Decisions of Value via NHS Providers

Data from The King’s Fund in April 2015 gave us the latest snapshot of opinion from finance professionals on their views of NHS sustainability. It showed increased levels of concern about the forward picture for local health economies, but also highlighted the different perspectives that commissioners and providers appear to have, for example, on successfully managing demand as well as their own organisational health in the next year. These differences in perception struck home because of work we are currently doing on best possible value as part of the Future Focused Finance initiative (a five year programme building capability in the finance profession).

To do the best we can for patients, i.e. to build sustainability and value into how we organise and deliver services in future, we need to see these commissioner and provider perceptions become more aligned. There needs to be a shared understanding of the challenges faced (based on shared evidence); which decisions can deliver best possible value; and how agreed outcomes will be measured and incentivised.

First of course, we need to know what we mean by value – value for whom, and in respect of what? A discussion on defining value featured in a roundtable we held at the end of March with system leaders, financial, clinical and local government colleagues. We felt that the two most significant perspectives defining value in the health context were those of the individual patient, and the population at large (both as taxpayers and potential users). Value decisions will need to reconcile the inherent tensions between these interests, though some managing of this boundary will be inevitable – and perhaps we ask clinicians to manage the boundary the most. It is crucial that the clinical, finance and management professions work together and support each other on value, with finance professionals acting as business enablers, providing the data necessary to make high value clinically-led decisions.

An important consideration in achieving value is identifying a common approach to the currency we are using to measure both the problem and its solution – what is the real problem, how big is the problem, and what will success look like? This came out of the roundtable too. A coherent common currency will support evidence based assessments of the change potential around particular decisions. Agreeing the necessary definitions and measures is likely to be complex and imprecise at first – the development of social value reporting has demonstrated that it is not an easy task, albeit ultimately worthwhile. Incidentally, if you are interested in value, and demonstrating its impact, the International Integrated Reporting Council (IIRC) is doing some really interesting work on social value and integrated reporting, and are looking for pioneer sites at the moment.

But in any case, it is important in the early stages of making best possible value decisions at least that people come together with the intent and openness to focus on value rather than get held back by disagreement on the specific component parts of the numerator and denominator in a value equation: it is a shift in mind-set.

It is really important too that the sector is not just told to make decisions of value, but is supported in doing so. Over the last year the Future Focused Finance best possible value team has been identifying what would be most useful to the sector by way of resources, tools and support, to help people integrate value into their way of working. Working with the sector we have been co-designing a decision-making framework that we hope will be a useful means of first, focusing discussions on value, which is an important step forward in itself. Second it will support bringing together the right people who are parties to a particular decision, identifying the respective roles of each and when / how these will best input to the decision – so that value is derived from the process as well as the finally agreed intended outcome.

Before we launch it formally later in the year, we are to go through the framework with a number of demonstrator sites in May, to test, modify and learn from their experience of using it, to be written up as case studies or other resources that will help us address the challenges that we have in common. Until the learning from these sites is available we are compiling a number of case studies around decisions of value, and applying the framework retrospectively! The first of these is the example of Northumbria Healthcare NHS Foundation Trust and their decision to buy out their PFI commitment. This is now available on the Future Focused Finance website. We are also compiling a resource around tools that assist decision-making, both on the financials, but also in terms of wider data considerations, for example on safety and effectiveness.

Approaching the challenges of today in terms of value can look daunting as it is a different way of approaching decision-making; and there is an element of asking people now to do the right thing in terms of value, which could sometimes be ahead of the systems and processes that currently gauge our organisational performance. But the opportunity is significant and it is undoubtedly going to be the way that we will be asked to deliver services in the months and years ahead. Our hope is that the tools and resources we are working on now will help the sector to meet both this challenge and opportunity.


Caroline Clarke and Mark Redhead, Future Focused Finance (FFF)

Caroline Clarke is senior responsible officer for the FFF Best Possible Value work stream, and Mark Redhead is a member of the delivery team. 

This was orignally blogged at NHS Providers