Feature / From bedside to spreadsheet

Having spent several years as a nurse, finance manager Dinah McLannahan clearly knows the business. She tells Steve Brown how she has applied her ward experience to finance

When HFMA president Tony Whitfield called on finance managers to spend time on the front line as part of his ‘knowing the business’ theme, he was thinking in terms of a few shifts or days. Dinah McLannahan fully supports the aim. ‘There’s huge benefit from seeing care being delivered,’ she says. ‘It is about understanding what we are all here for.’ She should know, having spent six years in the mid-1990s first training, and then practising, as a nurse before switching to NHS finance.

Ms McLannahan, is currently acting director of finance and performance at Dudley and Walsall Mental Health Partnership NHS Trust, following a relatively rapid rise in her second career as an accountant. She rejoined the NHS in 2003, after completing the early part of her ICAEW chartered accountant training in the private sector. This had been the plan since she turned away from nursing. Her target was not simply to retrain as an accountant, but specifically to work in NHS finance.

There are not thought to be many people who have switched from clinical to financial roles in the NHS, at least at qualified accountant level. This is in part a reflection of the significant training involved in both areas. But Ms McLannahan says the disciplines are, or at least should be, united by the same goal  – delivering high-quality, safe care to patients.

She has many fond memories of her time in nursing, but knows the switch was right for her. And she is keen to use her own experience to guide the development of the wider finance team at the trust. ‘As is happening in other trusts, we are keen that all the finance team should work a shift on a ward or work in some way with frontline services,’ she says.

Services in practice

‘You have to hear from the patients and from the nursing and medical teams about how services operate in practice and what pressures they are facing to truly understand the finances and work effectively with clinical staff.’

Ms McLannahan is a big supporter of the current focus on safety – in particular eliminating patient harm – and quality. She accepts that much will have changed since she spent her three years as a registered nurse, but still thinks there are things that can help her in a finance role. ‘I’ve seen the pressure sores, the accidental harm caused to patients and the waste that can be created. Many things have changed, but many of the issues we were trying to deal with as a health service are still with us – delayed discharges, infections, pressure sores and social care provision. Seeing these things first hand really helps me – perhaps makes the need for improvement seem more urgent.’

With all staff focused on improving patient outcomes and experience, she says the knock-on benefit should be reduced costs – fewer infections and pressure sores and fewer readmissions, leading to shorter lengths of stay and, eventually, the ability to remove beds.

But there are challenges as well. ‘There were parts of my nursing job that I loved. I took huge pride in delivering patient-focused, high-quality nursing care, which I wanted to do as part of a multidisciplinary team, but each shift was an eight-hour adrenalin rush. You’d take a breath at the start and then let it out at the end.’

Management block

However, she perceived a lack of support and a hierarchical structure – typified in nurse managers who were divorced from the rest of the team – which made Ms McLannahan think that nurse management was not for her.

What teamwork there was did not include finance. ‘I had no contact with finance at all as a nurse,’ she says. ‘I was never consulted about any cost reduction plans.’ In fact, she says, she had no awareness of the financial position of the ward. High levels of agency nurses on shifts added to some of the challenges in delivering high-quality services – as agency staff would often not know the wards or patients – but she was unaware of the financial implications of these staffing levels, only the risks to quality.

She thinks this was a missed opportunity. She acknowledges that ward practices will have altered and there has been much more effort to engage all NHS staff with their financial management responsibilities – in part using

e-learning. ‘But the front line is where you will get ideas about how waste can be reduced, as long as the culture allows these ideas and feedback to be heard,’ she says.

‘And while the finance profession can be good at running numbers on waste, we are not always best placed to understand the quality impact of changes. Increasingly we need to be working with the front line to find ways to improve quality and in most cases this is likely to help financially too.’

Perhaps the final factor in Ms McLannahan’s decision to change career was her perception of a glass ceiling in the profession. She had met her unit accountant – not through an act of clinical engagement but when he spent time on the ward as a cardiac patient. Discussions with him about his role, coupled with hands-on experience balancing the till in a hotel restaurant when she was a student nurse, told her that accountancy was her way ahead.

Training initially at a three-partner practice, she then spent a year at Baker Tilly, before rejoining the NHS at South Birmingham Primary Care Trust in 2003 as a finance manager. When she qualified in 2005, she took a band 8a financial management job in the children’s and community services team.

After two years, she joined Birmingham and Solihull Mental Health NHS Trust, again in financial management, helping prepare for the trust’s foundation trust application. She took a further role at the trust, working in the youth offending secure and complex care division, before moving to the Dudley trust in January 2010 as deputy director of finance.

Culture is key

Culture is important to Ms McLannahan and this includes an understanding that while high-quality, safe services are the goals for all staff, delivering these services in a sustainable way, within budget, is also everyone’s responsibility.

An example of this is her work on a business case to move a female acute inpatient ward, which was poorly ventilated, lacked therapeutic space, and had no secluded gender-specific space for female patients. While there would be a qualitative improvement, the cost of the move was unclear – the service was provided under a block contract and there was no patient-level costing. She engaged with stakeholders to produce a business case that included the work needed to make the financial impact of proposals clearer. This won board approval and the ward opened in January.

She thinks the trust has achieved a culture change, with financial ownership spread far beyond the finance department. In 2011/12, a difficult first quarter left the trust in danger of not achieving its financial plan. Instead of a traditional approach of the centre locking down finances and imposing cuts, the services themselves were charged with fixing it, with support and analysis from the finance team.

It took time for this change to kick in, but the trust held its nerve and the turnaround was visible by month eight. As a result, the trust exceeded its original forecast outturn.

One example relates to medical locums, which were causing overspends on the medical budgets. The finance team rebased team budgets (setting all vacancies at the bottom of each pay band, rather than at the midpoint, creating a central reserve). But the solutions were down to the teams.

The result has been £150,000 savings a month on budgets already £700,000 lower, and a forecast underspend for 2013/14. ‘Clinical areas are best placed to take these decisions and we are there to support them with high-quality information,’ she says.

To provide the right support, finance staff must understand how clinical areas operate and the challenges they face. ‘We need to get out there and understand what frontline services are doing,’ says Ms McLannahan. ‘It makes us all better accountants.’