Feature / Finance focus on quality

HFMA president Tony Whitfield outlines the principles against which NHS finance staff should test themselves in ensuring the service’s focus is on quality of patient care


Delivering safe, high-quality, sustainable services for patients are the goals for all NHS staff. They are the same for doctors, nurses and other health professionals, and for support staff, including those working in NHS finance. However, the failures at Mid Staffordshire NHS Foundation Trust that led to unacceptably low levels of care and the appalling suffering of many patients are evidence that the NHS sometimes falls short of these clear objectives.

The inquiry, led by Robert Francis QC, led to 290 recommendations on how the service should respond to Mid Staffordshire. Mr Francis flagged up concerns about standards of service, staffing, governance and finance. But a message throughout the report was that finance had at times taken priority over patient care.

Perhaps one of the central observations in the report was that the challenge of balancing quality of services and an acceptable financial position may have been unachievable under the plan the trust was pursuing.

While Mid Staffordshire is an extreme example, reviews of 14 hospitals, launched in the wake of the Francis report, have revealed other examples of poor practice. There are lessons that the whole service can learn in ensuring the focus remains at all times on the quality of services delivered to patients.

Chief finance officers (CFOs) and their teams have a major role in ensuring that finance issues do not become the centre of attention and are considered alongside quality. All decisions must be made with careful consideration of the effect on both finance and quality of care. This will be of particular importance as the NHS looks to improve productivity and find new ways of working to meet significant financial pressures from within broadly flat real terms growth.

The HFMA believes the highest quality care is often the most cost-effective. Focusing on quality and safety – for example, supporting patients in the community so they avoid acute admissions, ensuring patients get the right outcomes first time and eliminating patient harm – can improve cost-effectiveness. But the impact of any decisions, developments or efficiency programmes on the quality of services must always be considered. At Salford Royal, the safe reduction of costs is a key part of our quality improvement strategy.

Getting best value for patients – measured in outcomes and cost – will demand that finance leaders know three things:

• What value for money their organisations’ services offer relative to others
• Which of their services could deliver better value for money
• How successful they are in making improvements.

However, at times, finance staff may need to be braver and bolder than in the past. They may have to make the case for major transformation and reconfiguration to safeguard high-quality care. Convincing stakeholders – from boards and regulators to politicians and the public – will require skill and hard work. Putting patients’ interests first may lead to reconfiguration plans that are in conflict with the aspirations of individual organisations.

Finance staff must be ready to back these changes and provide robust data and analysis to inform decision-making.

Visible on the front line

CFOs should be visible on the front line. Many already are, but making time to talk to staff and patients and getting a first-hand view of services is vital to help them understand the challenges for staff and services. They need to be ready to speak up if the cost of providing the right quality of services is no longer affordable with the current approach or service configuration. Financial performance can only be judged as successful if it delivers both on service quality and the bottom line.

At times, CFOs may need to use their collective voice – through the HFMA or other channels – to seek amendments to health policies and practices that no longer work. The HFMA has recently reviewed the roles and responsibilities of CFOs. The role of the NHS chief finance officer sets out the skills and values needed in the most senior finance roles and should also help inform chairs, governing body members and other stakeholders about the role and what they should expect from their CFO.

But all finance staff, not just CFOs, have a duty to understand what is driving financial decisions and the effect they will have on quality. My theme for my year as HFMA president is ‘knowing the business’ and this means finance staff spending time with clinicians to understand the impact of financial decisions on staff, buildings and equipment, and the compassionate, moral and logical decisions that drive clinical colleagues.

Where changes are needed – whether to transform services or to implement cost improvement programmes – there needs to be openness and transparency about the changes, why they are needed, and the benefits that will be delivered. There also needs to be reliable monitoring and reporting of quality indicators, both during and after changes.

Decision-making should be clinically led and supported by indisputable evidence. Finance’s role is as a support function, albeit important. But the finance team needs to be involved in decision-making. It can provide expertise to help create the environment to achieve the best outcomes for patients. Finance staff must provide clear and understandable reports, based on accurate information about the costs of services and options. They will do this best if they are aware of what is going on in the service areas being considered.

The HFMA strongly supports the seven principles of public life – or Nolan principles. Established by the Committee on Standards in Public Life nearly 20 years ago, the standards set out the guiding principles for finance teams. Failure to follow them could lead to similar failures to those at Mid-Staffordshire.

The HFMA has also identified a supporting set of actions/principles against which finance staff should check themselves to ensure they get the right balance of quality and finance: 

• All finance staff should remind themselves of the contents of the codes of conduct of their professional bodies, employing organisations and the NHS constitution, and adhere to them.
• All governing board members are equally responsible for quality, patient safety and financial performance of the organisation.
• All NHS finance staff should understand how their role supports the achievement of organisational objectives and the delivery of high-quality patient care.
• 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.
• A focus on knowing the business and understanding the finances will lead to better services for patients.
• Finance staff have a duty to promote the best use of resources and value for money.

The association has described what each of these points might mean in detail. For example, on data the association believes finance staff should make better use of real-time reporting of quality indicators and pair this with up-to-date cost data where possible. And in terms of promoting best use of resources, finance staff should ensure financial plans, business cases and decisions are supported by an audit trail of evidence and sound backing. This should demonstrate the underlying rationale to stakeholders and the anticipated impact on quality and patient safety.

Most finance staff joined the NHS because of a commitment to public service and to make a difference to patients’ lives. The failures at Mid Staffordshire provide all NHS staff with an opportunity to reinforce this.

The HFMA believes finance staff should test themselves against the identified actions. By making small changes to their ways of working and long-established cultures, it believes finance staff can have a positive impact on getting the quality and finance balance right.

Tony Whitfield is HFMA president and executive director of finance/deputy chief executive at Salford Royal NHS FoundationTrust