interviews

Empowering clinical staff to take control of budgets

Barbara Baker, director of Derby Hospital, discusses the ‘coaching culture’ she has implemented at the organisation, the additional financial power given to clinical staff, and how chartered director training has helped her career.

Barbara Baker was appointed hospital director at Derby Hospital, part of the Nuffield Group, four years ago. She originally trained as a nurse and worked as a Lieutenant in the QA (Queen Alexandra’s Royal Army Nursing Corps, the nursing branch of the British Army) and as a nurse in South Africa. Later in her career, back in the UK, she founded a childcare business at NHS hospitals and became a non-executive director at the East Midlands ambulance service before joining Derby Hospital.

She undertook professional director training with the Institute of Directors (IoD) and has since become one of just 1,000 board members to achieve the status of Chartered Director. Her motivation, she says, comes from having been diagnosed with cancer as a young nurse and given 12 months to live, which has encouraged her to make the most of life.

The IoD has praised the “entrepreneurial approach” she has brought to Derby, having empowered staff to manage their own budgets, and adopting a coaching culture to manage performance.

Service Line Reporting

After seeing Service Line Reporting introduced at East Midlands ambulance service when she was a non-exec director there, she decided to introduce the concept to Derby Hospital.

She explained: “We have here around 12 different departments, some clinical, some nonclinical. A lot of these staff are very clinically stanced in how they approach their work, and were not aware of what they were spending in their department, what their budget was.”

It has affected staff across a number of hospital units and disciplines – radiology managers, theatre managers, ward managers, pharmacists and so on. Baker said: “People would make demands for funds to be spent, but without taking accountability or responsibility for the spending, she suggested. So she set up a system of dashboards and key performance indicators for each department. “On a monthly basis, as a senior management team, we sit down with each department head.

“They’re given their budget for their department and if they ask for anything we ask ‘is it in your budget?’, ‘can you spend that?’, ‘how is this going to work?’ It’s got them to really focus on the financial aspects of running their own department.

“It’s taken about 18 months, but they are now looking at their own P&Ls [profit and loss statements] and asking us questions like ‘what was that spent on, because I don’t think that was me’ and they’ve really taken it on board, which has been brilliant.”

Taking responsibility for financial decisions

There are individual department budgets, but they are all part of the wider hospital budget, and a minor capital process also exists where the business case can be made. But individual clinical department heads can now make those bids themselves, which will be reviewed by the board.

Where the business case isn’t strong, departmental heads take responsibility for that themselves, rather than getting upset about it.

Baker explained: “They not only take responsibility for what they want and what they need, they are also a lot more realistic about the fact that they’re accountable, and the need to ask ‘is it making money’, ‘is it improving patient experience’ – what is it doing, where’s the benefit, except that they want something that’s nice and shiny and new.”

Coaching culture

Learning the new way of working and financial responsibility has been introduced as part of broader changes to staff development implemented by Baker, including her desire to ensure the hospital has a ‘coaching culture’.

Baker herself is a qualified coach and mentor through the Institute of Leadership and Management (ILM) and a chartered director through the Institute of Directors (IoD), with the IoD course in 2005/6 paid for in the place of a bonus at her old business.

It has had a “massive” beneficial impact on her career, she said, and gave her a thorough knowledge of the legal duties and responsibilities of directorship and of good corporate governance. That knowledge and experience helped her secure the non-executive director position at East Midlands ambulance service, with many other board members retired or semi-retired.

Governance arrangements proved important once again when she joined Derby Hospital.

A new working culture

NHS organisations frequently have ‘command and control’ structures, she said, with ambulance services even more so, with staff wanting to be told how to do things and what to do. “Because it’s such a high-risk working environment,” Baker said, “people don’t want to have the finger pointed at them. Historically, there’s very much been a blame culture. I inherited it coming into this hospital as well.

“Nobody wants to put their head above the parapet, which means you can’t learn from near-misses and mistakes. Having a coaching culture means getting away from that, working away from blame and towards ‘lessons learned’.

“We can’t learn lessons unless people share when they have made mistakes and know they are safe in doing that, although there can be consequences as well. I’m just coming into my fourth year and it’s probably taken me two to two-and-a-half years to shift that way of thinking.”

Some people, she said, are unlikely to ever shift, especially if they have worked in the same place for decades – often working in the same way, too. But those people will always be very much in the minority.

The change in working cultures has also had an effect on managing behaviour and attitudes, rather than focusing only on competencies. “We won’t tolerate people being disrespectful or rude – consultants included!” Baker said.

Francis fall-out

Derby Hospital is part of the Nuffield Group, not the NHS, but the lessons that came out of the Francis report are just as applicable.

Baker told us: “We have had lots of discussions around this. None of us are perfect, everyone’s trying to make savings and the biggest cost is staff, so how do you manage a really high quality service and also manage the costs? You’re always being compared and benchmarked against other providers and how they’re doing it without necessarily knowing whether they’re doing it well or not.

“I’m aware of the cost issue but I’m also aware of what I know feels safe and what doesn’t. We will go to as far as we feel we’re safe and we won’t be pushed beyond that. I will stand up here and lose my job rather than allow that to happen, because it’s my responsibility.

“I appreciate that it can be very hard to know what is safe, because different patients need different levels of care and input. It can be quite an individual thing.

“If you’ve got staff who perhaps aren’t working to the right level, that’s either a training issue or you need to increase your numbers. It’s a constant conversation that is going on all the time.”