Service-Line Management: an Overview

114052_Monitor_Conf_briefing_sheet.indd4052_Monitor_Conf_briefing_sheet.indd Sec1:1Sec1:1 221/4/091/4/09 111:18:371:18:37 Introduction What is service-line management?

Service-line management (SLM) identifi es Service lines are the units from which the specialist areas and manages them as distinct trust’s services are delivered, each with operational units. It enables NHS foundation their own focus on particular medical trusts to understand their performance conditions or procedures and their own and organise their services in a way which specialist clinicians. Each unit also has benefi ts patients and delivers effi ciencies for clearly identifi ed resources, including the trust. It also provides a structure within support services, staffi ng and fi nances. which clinicians can take the lead on service development, resulting in better patient care. Many trusts have already implemented service-line reporting (SLR), which provides the fi nancial and SLM was developed by Monitor for NHS foundation operational picture for each service. SLM takes trusts, although its principles apply equally to other the service line concept to a higher level, providing NHS settings. It draws on evidence and best practice an organisation structure and management from UK pilot sites and the experience of healthcare framework within which clinicians and managers providers worldwide who use similar principles and can plan service activities, set objectives and approaches within their healthcare systems. It is a targets, monitor their service’s fi nancial and dynamic and constantly evolving programme which operational activity and manage performance. will continue to explore the issues and challenges faced by trusts and develop best practice solutions. To date over 30 NHS foundation trusts, including some mental health trusts, have implemented SLM or are working towards it. Many are already experiencing the practical and strategic benefi ts it offers. This briefi ng provides an overview of the principles and techniques that underpin SLM, the benefi ts it ‘Service-line management gives offers, the implementation process and information clinicians the power to achieve about further reading and support. what they want to achieve.’ John Jacob, Clinical Director of Specialist Surgery, Royal Devon & Exeter NHS Foundation Trust

114052_Monitor_Conf_briefing_sheet.indd4052_Monitor_Conf_briefing_sheet.indd Sec1:2Sec1:2 221/4/091/4/09 111:18:371:18:37 The SLM framework

The SLM approach comprises four key Performance management elements which interlink to create an An effective performance management system integrated framework. However, it is not which creates transparency and accountability a ‘one-size-fi ts-all’ system, and the core around the delivery of an organisation’s strategic principles can be used to focus on a trust’s objectives is an essential component of SLM, specifi c objectives and implemented according linking each service’s objectives and targets to to its culture and local circumstances. team and individual performance. Organisation structure Each service uses its annual plan to identify Moving towards SLM requires trusts to identify clear performance indicators, targets and lines their service delivery units. They do this using a of accountability. These are tracked and monitored clear set of criteria to assess the extent to regularly through a cycle of performance review which different activities are self-contained, are meetings at each level of the trust. of comparable size and complexity and have By setting and measuring performance and putting comparable measures of success. incentives in place, performance management Each service line should be structured so that it fosters a culture of continuous improvement. It can operate as an autonomous business unit. makes clear what is expected of staff and provides An effective service line will have clear decision- the means to tackle poor performance if necessary. making and accountability lines. Clinicians will hold To implement performance management, a prominent leadership roles, integrating the ownership trust needs to ensure that effective data collection of clinical, operational and fi nancial performance. systems and human resources support are in place. The structure will balance cost effectiveness and practical necessity, with extra divisional layers only Information introduced if the benefi ts are proven. SLM relies on the production of timely, relevant Strategic and annual planning process information that provides the fi nancial and operational picture for each service line and enables analysis of SLM promotes a ‘bottom-up’ approach to planning, the relationship between activity and expenditure. taking the view that clinicians and managers are best placed to identify the opportunities and threats The fi rst step to achieving the necessary level in their specialist area, to consider future goals and of fi nancial detail, comparing income against set objectives to realise these goals. expenditure, is the move to service-line reporting. This gives a statement of profi tability at service-line A service line’s strategy should be informed by a level. Over time, trusts would be expected to be detailed analysis of its current position and guided able to provide fi nancial and other data at patient/ by a two to three-year vision, aligned with the trust’s consultant level. overall vision. The strategy is broken down into specifi c short term strategic objectives as part of By linking expenditure to individual healthcare the annual planning process. A robust action plan resource groups (HRG) and the resources that with clear responsibilities, milestones and monitoring support them, such as theatre costs and nursing is developed and the service’s targets are agreed time, patient level costing gives trusts insight into through negotiation with the executive. their activities. It also provides the link between operational and fi nancial effectiveness required to review and manage performance within each service.

114052_Monitor_Conf_briefing_sheet.indd4052_Monitor_Conf_briefing_sheet.indd Sec1:3Sec1:3 221/4/091/4/09 111:18:371:18:37 The beneﬁ ts of SLM

Implementation of SLM can deliver a range Seeing the big picture of benefi ts to trusts, clinicians, staff and for Trusts face challenging strategic decisions about patients and service users. the increasingly complex services they provide. By reporting and monitoring cost and profi tability as a Better patient care portfolio of service lines rather than at an aggregated By bringing clinicians to the forefront of service level for the whole trust, a trust’s board, managers development and promoting a culture of continuous and clinicians can make informed decisions about improvement, SLM has the potential to improve how to manage existing services, prioritise new services and result in a better experience for developments or plan investments. SLM helps patients. Trusts using SLM report benefi ts including to free trust boards from operational matters, reduced waiting times, shorter hospital stays and allowing them to focus on strategy. reduced incidences of hospital acquired infections.

Empowering clinicians to take the lead Unlike traditional NHS trust structures in which ‘We used to make decisions on the clinicians can feel disenfranchised from the basis of who shouted the loudest. management of their specialist area, SLM puts them at the heart of service-line operations. That will not happen any more; They can take greater charge of the development, now it must all be evidence-based.’ performance and quality of their services. They Chief executive of an SLR pilot trust can reshape service delivery to meet direct patient needs. A robust planning process Greater effi ciency and productivity The approach to planning required for SLM means The robust reporting systems that underpin SLM those who are best placed to identify a service’s show the link between operational and fi nancial opportunities and threats are able to input into information. This gives clinicians and managers a its objectives, which are aligned with the trust’s more profound understanding of their resources overarching aims and refl ected in team and and costs and helps them to identify areas where individual performance goals. savings can be made, for example by reducing average length of stay or maximising the use A stronger negotiating position of theatres. SLM data gives the true cost of treatment at a patient level, putting trusts in a stronger position SLM promotes the ownership of budgets at a when negotiating with commissioners. This brings service-line level. This means that if profi ts are direct benefi ts not only for trusts but also the whole made within a given service-line, a signifi cant health economy. This is of particular importance for percentage of such profi ts can remain within mental health trusts where SLR has helped build the unit and not be absorbed into the general proxy tariffs which are now being used in negotiations corporate account. This means that business unit with commissioners. leaders will have a real say in investment decisions.

‘We have known that non-elective average length of stay is an issue; we’ve just never been able to quantify it before.’ Member of SLM implementation team, Chelsea and Westminster Hospital NHS Foundation Trust

114052_Monitor_Conf_briefing_sheet.indd4052_Monitor_Conf_briefing_sheet.indd Sec1:4Sec1:4 221/4/091/4/09 111:18:371:18:37 Manageable structures Organising a trust into service lines enables ‘These targets are better – effective delegation to a unit of a size and scale we created them.’ that is manageable for developing strategy and Member of SLM implementation team, Chelsea driving improved performance. Each service and Westminster Hospital NHS Foundation Trust line can act as a ‘mini foundation trust’ with the autonomy for managing its own performance within an agreed set of goals and resources.

Decision making at the right level NHS structures don’t always enable staff to take ownership of their area of work and important decisions are often divorced from ‘shop-ﬂ oor’ intelligence. By devolving authority to service-line managers and clinicians, SLM allows decisions to be made by those with experience and knowledge of the service.

Engaging front line staff SLM’s combination of clear decision making and accountability lines, bottom-up planning and target setting and increased autonomy give staff greater ownership of their service. Incentives introduced through performance management can also result in a more motivated workforce. Trusts which have introduced SLM have reported evidence of improved morale, focus and commitment within staff groups at all levels.

114052_Monitor_Conf_briefing_sheet.indd4052_Monitor_Conf_briefing_sheet.indd Sec1:5Sec1:5 221/4/091/4/09 111:18:371:18:37 Putting SLM into practice

Implementation of SLM involves the In the long term: incremental introduction of a series of changes. The required shift in behaviours and • clinicians will take greater ownership and outcomes may also take time to fi lter through. recognise the potential to reinvest in their service in a sustainable way; However, initial benefi ts can be seen in a relatively short time span. Service-line fi nancial and data • front line staff will set their own targets for reporting can be implemented within three months, continuous improvement and service optimisation; with the identifi cation of key areas for SLM focus, • clinicians will routinely receive fi nancial and such as organisation structure or devolved decision operational metrics and use them to make rights, possible within a further three months. decisions; and A journey through the implementation process may • incentives can be clearly linked to quality and take the following course: productivity improvements. In the short term: Effective leadership and engagement • the trust will be able to produce basic information For implementation to be effective, SLM requires and expenditure information by service line; strong senior leadership at operational, fi nancial and clinical levels. Work with pilot studies has shown • fi nance departments and clinicians will begin to the importance of fully engaging stakeholders in the work together to continuously improve the quality change process. Communication of the benefi ts of of service-line data; and SLM, the development of a common language to • clinicians will gain an understanding of how defi ne the process and robust training and support income and cost relate to one another. are vital ingredients for a successful roll-out. In the medium term: Supporting SLM implementation Monitor can support trusts that wish to move • clinicians will understand how their actions affect towards SLM. This might include materials, the profi tability of the service; consultancy support, one to one coaching, • drivers of profi tability and quality will be linked and learning sets, peer group support or support understood by the people who can affect them; and for trust boards. • internal and external benchmarking is possible, highlighting areas for improvement.

114052_Monitor_Conf_briefing_sheet.indd4052_Monitor_Conf_briefing_sheet.indd Sec1:6Sec1:6 221/4/091/4/09 111:18:371:18:37 Further information

Monitor has produced a range of publications on service-line reporting and management, available at www.monitor-nhsft.gov.uk

For further information or advice about SLM contact: Robert Harris Policy Director 020 7340 2400 [email protected]

114052_Monitor_Conf_briefing_sheet.indd4052_Monitor_Conf_briefing_sheet.indd Sec1:7Sec1:7 221/4/091/4/09 111:18:371:18:37 4 Matthew Parker Street London SW1H 9NP

Telephone: 020 7340 2400 Email: [email protected] Website: www.monitor-nhsft.gov.uk

This publication can be made available in a number of other formats on request.

Application for reproduction of any material in this publication should be made in writing to [email protected] or to the address above.

Printed on 100% recycled paper

114052_Monitor_Conf_briefing_sheet.indd4052_Monitor_Conf_briefing_sheet.indd 2 221/4/091/4/09 111:18:371:18:37