We ended the previous post with our Challenged Trust looking at its money quite differently. Instead of squeezing the biggest-spending budgets in time-honoured fashion, we now know which services are profitable and which are loss-making, which means we can focus on turning our loss-makers around without hurting our profit-centres. We also know the price of each theatre minute, bed day, X-ray and so on, making it much easier to spot things that look expensive (£1,300 for an ophthalmology inpatient bed day? £400 for a histology test?).

In effect, we have turned our organisation upside down.

Now we can see our income coming in at patient level, and our expenditure going out at patient level too. We can see how every part of the hospital is trading, not just with commissioners, but with every other part of the hospital too. Consultants are starting to wonder things like “if theatre time costs £25/minute, why are we wasting all that money by starting half an hour late every morning?”, and “why is the recovery room fully-staffed first thing, when the first patient never comes out of theatre before 9:45am?”.

These are good questions. If it was their money, they wouldn’t spend it like that. Suddenly they’re noticing a hundred details about the way they work that don’t make sense. But they still aren’t doing anything about it. Why? Because decades of experience has told them it isn’t worth the effort. But if it was their money…

Up in the management offices, we know we’re still struggling to turn our hospital around, to get it into good enough financial shape to be a Foundation Trust. Big organisations like this don’t go from awkward to nimble just like that. In a hospital, managers can’t implement change like we could in a factory. The Trust is full of autonomous professionals: medical consultants, nurse consultants, consultant scientists; they all have their own ways of doing things, and a fair bit of power to do it that way if they want. That’s a good thing, but it is also why change can be so grindingly slow, and often expensive if you have to lubricate the wheels of change with extra money. But time and money are the very things we don’t have.

It’s an old joke that a hospital would be a doddle to manage if it weren’t for the patients. But seriously, it would also be easier if it weren’t for the consultants. We could be running a superb Trust within months if our remit was to manage all the staffed facilities, including most of the nurses, but minus the consultants. Now that our newly-improved accounting has turned our organisation upside down, we can see a way of making that vision reality.

So we could have the GP commissioners buying orthopaedics directly from the orthopaedic surgeons, medicine from the physicians, and so on. The doctors could carry on working here as usual, and buy the theatre time and bed space and diagnostics from us. We could get on with running a great Foundation Trust with a large estate and thousands of staff, and they could get on with delivering the standard of care that GP commissioners expect, and using our facilities as efficiently as they can.

Working like that, it surely won’t be long before 9:01am is considered a “late start” in theatres. Who knows, we might even see anaesthetists wheeling the patients down themselves…