age and made my career path inevitable

My introduction to the NHS in England was as a Management Accountant at a time when NHS Trusts were multiplying rapidly and the job market for NHS accountants was on the increase, which was lucky for me given I needed a job and I thought altruistically I could make a difference working in the public sector as oppose to commercial entities. That was 22 years ago and as we know the NHS has had many a restructuring, reimagining and reinventions since then, with my move to Dumfries in 1998 triggered by the latest iteration at that time.

Having decided to move here for a couple of years and accepting my chosen career as an accountant which came out of my ability in Maths, a dad who was a bank manager and saw it as a “safe job” rather than a burning ambition and was pretty much set when at 5 years old I had my first responsibility of collecting and adding up the school dinner money. The move to Dumfries proved to be an excellent but incredibly challenging career move for me and 16 years later, recently appointed to Director of Finance, it appears I’ve settled here for good!

The role of the accountant within the NHS has changed unrecognisably since I put on my first “grey suit” with the role these days much more focusing less on the “bean counting” and much more on the business partnering, added value role with the finance manager a key team member alongside the General Manager, Nurse Manager, Clinical Leads in supporting the decision making processes of the organisation.

I firmly believe that finance must earn its “keep”, we are a support function and are continually challenged to demonstrate it worth and value we provide to the organisation beyond the “technical” functions we provide and that our key role is as enablers to support the critical decision making within the organisation. But also to provide that critical friend role, to challenge outcomes, decision making to ensure that we haven’t been lazy in reaching an end point, that we have considered all alternatives, come up with new ideas and provide an important and different viewpoint to the argument being presented.

As Director of Finance I have a clear leadership role in the organisation and as defined by the Healthcare Financial Management Association (HFMA) in their publication “the Role of the Chief Finance Officer 2013” described the role under four main headings:

• Corporate leadership
• Stewardship and accountability
• Financial management
• Professional leadership and management

 The role is not just about balancing the books (although that is an incredibly important part of the job!) but engaging as part of the leadership team and taking corporate responsibility for decisions which the Board makes.

You will all be familiar with the publication last year of the Francis report and this has been considered very seriously by finance professionals given the concerns about the focus on financial issues to the detriment of quality of care.

The HFMA published their response to this report which reminded financial professionals of their responsibilities to operate in a professional manner at all times and highlighted the following points:

1.  All NHS finance staff should remind themselves of the contents of the codes of conduct of their professional bodies, employing organisations & NHS constitution and adhere to them
2. All governing Board members are equally responsible for quality, patient safety and financial performance of their organisations
3. All NHS finance staff should understand how their role supports the achievement of organisational objectives & delivery of high quality patient care
4. NHS finance staff should provide the most up to date, reliable, useful and complete financial information possible and aim for the highest standards of financial probity and financial reporting
5. A focus on knowing the business and understanding the finances will lead to better services for patients
6. Finance staff have a duty to promote the best use of resources and the achievement of value for money

 As finance professionals this has reminded us of our responsibilities beyond the just the money and we can’t just drive financial efficiencies at the expenses of everything else and our professional and ethical codes supports this approach. The focus in NHS Scotland is driven by the quality strategy at the heart of what we do and to use this to drive improvements in person- centred and effective care. The engagement we have as financial professionals with clinical staff must reflect this, recognising that understanding the clinical challenges and engaging on quality and efficiency improvements can lead to a much more productive and constructive outcome for all involved.

Since the downturn in the economic position in 2008 the need to deliver efficiencies to balance the books has been an important consideration. We are clear that finance forms one of the four dimensions of our thinking along with our workforce, quality and service issues. None of these are more important than each other overall and we must take use a balanced approach to this and keep the patient at the centre of our thinking to ensure we come to the best decision. The focus has to be on quality driven financial management. Do we believe that if we get the quality right the financial efficiencies will follow?

As we move into what are set to be an incredibly challenging few years with the building of the new Hospital, Health and Social Care Integration and the demographic and economic inevitabilities, we must to focus on the opportunities, and continue to trust the people in “grey suits” to support us to make the decisions we need to make as an organise and to value/ develop the role within the clinical teams.

 Footnote: although a reference the term grey suits to mean accountants neither myself nor most of my team conform to the stereotype     

Katy Lewis is the Director of Finance for NHS Dumfries and Galloway

All Men (& Women) are created equal? by @lynseyfitzy

Since taking up the post of Equality Lead at the end of October 2012, I’ve heard various comments such as “What does THAT involve?” and “Surely that’s a made up job?”.  If only.  If only it wasn’t the case in Scotland that only 0.3% of apprenticeships go to people with a disability or that women are paid 14% less than men in full time work.  But possibly the worst comment I have heard so far is “people need to have a sense of humour about some things”.  I’m sure those people that have suffered discrimination would be delighted to hear that all this could be resolved if they simply lightened up and learned to laugh about it….

With the ongoing work around person-centred care and  patient experience, equality and diversity couldn’t be more relevant, after all, each and every one of us has at least one ‘protected characteristic’ and we are all at risk of being discriminated against at one point in our lives.  Most of us will at some point have to engage with health services and I’m sure that none of us would like to be treated less favourably because of one of our protected characteristics.

After attending the Patient Experience event in September 2013, where I couldn’t help but think that equality and diversity is at the heart of so much of this work, I came across the following articles by columnist Ian Birrell who has a disabled daughter and writes passionately about discrimination. He cites an example of a patient with Downs Syndrome being made “not for resuscitation” without any discussion with loved ones as it was just assumed by medical staff that his life held no quality. He also quotes some frightening statistics about disabled patients being left to die as it was considered “the kind thing to do” by medical staff. Two of his articles can be read here and here.

It would be easy to think that we work in a place where discrimination like this doesn’t exist, and I often hear the words “I treat everyone the same” as if this excuses someone from needing any further training or development on equality issues.  One thing which is clear though is that treating everyone the same or basing decisions on our personal assumptions is not equality and, as these articles highlight, can be dangerous.  People (staff and services users) should be treated as individuals, with a range of different needs.  Some of the complaints which I have been involved in since October 2012 could easily have been avoided if those involved had taken the time to consider the needs of the individual rather than a ‘one size fits all’ response.

At the recent Big Burns Supper event held in Dumfries, I had the wonderful opportunity to see a one man show called “If These Spasms Could Speak” which was about the way in which disabled people experience the world and how they feel about their bodies.  The show is by Robert Gale, a disabled actor, and had rave reviews when it was shown at the Edinburgh festival (There are clips on You Tube for anyone that might be interested in finding out more, one of which can be viewed here).  Despite the spasms which are probably the first thing people notice, and are so very aware of, the first thing that Robert sees when he looks in the mirror is a “cute face” despite the attitudes of others to his own physicality.  However, one of the funniest, yet probably most worrying parts of the show is when he describes visiting his brother in hospital and a young doctor proceeds to ask him personal inappropriate questions, assuming that he “must be somebody’s patient”.  This highlighted the way in which non-disabled people often view those with disabilities, in this case Robert’s own cerebral palsy and speech impediment.

Not only is it good practice to consider equality from a moral viewpoint, but by law we have had to become more pro-active about eliminating discrimination, advancing equality of opportunity and fostering good relations.  One of the ways in which NHS Dumfries and Galloway have done this is to come up with a set of equality outcomes, which you can read more about here.  We are also in the process of reviewing our equality impact assessment policy and toolkit, again something which is required to be completed by law but something which is often seen as something which is a bit of a nuisance.   If the fear of being personally fined if there was ever a claim against us isn’t enough, then think of it this way.  You have gone to all the bother of writing a policy/coming up with a strategy/started the process of service change (delete as appropriate).  Surely it makes sense to ensure that you have considered and consulted as many different people and groups of people as possible.  This can only improve your service or your policy and make it better than it already is, and may save you having to go back and make changes at a later date.

This is not to say that there isn’t already lot of good work being done out there.  For example, we have several areas within our Board currently undertaking the LGBT Charter Mark.  As an employer we are signed up to the disability two ticks symbol and each of our directorates have developed their own action plans on how equality and diversity can be mainstreamed into day to day business.  There is a lot of good work being done out there and a lot of our staff willing to consider people as individuals with a range of needs and requirements which they are more than willing to try and accommodate.

But, for the time being anyway, it looks like I do have a ‘real’ job as equality and diversity is no laughing matter….

Lynsey Fitzpatrick is Equality and Diversity Lead for NHS Dumfries and Galloway

The KIS of life by @NeilGKelly

What a great acronym!  It opens the way to multiple catch phrases some of which convey the meaning or intention better than others.  The key letter is of course the ‘I’ for it is the information that is key and the sharing that makes it function.  In a world where paranoia about personal information is rife and misdemeanours make frequent headlines, effective sharing of appropriate information about the people we care for can feel challenging.  However we all know that patients expect those who care for them to have details of their problems, tests and medication. They are often surprised to learn how poorly this information is shared and frustrated by having to answer the same set of questions time and again.

Ae fond KIS

Scotland took the bold step in 2006 and set up the universal Emergency Care Summary (ECS) which made available a small set of data about patients including details of allergies adverse drug reactions and current medication as recorded in the General Practice record.  Following wide consultation within the NHS in Scotland and with the wider public, it was agreed that permission to view this information would be ‘at the time’ the patient presented looking for help.  There was, of course, an opt out option for patients (exercised  by only 0.01% of the population) which stopped any information being sent from the GP practice to the central ECS store.  The initial program was designed to support emergency and unscheduled care. However it quickly became apparent it had application in the wider acute hospital setting and in 2012 it was permitted to access the data to support medicines reconciliation processes for any patients in hospital.  It was however the limitations of the dataset that prompted first the development and the electronic palliative care summary (ePCS) and more recently the Key Information Summary (KIS).

Beyond the KIS of Death

As we struggle with caring for ever increasing numbers of older and frailer people, many of whom have multiple medical problems, it was sometimes difficult to pause for long enough to reflect with the patient about their expectations for the future and what care and support they would really like. Even when we did find the time it was often difficult to record and share this information.  This gap was partly filled by an increasing move to ‘anticipatory care planning’ particularly with patients who were likely to have a flare up of their problem and needed to know what to do.  It is only with the advent of the KIS that we now have an effective mechanism for the sharing of this information.

 

 

It started with a KIS

Recording patient’s wishes is now very straight forward and all General Practices are able to do this as part of the day to day job in their practice computer systems.  The value of anticipatory care planning has been recognised with it being incorporated into the GP Contract and part of the deal is ensuring the KIS is completed and sent to the central store so the information can be accessed by those involved in providing care should the need arise.  At present patients are identified as being at risk of an exacerbation of their medical problem and a possible hospital admission and will be assessed and the relevant information recorded.  This will include details of carers, current clinical and caring issues, medication, facilities and equipment available in the patient’s home, care plans, place of care considerations, views on resuscitation and any arrangements in place for palliative care. This is an extensive list of possible information which can be recorded although it is not essential to record it all before some is shared.  It is also possible to review and revise the summary as time goes by and in particular add any special note which could be relevant in an out of hours situation.  The more sensitive nature of much of this information means the consent to share is sought at the point of recording before it is uploaded into the central store.  Without this consent the data cannot be shared.

KIS me quick

So what is the point of telling you all this?  Well firstly if you or your patients like the idea of having a Key Information Summary you need to ask your GP practice about how this can be set up and encourage them to do it. As time passes the numbers of patients with a KIS is growing and they will become more available.  If you are a clinician working in an area delivering unscheduled care or in any ward or clinic setting in the hospital you need to get in the habit of asking the patient if they have a KIS or checking to see if one is there.  Communication is only effective when the sent message is read.  If you are not sure how to find them you need to ensure you find out and get the appropriate access set up and passwords organised. If the KIS needs to be altered as a result of a visit to the hospital some feedback to the practice on what needs to be updated would be helpful and if there hasn’t been one set up advise the patient to ask for one.

Full on KIS

This is a project which is evolving and growing all the time but will start to bridge the information chasm between primary and secondary care.  Let’s face it, there is nothing better than a full on KIS.

 

Dr Neil Kelly is a GP in Annan and is Clinical Lead for Annandale and Eskdale LHP.

Take a deep breath by @ginaalexander

No, this isn’t the start of a blog on the effective management of labour!  But instead my recommended first step when you are about to receive a piece of feedback.

In a previous life as Personnel and Training Officer (that’s what we were called back in the days before HR Consultants) a big part of my role was supporting the organisations appraisal system.  We were highly focussed on training managers how to measure competencies, set SMART objectives, creating development and in giving constructive feedback to get the best out of human resources! 

There’s lots to read about how to give feedback.

I used to suggest this acronym to structure feedback in an appraisal context: BOOST.

 http://10minutemanager.com/boost-constructive-feedback-technique/

I am sure many of you will have your own strategies and techniques.

Human nature finds it hard to be critiqued, challenged, measured, assessed.  As the mother of a 15 year old facing “big” exams for the first time, I am keenly aware of the pressure this scrutiny brings to bear.  (Who knew I’d ever have to tussle with a quadratic equation again!)

Resistance and defensiveness is built into our DNA.   And, on the whole, when we look at health and care and what drives people to do the jobs they do, the intensity at which they work, the complexity and life-in-the-balance decisions they deal with, you see people who desperately want to do their best, be the best.      Being on the receiving end of feedback telling you, you could do better is at odds with the way most of us are wired.

I saw a tweet containing this great infographic recently.  The title could easily read “to stay “productive, sane, encouraged” and there slap bang in the middle is “Get feedback”.

http://t.co/6eYNPbA8C3

Given that a key aim of feedback is to improve, surely we’d want to embrace it?   But it’s so dependant on our motivation to receive as well as the motivator of the giver, the way it’s communicated, how we are feeling about ourselves and others and also, crucially, the prevailing culture of the organisations we are part of.   We know it’s good for us, and it is, but sometimes it feels like being fed a spoonful of castor oil! (Back to labour!?!)

We have all been on the receiving end of feedback and are, no doubt, aware of the profound impact it can have.

In our world of instant communication, feedback is available in real time!    I have seen lots and lots of feedback which would make you fit to burst with pride – hurray! 

But sometimes the giver hasn’t heard of “BOOST”, perhaps their motivation is frustration, pain, fear, worry, grief, confusion, anger.  Feedback might not follow a constructive pattern, is one sided, can be ill thought through and, to be honest, pretty brutal.   

What can we do?   Do we ignore it, dismiss it, disengage, move to self protection? 

We can manage our reaction.  We can choose to listen.  We can seek to learn. We can strive to improve. 

Do we need to develop our skills in receiving feedback?    I think so.    I speak with lots of different people across health services about receiving and responding to feedback through Patient Opinion – 50% of which, I hasten to add is positive! (see link above)  The first thing I encourage people to do is …. take a deep breath.

Then, some things to think about:

• Take your professional hat off; seriously take it off!  Remind yourself of the other roles you have in life: son, wife, father, sister, friend;
• Imagine it’s you, from or about someone you love, try standing in their shoes, empathise;
• Try to understand and connect with the feedback and the motivation;
• Control any inclination to defensiveness and stay open;
• Walk away, reflect, get someone else’s viewpoint;
• Examine your own motivation – to learn, to improve, to protect, to defend;
• Decide to respond and act, check your decision with others.

As I always say, it’s not rocket science, but neither is it easy.  We need practice and we can learn from others who do it well.

Oh, and we also operate within the phenomenon which is the NHS, and although progress is being made, we still don’t, organisationally, handle critical feedback all that well!  Another blog in the making there methinks.    Still perhaps we, as individuals, can be the change we want to see in others.

Good luck!

Gina Alexander, Director of Patient Opinion Scotland, an independent not for profit organisation who run an award winning website where people can share their experiences of care services.

gina.alexander@patientopinion.org.uk

@ginaaalexander