Working Together on Better Decisions via the Faculty of Medical Leadership and Management

The launch of the Academy of Medical Royal Colleges’ initiative “Choosing Wisely” last week in the BMJ highlighted the importance of encouraging doctors and patients to have conversations about the value of treatments, and avoiding the over-medicalisation of illness.

It adds to the body of work [1] being done by clinicians and in the wider sector targeting value as a way forward for the NHS. There appears to be a growing awareness and agreement that we need a reinvigorated collective focus on doing the best for patients and the public with the money we have. And in my mind it would not be unreasonable for value to be the explicit organising principle for our times, in the same way that Ara Darzi’s work on “High Quality Care for All” renewed the priority given to quality in the last decade. For what is the Five Year Forward View if it is not a means to achieving better value, underpinning a sustainable patient-centred NHS?

Colleagues in NHS finance are engaging more closely with value as part of these efforts. In an initiative called “Future-Focused Finance” (FFF) the finance community has devised a five year work programme to build capability in the 15000-strong profession.

The FFF programme is finance-oriented, but a critical component of the programme is to ensure we get out of our professional silos and work collaboratively on the value challenge. In this regard, there is a specific work stream, “close partnering”, led by Sanjay Agrawal, a Consultant in Respiratory and Intensive Care Medicine at University Hospitals, Leicester, ensuring that the work speaks to clinicians too. Amongst other things, Sanjay and his team are advising how finance teams can support the work clinicians do, to act as helpful enablers and business partners progressing clinically-led value decisions.

I am attached to the FFF’s “best possible value” team, exploring how we can approach the decisions we make in the NHS so that they are defined more explicitly in terms of patient benefits, rather than merely bringing in the financial bottom line (though clearly this remains part of the equation). In essence we are asking the question “how can we help the sector get round the table together, with a focus on value as one of the critical asks of our decision-making?”

We chose to look at decision-making, as the evidence we identified over the past year showed that better quality decisions were drivers of better value, on both finance and human factors – for example organisations with high decision effectiveness have higher levels of staff satisfaction (scoring higher on the question “how likely would you be to recommend your organisation as a place to work”. On the finance side, organisations with higher decision effectiveness achieved almost double the return on capital employed – which in an NHS context frees up more resources for patient care (Source: Bain).

At an event the FFF team for finance staff held in Birmingham earlier in the year, we asked attendees what decisions or aspects of decision-making they struggled with most. The responses will be familiar to most and included: how to invest properly in prevention; how to decide when to tender services; how to get the right data; finding non-recurrent funding for recurrent ideas (i.e. investing to save/improve); how to identify shared objectives; how to get the right people involved in the decision (but also the problem of including people for the sake of it); and how to remain focused on delivery.

We want to provide tools and resources that help answer these points, and have identified what we think is a suitable framework for decision-making which unpacks the process, providing a usable and effective means of thinking about value in your day to day work.

The framework helps people come together around a decision so that first, they are beginning to think about answering questions from the perspective of delivering value. Second, it clarifies “What, Who, How and When” – what the decision is from a value perspective; who is engaged to ensure focus on system wide value; how to achieve an integrated value approach and when to carry out the agreed decision to maximise value. Third, it helps stakeholders have clarity about their respective roles in a decision – ultimately who decides?, but also, who recommends, agrees, performs and provides input?

We are piloting the framework in two demonstration sites in May and June. Mid-Cheshire NHS FT is going to be using the framework to test the value of investing in elective care to protect and improve services for patients, in the context of the rise experienced across the sector in non-elective activity; Liverpool CCG is exploring the value in investing in a preventive and early-diagnosis programme for respiratory illness. We hope that this piloting will help deliver better outcomes in these two sites, but also a better product for a wider launch later in the year.

Our hope is that the framework currently in testing will help at least in part with many of these issues, at all levels of the service, be it at a team, directorate, organisation or local health system level. Taken together with the case studies, toolkits and training materials we are presently compiling we want to provide a range of resources that will help us all with putting value into the decisions we are asked to make every day.


Mark Redhead is a member of the FFF Best Possible Value delivery team.

This article oringally appeared on the Faculty of Medical Leadership and Management on 20 May 2015.


[1] For example the 2014 Academy work on waste; joint Academy and NHS Confederation report on value; and FMLM seminars on value.