Service Line Management, to operate effectively, needs a change in management culture/philosophy from Board to Ward that releases the creative energy of front line staff to find solutions and implement change. However just implementing the “tools” of service line management on their own will not deliver the full benefits. The challenge facing the NHS requires a commitment to change the way in which many NHS organisations are managed.
After years of cost reductions, often focused on salami slicing budgets and tackling non clinical areas it has been clear to most Trusts for some time that a different approach is required. The NHS has to challenge clinical areas on performance, delivery, and cost effectiveness and to develop those elusive outcome measures and tackle unacceptable variations in clinical practice.
One of the important lessons of Mid Staffordshire Hospital is that cost improvements are now risk assessed for the impact on patient safety and experience and signed off by the Medical and Nursing Director. The pressure on hospital budgets has never been greater with increasing emergency activity, an aging population, increasing technology and drug developments all whilst the tariff is reducing in real terms. Never before has it been so important for the NHS to work together as a team across all professions and align clinical and managerial objectives. This requires an acceptance that services have to be clinically, operationally and financially viable and must have patient safety and quality integral to the organisation’s culture.
Trusts have to be better at providing strong leadership to create an environment where devolved management can deliver better and quicker decisions. As the pressure continues to deliver targets the desire to centralise control and decision making becomes, in many cases, impossible to resist. Perversely it is just the time when the NHS needs to devolve management. The benefits of implementing Service Line Management are both achievable in the short and long term. The most important benefit is improvements in quality of care for patients but brings with it improvements in productivity and real recurrent financial savings. The comprehensive list of benefits is
- Improvements for patients in better access.
- Cultural change – seeing the whole of the challenge, clinically, operationally and financially.
- Improved team working involving doctors, nurses and managers acting together.
- Faster more responsive decision making that works for the Service Line without compromising the Trust’s position.
- Improvements in productivity and profitability.
- Strategic view of the service being taken and its place in the Trust’s portfolio of services.
- Acceptance that Trust need to tackle non profitable areas of activity.
- Implementing change in clinical areas that would have previously been a challenge.
- Ownership of information and the recognition the solution to more accurate information is often with the service line.
- Peer pressure to improve performance.
The traditional top down managerial style is being challenged in many Trusts. Increasingly devolved management is being introduced to give clinicians at the front line more managerial responsibility. However it is not a one way street. With responsibility there has to be transparency and accountability.
Information has been the achilles heel of the NHS often being inaccurate, incomplete and untimely. This despite decades of initiatives to improve information processes. Information on costs/activity is part of the Service Line tool box, however it is the change in culture, attitude, approach that delivers the most of the long term sustainable benefit.
That is not to say that accurate, timely and relevant information is not important. Just that on its own it is not the solution to the challenge. And when we have got the information, we know not only what is losing money, but who is losing us money. Then the difficult and challenging debate begins. The important key issue is to look for solutions. One simple, but very effective, high level information that can be produced is a breakeven graph for service lines. How many more operations, outpatients etc. would the
Service Line Team have to do in a year to move from loss to profit? Often the answer is not many. Broken down over a year it often amounts to no more than one extra patient per outpatient clinic per consultant and a similar position for theatres. Even with this high level of information the conversation can begin. Not just with managers and finance, but between the Consultants and Clinicians.
Experience has shown that when provided with the relevant information change can happen and happen quickly. Theatre lists change, outpatient booking rules change. No long consultation period. The consultants have understood the problem, identified the solution and recognised the need for change.
But what this example demonstrates is that it is not about the numbers, but about the philosophy and culture of the organisation that has the confidence that when provided with the right information consultants can and will identify the same and often better solutions than have been identified previously.
By adopting a management of change approach to implementing service line management the culture is changing in the NHS. There is now a wide spread acceptance that loss making services cannot continue. This will not lead to wholesale closures of non-profit services. It will start the search for what is best practice, examining the clinical pathway and using PLICS to understand clinical variation between consultants to identify where clinical and financial viability may be achieved. Where long term financial viability cannot be achieved it is highly probable that clinical viability is also unachievable. This will lead to some of the more difficult areas to influence, manage and change in the NHS being challenged, but from within. To achieve viability this will potentially lead to the creation of cross provider alliances and networks so that services cannot only be provided safety but cost effectively.
There has to be consequences at work as there is in life and the performance management framework is a key part of Service Line Management and how the Trust manages the risk of devolving management responsibility. Holding clinicians to account requires agreed rules up front and is the mechanism by which we make devolved management a reality and not an abdication of responsibility by senior managers and the Trust Board. A clear, firm, fair and transparent effective performance management system is an essential part of devolved management.
Top 10 Tips for implementing Service Line Management
- Have a plan - this is major organisational and cultural change from ward to Board.
- Gain commitment across the whole organisation – clinicians are enthusiastic.
- Tool up – this is not a part time add on to somebody’s job
- Sort out the rewards and consequences strategy.
- Work out the decision rights – what responsibilities will the service lines have.
- Think through the performance management strategy and integrate changes into your framework
- Develop and resource the training/OD plan
- Don’t wait for the information to be perfect but develop an improvement plan.
- Identify the criteria for becoming a Service Line and what is the assessment process.
- Be realistic about the timescale for achieving benefits – this is a long term solution
It will always be possible to demonstrate that centralisation costs less, in the short term. However the long term deterioration in the quality of decisions reduces efficiency and effectiveness. Centralisation disempowers people. Command and control may deliver short term wins but ultimately is not sustainable to deliver improved quality of services at ever lower costs. What SLM has the potential to deliver is the changes in behaviours, at all levels in the organisation, which focus on service line delivery and empowering front line clinical staff. Instilling a new philosophy and management culture in the organisation is essential as getting the “tools” of SLM in place. People have to own the problem. If everything is decided elsewhere it is somebody else’s responsibility. Service Line Management gives us the opportunity to succeed by empowering front line clinical staff.
It may be that you have already implemented Service Line Management or Service Line Reporting and may not have realised all the benefits. You may not have even started on the journey. If you would like to know more without making a commitment or would like to share your experience please contact me at IMD.
Chris Calkin
Director of SLM Programme
Tel 01332 856321
IMD Service Line Management adapted from article published in HSJ 7th January 2012.
What the King’s Fund said about Service Line Management*
- To manage services well and achieve improvements in quality and productivity, hospital trusts need to gather and analyse detailed information about the performance of services and to support clinical leaders of those services to manage their services and lead improvement. Service-line reporting (SLR) and service-line management (SLM) together offer an approach to achieving this.
- We conducted interviews with staff in seven trusts using or developing SLR and SLM, and found considerable variation both in how successfully they were being applied and in the impact they could have.
- Realising the benefits of SLM requires skilful implementation within trusts. The role of the board is critical to drive the roll out and progression of SLM, enable real devolution of decision-making to take place, provide strategic leadership and promote co-ordination across services. Clinical engagement is essential and can be facilitated by working with and supporting clinicians to use SLR data, ensuring that expectations are realistic and recognising and responding to the different motivations and interests that different staff will have. Effective use of data involves working with clinicians to identify useful data sources, tailoring presentation to the audience and understanding that improving data quality will be an ongoing process. Time, expertise and continuous training are needed to support implementation and minimise the effect of staffing changes.
- Despite its potential, there are a number of tensions and challenges inherent to the SLM approach, for both policy-makers and local leaders. Clinical interdependencies and overall population needs mean that cross-subsidisation of unprofitable service lines is often inevitable. Trust boards need to guard against allowing current financial pressures to prompt them to reverse progress made towards devolving decision-making to clinical teams.
- SLM is designed for use within hospitals, and is not able to support the wider opportunities for quality and productivity improvements derived from looking at clinical pathways across care settings. SLR and ultimately even SLM approaches could, however, be adapted over time to support more integrated care.
**The King’s Fund Service-Line Management Can it improve quality and efficiency? January 2012. Authors Catherine Foot, Lara Sonola, Jo Maybin and Chris Naylor Follow the link for the full paper http://www.kingsfund.org.uk/publications/slm_paper.html