Feature / Counting counters

Steve Brown analyses the latest profile of the NHS finance function and reports on the results of a first ever major survey of finance staff attitudes to their jobs and careers

There are fewer finance staff in the NHS following the Health and Social Care Act changes. These staff in the main retain high levels of job satisfaction, despite some difficult working conditions. However, staff have concerns about the perception of their role and the value placed on it by those outside the function.

These are some of the key findings from the latest NHS finance staff census, published jointly by the HFMA and the NHS Finance Skills Development (FSD) Network, and a staff attitudes survey, undertaken by the association to complement the census figures.

The latest biennial census – which incorporates all core NHS bodies – records staff as at the end of June 2013 and so captures the staff in post at the start of the new NHS structure. The census covers a broader range of staff than in 2011, in particular reflecting the movement of responsibilities and staff from the Department of Health (outside the census boundary) to NHS England, the NHS Trust Development Authority and Health Education England.

Falling numbers

Even with the changes in scope, staff numbers have fallen in absolute terms by more than 600, from 16,368 in 2011 to 15,730 – a 4% reduction. This same percentage reduction is seen within the core NHS – providers, NHS England, clinical commissioning groups (CCGs) and commissioning support units (CSUs).

There have been significant structural changes since the last census in 2011, with the abolition of strategic health authorities and primary care trusts and the creation of NHS England and CCGs. Commissioning functions are now split between the various tiers of

NHS England and local CCGs. The reduction in finance staff is biggest in these areas – which corresponds to a commitment to reduce running costs as a result of changes brought about by the Health Act.

Comparing staff in CCGs, CSUs and NHS England area and regional teams with previous staff levels in PCTs – seen as the closest meaningful comparison – numbers have fallen by 11%. Given the changes in role, the real reduction in commissioning finance staff is almost certainly greater than this.

Analysis of the commissioning finance numbers also reveals an almost equal split of staff between the 211 CCGs (1,190 staff) and the 19 CSUs (1,055). The census shows that there were 12,164 finance staff working in trusts and foundation trusts – a 1% reduction in staff compared with 12,252 in 2013. Provider staff make up 77% of the overall NHS finance function (see table right).

The average staffing level in a CCG was six. However, the detailed returns show that CCGs are taking widely different approaches to the provision of their finance function.

In the majority of cases, there is a finance director with a separate team. However, there are also variations on sharing resources, with either both the finance director and team shared across multiple organisations, or just the director or team being shared.

Some CCGs have only a finance director within the in-house team, with all other financial support provided by a CSU and NHS Shared Business Services (which provides the integrated single financial environment to all CCGs). A small number of CCGs have more than 20 staff, although a number of these provide services to other CCGs.

Average staff levels

The average staffing level for an acute FT is 56 finance staff (58 for acute NHS trust), compared with just 41 for mental health

trusts and FTs. Overall, the average staffing level for a provider was 49, although the biggest finance department employed approaching 200 staff. This is in part driven by the level of services provided externally to other local organisations – some are major providers of payroll and other financial services, for example, to local NHS bodies.

However, the biggest driver of finance staff numbers is turnover. Average staffing levels in acute providers, for example, rise from 19 in organisations with a turnover of up to £100m and reach more than 100 staff for providers with an income of £500m and more. The averages are virtually the same for mental health bodies.

The census continues to provide a breakdown of the finance function by agenda for change pay band. Some 35% of staff are band 7 or above (not including directors), compared with a similar level (34%) at bands

1-4. A further 26% are in bands 5 and 6, with the balance made up by other staff (non-Agenda for Change staff at or below band 8D) and directors. In terms of proportions, this represents a similar picture to the grade mix of staff in 2011. However, it is clear that the bulk of the reductions in the overall size of the function have come in bands 1-6, with a 10% reduction in staff in bands 1-4 and a 6% reduction in staff numbers in bands 5 and 6, offset by a small increase in the number of finance staff at bands 7 and above.

Top-level increase

A significant increase in the number of NHS finance directors/chief finance officers is because the 2011 figure reflects PCT clustering arrangements, which effectively reduced the number of PCT finance directors from a maximum 151 to just 50. The commissioning functions undertaken by these 50 PCT clusters have subsequently been taken on by CCGs and NHS England.

Some of the reduction in bands 1-4 will be a result of the greater use of shared services. For example, while some PCTs retained fully in-house financial services, all CCGs have their core transactional financial services provided externally as part of the ISFE with NHS Shared Business Services.

However, regional analysis of the band mix shows a significant difference in the make-up of finance teams across England. In London, 43% of staff are at bands 7 or above, compared with the 35% nationally and 32% in the north of England.

Similarly, 24% of staff are at bands 1-4 in London compared with 40% in the north. Again, some of this may be due to different levels of usage of shared services for core services. However, it is possible that some of

it may reflect the perceived need to appoint staff on higher pay bands in some areas as a result of labour market conditions, although high-cost area supplements within the

agenda for change pay arrangements are intended to address this.

Half of NHS finance staff work in financial management, with 29% working in financial accounting and 19% in financial services.

Of the 15,730 staff, 43% are either qualified with or studying for a CCAB (or equivalent) qualification. In 2011, a slightly smaller proportion (41%) of a bigger function was CCAB-qualified or students. Looking at the split between qualifieds and students, there are 319 more qualified accountants now (4,715) than in 2011, but 200 fewer students.

 Of the 6,732 CCAB-qualified and student staff, CIMA accounts for half, while ACCA accounts for almost a third. CIPFA now accounts for just 14% of qualified and student accountants in the NHS.

The census also shows that 62% of the NHS finance workforce are women. However, the male-female split changes at different levels across the service. At band 6 and below, women make up 72% of the finance workforce, but this falls to 49% for bands 7 and above.

Women outnumber men at every band until you reach band 8b, when the trend is reversed (see table, page 13). This trend at senior management level continues into director

level, where just 27% of directors are women. This proportion increases to 33% in CCGs and NHS England area teams, but falls to 21% across all providers.

Staff attitudes survey

While the census provides a factual picture of the make-up of the NHS finance function, the HFMA’s new finance staff attitudes survey attempts to assess the mood of finance staff – their views of their job and career aspirations.

The survey, run for the first time last September 2013, attracted more than 900 responses, primarily from the CCAB-qualified and student community in England. Most respondents fell into age groups between 25 and 54 and just over half the sample were women.

The sample demonstrated significant levels of NHS experience. More than 40% had five years or more in their current organisation. About a third said they had spent their entire career to date in the NHS, although most of these were at the start of their careers with less than five years’ service in the NHS. However, there are clear examples of staff committing themselves to the NHS. Nearly 40% of those in senior positions, at pay band 8d or above had spent their entire career in the NHS.

Of the two-thirds of respondents who had experience in different sectors, there was a high proportion of people with private sector experience. There was some evidence of

people staying within their own sector of the NHS – either commissioning or provision. About two-thirds of provider finance staff

have never worked in a commissioning organisation or at the strategic level. And 58% of CCG, CSU or area team staff have never worked in a provider.

Staff in the main have high levels of job satisfaction. Asked to rate their job satisfaction over the last year on a scale of 1 to 10, the mean score was 6.8, with this increasing even further at the higher grades.

Positives mentioned included new roles and new challenges, while, on the negative side, people talked about uncertainty over job security and the way changes had been communicated or staff line managed.

About a third expected their job satisfaction to improve over the next 12 months, a result of the new structure settling down and the greater clarity of role for many people. Some concerns were raised about the impact on morale of seeing experienced staff taking voluntary redundancy leaving inexperienced staff unable to cope with the demands placed on them.

These high levels of job satisfaction are despite long working hours. A quarter of staff said they always worked in excess of their normal hours, while 70% said they worked longer hours at least twice a week. For many this was just part of the finance culture – the need to get the work done.

The need to work longer hours was often connected to specific projects or times of the year: the transition to the new commissioning arrangements; year-end reporting; reference costs; foundation trust applications; and the budgeting and planning round.

Overall, 80% of staff are keen to stay in the NHS and 63% expect to see out their careers in the health service, although within this 63%, only a third felt very secure in their current job.

The vast majority of finance staff think the finance department adds value to their organisation, although a few identified opportunities to improve this value. For example, half of respondents identified a need for finance staff to improve their knowledge of healthcare alongside an improvement in the financial literacy of non-finance staff.

Better technology was also cited as a necessary driver for improved value. One respondent suggested there needed to be a shift away from providing historical commentary towards forecasting and modelling.

There is a less positive story to tell on how finance staff believe their role is valued. While 89% felt valued by their line manager, this dropped to 69% for feeling valued by the board and 61% for clinicians (although some pointed out it was difficult to generalise – for example, finance staff may feel valued by individual clinicians but not clinicians in general).

But just 30% felt valued by their national government health department. And this fell even further to 18% for patients and 17% for the general public. Individual comments provided further insight. ‘Patients and public will not value us due to the negativity of the press in relation to NHS managers and as the burden on frontline staff that we are made out to be,’ said one respondent.

Another admitted it was ‘tricky’ to admit to working in NHS finance to a stranger, while a third said: ‘There is very little understanding of what finance departments do. We are not very good at blowing our own trumpets.’

Some 43% of finance staff thought their status would be higher in the private sector (where status is defined as the value attached to the role by public, friends and colleagues). This compared with just 12% who thought they enjoyed better status in the NHS. More than 50% also thought salary and financial rewards would be higher in the private sector.

Public sector values

This underlines NHS finance staff’s motivation for working in the NHS. Seven out of 10 said they were motivated by ‘public sector values’ and 60% by the ‘opportunity to improve services for patients’. Just 5% said they were motivated by being held in high esteem by the public and politicians.

‘It is clear that NHS finance staff join the NHS for the right reasons – they actively seek out public service and believe in the NHS. They want to make their contribution and play a part in improving patient care and they get good job satisfaction from doing so,’ says Paul Briddock, policy and technical director at the HFMA. 

‘We need to ensure services remain clinically and financially sustainable,’ he adds. ‘This means good financial control is essential, but we also need finance staff to work alongside clinical colleagues to understand existing variation in clinical practice and costs and identify opportunities for improvement. And we need to understand the clinical and financial impact of moving to new service models.

‘Given this important role, it is disappointing the finance function is not sufficiently valued – or at least that finance staff do not believe their contribution is properly recognised. The focus for everyone in the NHS is the patient and ensuring care is of the highest standard possible. But we need greater recognition that achieving this is a team game involving both frontline and back office staff.’