Digital future

NHS finance can be a fulfilling place to work – helping clinicians to deliver the best outcomes for patients. But, as with most jobs, there are repetitive tasks, mainly transactional tasks, that also need to be done. Ensuring suppliers are paid – and paid the correct amount – for example, is vital to the financial buoyancy of any organisation. But the modern NHS needs these tasks to be done quickly, accurately and efficiently – outcomes that lie firmly in the domain of robotic automation.

A recent virtual HFMA roundtable, Is automation the way forward for the NHS?, sponsored by NHS Shared Business Services (NHS SBS), discussed the benefits of the technologies and the barriers to their introduction. While automation is not new to the NHS, and is used routinely in some finance departments, the roundtable heard that it was not deeply embedded in NHS finance

Chairing the event, Ian Moston, chief finance officer of Greater Manchester hospitals group the Northern Care Alliance, said the NHS had much to gain from automation. ‘If we get this right, there are considerable opportunities to redirect resources to where they make a bigger contribution to patient care,’ he told the roundtable.

Stephen Sutcliffe, NHS SBS director of finance and accounting, said he believed the technology was game-changing for the accountancy profession in the NHS. In its implementation of robotic process automation (RPA) – software that can replace repetitive and rules-based activity – NHS SBS has more than 100 software robots automating 250 processes, and saving 500,000 working hours a year. ‘It’s not as easy as some of the vendors will tell you it is, but it is worthwhile,’
said Mr Sutcliffe. The NHS has many processes, both clinical and back-office, he added, and technology could help efficiency in these areas.

Mr Sutcliffe’s NHS SBS colleague, Mathieu Webster, who is transformation lead for finance and accounting, said RPA aids connectivity. In an individual NHS finance function, automating the connections between enterprise resource planning and the electronic staff record is a relatively simple place to start, he said.

Leadership role

However, finance had a more fundamental role to play in leading automation in the NHS. ‘From a finance function, the starting place is to show some leadership,’ he said. ‘How can you ask the rest of your organisation to automate if you are still doing everything manually?’

Mr Webster said there were still some NHS organisations not using RPA. ‘We are not fast followers in NHS finance. In workshops we’ve had with some of our NHS partners, they don’t understand what the problem statement is. They see processes and they see things happening, and they just accept that’s the way we work. If we as leaders can educate them, that’s the first step; otherwise, we will never be fast followers.’

Management consultant Rakesh Sangani, chief executive of consultancy Proservartner, said automation was essential. ‘If you are not leveraging some form of automation – for example, for invoice processing, cash applications and bank reconciliations – you should be asking yourself why,’ he said. ‘In terms of what other NHS entities are doing, never mind what industries are doing, you are probably behind the curve. This is almost table stakes to get the credibility internally to do some of the stuff where you are providing value to the clinicians.

‘If you started a new hospital tomorrow, would you set up the finance function the way you have today? Would you not have processes a little bit more streamlined – with a lot more automation – and have your finance people providing more business partner roles into the rest of the organisation.’

Taking the initiative

The roundtable heard examples of how trusts have adopted automating technologies to release staff time for more value-adding work.

Phil Bradley, Northampton General Hospital NHS Trust’s director of finance, said the trust had just been appointed an RPA hub and had been given funding to develop it, and to share with other NHS providers.

A new head of emerging technology had developed a number of bots, he said. ‘The first one he developed was during Covid and it was a bot to take the readings from oxygen tanks. At the start of Covid, we had to have someone from the estates team take readings every hour throughout the day and night. This little bot did that automatically.’

Mr Bradley is working with the finance team on areas such as matching purchase orders and invoices, but also more complex processes such as those between HR and payroll.

Claire Liddy, managing director of innovation at Alder Hey Children’s NHS Foundation Trust, is leading the trust’s programme to bring new technologies into healthcare, but has spent 20 years in NHS finance. Alder Hey’s innovation centre is the site of its artificial intelligence headquarters, which includes the trust’s RPA centre of excellence, data science and machine learning.

‘Everything we do in innovation needs to have an impact on the way we care for patients and benefit patients,’ said Ms Liddy. ‘In our early wins, we started with some of the back-office functions such as finance, purchase orders, invoice payment and HR recruitment forms. We’ve also started to focus on clinical needs, because we see RPA – in terms of how it benefits patients – has taken some of the admin burden away from clinicians so they can focus more on caring for patients.’

The trust has been working on RPA in the referrals process, on transcription, and even scoping some frontline services, such as safe waiting list management. ‘The opportunities are almost unlimited. I see RPA as one tool in a package of technology solutions that we really should be harnessing in the NHS to optimise healthcare. As a finance community we have a role to play in terms of how we get the investment into these new technologies.’

Mr Moston added that booking and scheduling were ripe for using RPA. ‘It will take some of the steps out that are uninteresting to staff, but it’s also an area that, if we get it wrong, can have terrible consequences for patients. Getting it right nearer to 100% of the time with an automated process will have huge significance for the patient experience.’

Daniel Haigh, deputy director of finance at NHSX, said automated interrogation of the unwarranted variation in finance systems, using integrated patient costing analytics and Scan4Safety data, was likely to have the greatest benefit for patients.

He added: ‘This can help to reduce costs, but also increase the quality of care we deliver to patients. I think we can also drive the value-add accounting of RPA, and automating some of the accounting processes can divert more time to looking at the value-add activities. How can we procure our goods and services more effectively, more efficiently and at a better price?’

Integrating finance systems with operational business intelligence systems would improve forecasting accuracy and allow faster planning, ensuring budget holders get the information in a timely manner, Mr Haigh added.

The discussion moved on to how and when to automate. Adrian Snarr, director of financial control at NHS England and NHS Improvement, said that although he was an advocate for automation, he felt the finance community needed to take a step back.

‘If you’re not careful, the technology entices you in and you have to keep reminding yourself of the problem that you’re trying to solve,’ said Mr Snarr. ‘If we truly want to embrace technology and automation, we’re going to have to be realistic. The NHS is not very good at standardisation – NHS organisations do their own thing, by and large. If we’re going to maximise the use of technology, we’re going to have to look at where it’s scalable.’

For example, NHS SBS has been working on an RPA solution for NHS England’s control accounts. ‘We set them a double challenge – can you make an RPA solution work, and can you make it scalable so that we could quickly send it out across ISFE [integrated single finance system] to commissioning organisations.’

Guy Kirkwood, chief evangelist at RPA specialist UiPath, said scalability was critical. RPA only works if it’s available across the entire business, including the finance operation, he insisted.

Research has demonstrated the importance of employee
engagement to an organisation’s success, he added. ‘What drives employee engagement isn’t to do with how much they are paid, it isn’t to do with how much they are praised and so on – it’s all to do with the individual believing that the work they do is driving the business forward and achieving what they think, as individuals, is important. The more you can reduce the boring, repetitive work, the better the employee engagement.’

Mr Kirkwood said 80% of automation programmes were tactical – simply mimicking work that was already being done, though more efficiently. ‘For 2021, we need to focus on triaging and re-engineering the organisation as a whole,’ he said.

‘Ask for help,’ he added. ‘As you go through the process of building and scaling your operations, then ask us, the vendors and your support structures, and indeed NHS SBS.’

Removing unnecessary processes

NHS organisations must examine whether processes are necessary before automating them. Mr Sangani said: ‘There’s nothing more inefficient than to automate something you could have eliminated.’

Mr Snarr agreed. Referring to an NHS England project with Future-Focused Finance, NHS SBS and trust colleagues, he said: ‘One of the mantras we have set ourselves is whether the transaction is necessary. And if it’s not necessary, eliminate the transaction before you have a conversation about the automation.

‘We’ve spent a lot of time talking about non-contract activity, which is the invoice volume that drives low-value transactions in the NHS. We eliminated that at a stroke at the beginning of Covid and there hasn’t been any adverse impact. I think we will find a way through to make that a substantive change.’

Many believe that for technology to deliver change in the NHS, it has to be cutting edge, added Mr Snarr, but there are benefits to be gained from older tech – 50% of clinical commissioning groups do not use electronic invoicing, for example. ‘We have a lot of basic things to do that people might not consider technologically advanced.’

There was some feeling that the number of organisations in the NHS created a barrier to the use of automation – fewer organisations would reduce transactions and allow scaling up of the technology and standardisation.

Mr Moston asked if the finance function had to find a way to produce business cases in support of the new technologies, especially in clinical areas. ‘Once you get out of some of the smaller processes – and in relative terms, our corporate processes are some of the smaller processes – and take this into the forward-facing space, the introductory costs are huge. This may be partly answered by the need for scale, the need to standardise and potentially the number of organisations.’

NHSX’s Mr Haigh acknowledged it was sometimes difficult to show the benefits of deploying technologies up front, especially when the products or services are new.

‘There isn’t a tried and tested model to test against, and that’s something NHSX is looking at. How do we create a set of blueprints – digital exemplars that we can share around the system that people can build compelling business cases from, and understand the benefits that other providers of similar size and set-up have been able to achieve from deploying new technologies.’

NHSX is looking at outcomes from investment as a way of building the business cases, he added. ‘We know the outcome we want to achieve, and we know from experience it will cost in the region of x amount of money. So, how do we write a compelling business case that might not have all the information usually expected, but underpin that with a strong, agile delivery mechanism with the correct milestones and gateways in to access funding accordingly?’

Benefits realisation can take up to five years for a large-scale technological transformation deployment. NHSX is trying to build the blueprints to enable business cases to be more compelling, together with the roadmaps that allow benefits to be accessed more quickly, Mr Haigh added. The organisation is also providing matched funding through its provider digitisation programme to help implementation.

Annette Walker, director of finance at Bolton NHS Foundation Trust, said she has been cautious about artificial intelligence and RPA, but had recently been leading an internal programme looking into the technologies, the opportunities they presented, and what had been implemented at the trust already.

Members of her finance team, along with other departments in the trust, are looking to develop business cases to invest in technologies and there is a lot of enthusiasm to explore the potential benefits.

However, she pointed to implications that do need to be thought through – the social value of replacing people with robots, for example. ‘Is that the right thing to do for our employees? I struggle with that.’

Other delegates said new jobs were coming into the NHS. A whole new workforce was needed, with new careers and opportunities. Speakers said some roles such as RPA developer were difficult to fill, but the NHS was recruiting and training its own.

The point of automation was to deliver money back to frontline care, Mr Sutcliffe said, and even when headcount went down, as it has in the past at NHS SBS, this could be achieved while maintaining staff morale.

Mr Sangani said the biggest barrier to adoption of technologies such as RPA was passive resistance. ‘I think you need to think through your change management and communication, even when you’re doing a pilot, in terms of what it means for people’s jobs. People on the ground will be wondering what it means for them.

‘It’s these people who will help you make this a success or failure and, for me, the biggest barrier is winning hearts and minds.’

There were opportunities across finance – order to cash, procure to pay, order to report – that would generate efficiencies, reduce errors and improve outcomes, he added.

Finance had a key role in showing where the new technologies could help the organisation Mr Bradley said. ‘The biggest stumbling block to taking these things forward is culture and people’s willingness to change. Where automating a particular process can take a post out, we don’t just continually revert to moving the individual on to somewhere else. We actually start looking at how this can actually help us achieve the efficiency and productivity in the savings we require year-on- year.’

Lee Outhwaite, director of finance and contracting at Chesterfield Royal Hospital NHS Foundation Trust, and finance lead of Derbyshire integrated care system (ICS), said the finance function, together with other admin functions, would look ‘seismically different’ in the future, tilting away from transactional processing and towards roles such as business partnering and informatics.

He asked to what extent finance professionals were discussing technology to deliver improved, integrated and better care – and whether the finance community should even be discussing this. He believed it should – but were finance staff willing to have a separate discussion about back-office services and how processes could be delivered faster and more efficiently?

‘I’m a bit more interested in the conversation that leads us in the direction of technology adoption to lead to self-care and channel shift away from high-cost areas of treatments – and how we do that more proactively,’ said Mr Outhwaite.

‘I’m more interested in that than getting drawn into a conversation on how we consolidate our chart of accounts, or to what extent could we use robotic process automation for paying invoices.

“I’m not saying these are unimportant – they are entirely helpful things. But as finance people, I would hope we are a bit keener on the adjunctive technology to deliver taxpayer and patient value, and what that looks like.’

Integrated care systems

Speaking before the government white paper on NHS reform, delegates added that the advent of ICSs opened up opportunities to introduce automation. Mr Bradley said a lot depended on the duties given to ICSs. ‘Are they going to be old district health authorities with FHSAs built in? What are provider collaboratives going to be? Will they be separate entities? If we are going to be coterminous within a particular geography, we need to look at a standardisation approach. The end game will help some of the decision-making going forward.’

Ms Liddy warned that ICSs may not be the prompt for a fast implementation of standardisation. ‘We have talked for some time now about corporate services collaboration and standardisation across systems. There have been many collaboration vehicles that have talked for years about ledgers, chart of accounts and standardisation, but progress has been mixed and the conversation continues. We have to make a move now on RPA.’

Mr Outhwaite said the finance function may need disruptive innovation to make it more agile. ‘I think there’s something about the ICSs becoming a statutory organisation as a catalyst for change in the back office that I would grab with both hands. However, what is the new technology that will enable us to do different things around care integration and personally empowered care?

‘ICSs have two dimensions – are they the disruptive innovation that will give us a different way of running things? If I walk into my finance function, it does broadly similar things to the finance function I walked into at the start of my career in 1993. I’m not persuaded most finance functions have moved on that fundamentally. The other dimension is about how we do health and wellbeing, as a service, beyond the traditional NHS role around curing disease.’

A change in NHS finance culture could be needed to move automation into the mainstream. ‘As a finance function, we need to be more futurist in our thinking,’ Ms Liddy said. ‘If we are really serious about making the NHS balance its books, be sustainable and deliver high-quality care for the benefit of patients, the finance function has a role to play in thinking differently.

‘At Alder Hey innovation centre, we don’t think as much about annual budget cycles, we think five years out. We should be thinking now about what technologies are going to break through, delivering impact. We should be working collaboratively and co-creating with industry to help bring new technologies in that benefit hospitals and systems.

‘These disruptive innovations will probably save the NHS money and will probably deliver better patient care – for example, by reducing harm. If you can do that in a commercial way, there’s revenue back into the hospital in terms of licences and royalties to fund these new technologies. For the past 30 years, finance and innovation have probably been like oil and water. My challenge to the HFMA is: how do we make finance the futurist?’

Ms Walker said finance directors had been conditioned into thinking about value for money from investments, productivity gains and living within control totals. A change in mindset may be needed to start thinking over a five-year period, take more risks, and make the most of automation and new technologies.

‘It’s alien to us not to have every bit of a business case buttoned down before it’s signed off. But unless we get into that headspace, I don’t think we’re going to change anything. We’ve got to take quite a big risk – we saw it in Covid where we did it at scale and we got the benefits. I think there’s going to have to be permission for finance directors to be more risk-takers with some of the propositions we see. How we do that as a profession may well be a challenge.’

Mr Moston said the profession had to be prepared to fail. ‘The technology is such that we won’t get every deployment right. How we can afford the failure is a key part of this. Some of that comes back to the earlier points on scale and the number and size of organisations needed to be able to take a risk.’

Finance should act as a role model, Mr Bradley said. ‘We’ve got to embrace this and get on with it to show the benefits. We have to win hearts and minds. And we’ve got to think outside our silos – how can this help the system? At the end of the day, we’ve got to ask how this is benefiting the patient, to have that as a backstop for anything we do.’

There were concerns about automation’s potential effect on staff, and the need for the NHS finance function to be clear what it is automating and why, but in
general the roundtable delegates agreed that there were benefits in moving the focus to value-adding work in finance, operational and clinical areas. This would ultimately benefit patients.

Roundtable participants

• Phil Bradley, Northampton General Hospital NHS Trust
• Daniel Haigh, NHSX
• Guy Kirkwood, UiPath
• Claire Liddy, Alder Hey Children’s NHS Foundation Trust
• Ian Moston (chair), Salford Royal NHS Foundation Trust
• Lee Outhwaite, Chesterfield Royal Hospital NHS FT
• Rakesh Sangani, Proservartner
• Adrian Snarr, NHS England and NHS Improvement
• Stephen Sutcliffe, NHS Shared Business Services
• Annette Walker, Bolton NHS Foundation Trust
• Mathieu Webster, NHS Shared Business Services