Giving clinicians managerial responsibility can improve quality, think tank says

Giving hospital consultants responsibility for managing their own services can improve quality and efficiency and can also identify how well the services perform and what they cost, the healthcare think tank the King’s Fund concludes in a new report.

But to make it possible, boards and senior executives have to cede control and power to clinical teams.

Service line management, a concept first introduced into healthcare in the United States and championed by Monitor, England’s regulator of foundation trusts, devolves decision making in hospitals to distinct operational units centred on a particular service. The system aims to make better use of information and increase clinicians’ engagement in managing services. The King’s Fund report includes interviews with staff at seven NHS trusts that have used service line management to a greater or lesser degree.

The report finds that the effect overall has been limited, with most of the benefits being found in trusts that had used the concept longest. Benefits included the identification of outliers (consultants whose practice imposed undue costs or who treated patients differently without corresponding benefit) and of variation in length of stay between different groups of patients. Elimination of such outliers saved 10% of costs in the trust involved.

But some clinical staff feared that service line management was simply another way to drive down costs. Consultants were suspicious of the data generated and resented being held to account without a corresponding increase in autonomy; and turning clinicians into managers may reduce their clinical output. Issues such as these emphasise the need to get implementation of service line management right, the report says.

The hospital board and senior managers need to be behind the change, the report concludes, which includes ceding power for some decisions and budgets. “Control freak” managers who cannot resist jumping in to sort out service problems are the enemy of service line management. Providing information that clinicians trust is also important, and training clinicians to manage without losing influence and credibility among colleagues is a tricky balance to strike. Expectations must be realistic.

Even a better understanding of what each service is costing can raise conflicts, as some services are always cross subsidised by others, the interviewers found. This means that services that cannot generate surplus income feel threatened by the greater transparency of service line management. The fact that some services can generate surpluses but cannot then reinvest the surpluses because they are needed to subsidise other unprofitable services “doesn’t make sense to clinicians at all,” one service director said.

The financial pressures that the NHS is under had led in some cases to central control being reimposed, reversing the service line management process.

As one medical director put it: “SLM [service line management] has worked beautifully in a growing health economy, but it’s a bit different under pressure . . . I’m fighting tooth and nail to keep the delegated authority . . . and not to lose all clinical buy in. There’s a real tendency under crisis in the NHS to go back to command and control.”

Catherine Foot, a senior fellow at the King’s Fund and the report’s lead author, said, “The majority of those interviewed for the research recognise the value of SLM to the management of the trust. However, a balance needs to be struck between realising the benefits from implementing these approaches and understanding they are only part of a wider solution to improve quality and efficiency. Trusts must be careful not to oversimplify or oversell these approaches and must continue to look beyond their walls towards whole system efficiency.

“It is clear that hospitals need to resist any temptation to row back from progress made in service line management. Quite the contrary, increasing pressure for efficiency savings should drive hospital boards forward, as SLM offers a means by which to gain a clear picture of a hospital’s activity and performance. This in turn allows informed and effective choices and decisions to be made.”