Getting engaged

Calls for clinical engagement in costing are hardly new. A Healthcare Finance report from an HFMA costing conference in 2006 focused on the need to involve clinicians in compiling and checking costing data.

Thirteen years on and the importance of clinical involvement was still a core message at April’s annual costing conference, organised by the HFMA Healthcare Costing for Value Institute.

Back in 2006, costing was all about reference costs and a key focus was supporting the compilation of tariff prices as part of the fledgling payment by results system. There were people using reference cost data in a high-level way to identify variations between services and organisations.

But the ‘average’ nature of the costs and major concerns over data quality and comparability stopped many organisations from using the data to inform decisions.

Clinical involvement was seen as an essential way of addressing some of these data quality issues – helping to improve allocation approaches and ensure that costs made sense (at least at that average level) to those practitioners actually delivering the care.

The context for costing has changed dramatically. After spending some years encouraging NHS bodies to start costing at the patient-level, the NHS in England is now well into a journey that will see the whole service required to cost at this more granular level using detailed common standards.

Acute trusts will make their first mandatory submission this year, closely followed by ambulance trusts and mental health trusts next year. Providers of community services are likely to join them in 2021. But the message about the importance of clinical engagement remains a constant – though really we need to talk about collaboration, as engagement perhaps sounds a little like something done to the clinical workforce rather than with it.

This continued importance is not because people ignored the calls first time around, but because clinical engagement is a continual process. As one speaker urged costing practitioners at the April costing conference: spend more time on engagement and less on fine-tuning the costing model.

Now engagement is less about correcting allocations and apportionments – although a more detailed understanding of how clinicians spend their time is always helpful. Instead, it is about helping clinicians to understand what the data can tell them and take ownership of the data, trusting it so they can make decisions about patient pathways.

The data is increasingly meaningful and comparable – thanks to everyone following the same methodology. And it is at the patient level – so clinicians can relate costs to specific cases (especially if the data is delivered in a timely way), helping them to understand the reasons for outlying costs, for example.

Clinical collaboration is so vital because clinicians using costing data to inform service redesign is the point of costing. Accurate costs that reflect real clinical practice might be something for a costing team to be proud of. But if it doesn’t get used to inform clinical decision-making, it becomes a hollow exercise. Information is only useful if it changes behaviour – as one speaker told the conference.

Some still argue that the introduction of patient-level costing is using a mallet to crack a nut. Similar outcomes could be achieved by comparing variations in length of stay, time in theatre or number of tests. You don’t need to attach money to them, they say.

But attaching costs to these activities helps clinicians, supported by their costing practitioners, to focus on the best place to start looking – the areas that will deliver the greatest value. And the costing programme is more broadly about bringing patient-level information of all types into one place. The simple fact is that the exploration of variation simply hasn’t happened to any great degree in the absence of patient-level cost data.

Costing practitioners also point out that many clinicians love the detail of cost data once they get their heads into it, and find it incredibly useful in helping them see how resources are used along patient pathways.

Even finding just one clinical champion can make a huge difference to how costing data is viewed across a trust and – more importantly – how it is used to improve services and value.