Implementing service line management means recognising and promoting clinical leadership, says Monitor policy adviser Kate Hall.
While most people agree that trust performance has advanced over recent years, most also agree there is room for improvement. If now is not the time for established and aspiring foundation trusts to focus on organising in a way which ensures better managed services, then when is?
Hospitals operating with a service line management structure are more productive, have stronger clinical leadership, engage frontline staff in service performance and make better informed decisions. As a result they are increasingly efficient and delivering improved quality of care.
Service line management involves identifying costs associated with a particular type of treatment (see box, below). Monitor has been working on it with trusts since 2006 and although many say that they are operating a structure and benefiting from this approach, it seems few are realising its full potential.
Many use the terms service line reporting and service line management interchangeably, but they are not the same thing.
The reporting element, while undoubtedly important, is an enabler for service line management. Putting robust reporting mechanisms in place can be difficult and costly, and reorganising into a service line structure, with consultants leading business units, can be complex. Yet the toughest challenge is facilitating and driving the required change in mindset and culture.
There is variation in implementation across the NHS, both in foundation trusts and in non-foundation trusts.
Most organisations adopt an incremental approach to implementation. Some start with patient level costing or splitting information by service lines, others move to a new organisational structure to facilitate the service line approach, and for some the priority is strengthening clinical leadership in the organisation as this takes longest to achieve.
Individually, these can all have a positive impact, but you won’t maximise the benefits unless you combine all three.
What is service line management?
Service line management identifies specialist clinical areas and manages them as distinct operational units. It enables trusts to understand their performance and organise their services in a way which benefits patients and delivers efficiencies for the trust. It also provides a structure in which clinicians can lead on service development, resulting in better patient care. It was developed by Monitor for foundation trusts, but its principles apply to other settings.
Effective service line management requires an entirely different approach from how hospitals have previously been managed; greater transparency of costs, good service level reports, and real autonomy for clinicians with clear incentives (and not just lip service) will help improve clinical decision making, thus increasing quality and value.
If service lines are run in an autonomous way an enormous amount can be achieved. The key is to truly empower service line leaders so they can make decisions that improve all aspects of performance without unnecessary delay and without having to go through what can often be a very bureaucratic process.
As well as enabling clinicians to engage and participate, there is a separate challenge for executive teams. For some executives and senior managers it will be the first time in a number of years, if not their entire senior career, that there is no longer the expectation or need to micromanage. This is an important factor to consider for executive teams and boards; we cannot talk about empowering consultants and teams to be autonomous but not be willing to relinquish control. This can be an uncomfortable feeling for some executives, but it is essential this culture change takes place if service line management is going to work for your organisation.
Questions to ask
Effective implementation requires buy-in from clinicians, managers, and the executive team. This is not necessarily easy or straightforward, particularly in a time of financial challenge, but to support this process there are a number of questions trusts should be asking themselves:
- Is there a strategy in place for service line management that fits into the overall trust strategy?
- Does the board understand what this means and has it approved the scheme of delegation and devolved autonomy of the work?
- Are service line leaders truly accountable for performance?
- Does the executive team understand the change in their role and responsibilities as a result and are they ready to devolve decision making and autonomy to the service line leads?
- Has there been a significant shift in the organisation culture?
- Is value for money improving; are services seeing increased efficiency and improved quality?
Implementation of service line management will not be simple, but the opportunities are significant and in a period where there is a need to deliver quality and value, where medical leadership is crucial in the delivery and business of healthcare going forwards, it seems sensible to adopt a method that we know works.
Service line success stories
University Hospital of North Staffordshire director of finance and deputy chief executive Chris Calkin says: “Service line management will drive quality up and costs down as clinicians see opportunities that for managers are not immediately obvious. A change that would have taken months to achieve, if achieved at all, has been delivered in days. It brings together responsibility and accountability for service line success.”
Northumbria Healthcare Foundation Trust medical director David Evans says: “It has allowed our business unit structure to develop by each receiving a clear and timely indication of progress and pressures. It has allowed clinical teams to better understand the consequences of their actions and also to recognise revenue stream changes which occur as a direct result.”
He adds: “We have examples where this alone has changed clinical behaviour. The naturally competitive nature of many of the senior clinical managers has also been usefully harnessed by this open demonstration of performance. It has allowed a level of financial control which we had never been able to achieve in the past. It has given clinicians a much greater understanding of the way in which our service needs to run as a business.”