To make funding stretch far enough to meet demand in the next four years, the NHS must improve productivity to levels never seen before. The only way to meet this challenge is through new ways of working, write Sue Bailey and Johnny Marshall

As now confirmed, £8bn of additional funding over the next four years means the NHS having to make £22bn savings to fill the full funding gap. Yet, the problem with focusing on savings is too much time being spent thinking about where to make cuts, which perpetuates inefficiency, rather than delivering value in a way that gets the most out of the resources we already have.

‘Unfortunately, there are big barriers to supporting clinicians to be more involved’

Instead of considering ways to take 3 per cent out of the NHS’s cost base, we might instead look at finding ways to make 97 per cent of resources go even further. With this in mind, the focus switches from finance departments to clinicians on the front line. After all, clinicians are the people who spend most of the NHS’s resources, yet little attention is given to how they can make the NHS more sustainable.

The Academy of Medical Royal Colleges and the NHS Confederation have been working for a while on understanding the relationship between clinicians and NHS finances. In our Decisions of Value project, we highlighted the importance of supporting a stronger rapport between clinicians and financial colleagues to improve non-clinical decisions with an impact on both resources and quality of care. Furthermore, our recent briefing, written by Prof Sir Muir Gray, describes the responsibility on clinicians to lead the NHS in delivering better value.

Clinical engagement in NHS finances is crucial, then, to meeting the challenge over the next four years. Doctors and nurses are trained to understand risk and to use their judgement to determine the most effective option to improve a patient’s condition. These skills can certainly be harnessed to improve the financial condition in the NHS, alongside other aptitudes like interpreting and analysing data. For clinicians to deliver high quality, value based care, they must have a clear understanding of the system in which they operate and the worth of treatments and interventions.

Unfortunately, there are big barriers to supporting clinicians to be more involved. The most obvious is a lack of time for clinicians to balance considering finances with their clinical duties. Our central message to national bodies and policymakers has consistently been to put more faith in cultural shifts that improve relationships and behaviours, rather than relying on rules and structures to make the difference.

Knowledge gap

Overcoming a second barrier, which is the fundamental knowledge gap in clinical engagement with NHS finances, could help this shift in culture. Many clinicians find the way that money flows around the system bewildering and our survey published this week demonstrates the extent to which they are unaware of key aspects of it, such as NHS prices and costs.

‘Most clinicians think the costs of delivering NHS services are not adequately covered by NHS price’

It shows that most clinicians (62 per cent) do not know the prices paid to their organisation or practice for the services they deliver, while a similar amount (60 per cent) are unaware of the costs to their organisation or practice in delivering them. Our survey may have a sample bias that means the picture is even starker, when considering those less likely to complete a survey on finances, although it’s interesting to consider how these statistics change when compared with experience.

You’d expect people with more NHS experience to have more awareness of NHS prices and costs, yet only clinicians of 25 or more years’ experience were more likely to know NHS costs than to not know them. From this, we can make the inference that most clinicians will need more than 25 years to have an even chance of understanding basic aspects of NHS finances.

Furthermore, our survey shows most clinicians think the costs of delivering NHS services are not adequately covered by NHS prices. This verifies a common perception from the clinical community. Yet, the results from our sample describe how clinicians who were aware of NHS prices and costs were more likely to think prices adequately covered costs. This is an interesting statistic because it suggests greater clinical engagement can change perspectives on finance. Whether these perceptions are correct or not depends on the issue, yet it’s important to recognise the real impact clinical engagement can have.

Effect on behaviour

Finally, our survey shows a mixed picture from clinicians about whether they think financial mechanisms impact on their clinical behaviour. Clearly, there’s a debate to be had about whether they should have an impact, yet many mechanisms have been introduced under the assumption of an impact. It’s interesting to know therefore that there are as many clinicians that think it does have an impact than think it doesn’t.

The next stage to our work is to better understand how to support clinicians to be more engaged, by making it easier for them to access resources that close the current knowledge gap. This includes maximising the support already available and working to produce additional tools that could help.

Bringing clinicians more closely to the financial challenge facing the NHS is crucial to improving our chances of meeting it. While it will not be easy for clinicians to be involved, it can be made easier if they are supported to deliver better value, resulting in a more sustainable NHS which provides value based care.

Prof Dame Sue Bailey is chair of the Academy of Medical Royal Colleges and Dr Johnny Marshall is director of policy at NHS Confederation