Defining Financial Management
DEFINING FINANCIALMANAGEMENTA Finance Operating Model for Healthin Ireland30 August 2013FINAL REPORTCONFIDENTIAL – between PA and The Health Service Executive
PA Regional Office:PA Consulting Group2nd Floor, Embassy HouseHerbert Park LaneBallsbridgeDublin 4Tel: 353 1 6684346Fax: 353 1 6681771www.paconsulting.comPrepared by:PA ConsultingCONFIDENTIAL – between PA and The Health Service ExecutiveVersion no:1.0
EXECUTIVE SUMMARYStaffing levels have reduced by over 11,268 WTEs since the peakemployment levels in September 2007. Health services continue toexperience very significant budgetary challenges alongside increaseddemands for services.The new Finance Operating Model for Health in Ireland willsupport far reaching and fundamental change in financialmanagement practice and will be an important enabler ofwider Systems Reform. Underpinned by a singleintegrated financial management system and a mandatedfinancial management framework, these changes willensure financial stability within a reformed health systemand will drive a culture of collective responsibility and costconsciousness.Budget overspends during 2012 prompted external reviews into financialmanagement practices in Health, and managing Health finances became apriority for the Troika in ensuring the future economic stability of the country.The Programme for Government will drive significant changes to the wayhealth services are managed and delivered to ensure: A public health service that is leaner, more efficient and better integratedto deliver maximum value for money and respond to public needs; andThis report recommends a new Operating Model forFinance and seeks approval to progress with Phase 2 ofthe Finance Reform programme as outlined in theImplementation Strategy with immediate effect. Continuity of service delivery in the context of significantly reduced staffnumbers.The future sustainability of healthcare fundingremains a key Government priorityIn November 2012, the Minister for Health published Future Health: AStrategic Framework for Reform of the Health Service 2012 – 2015),outlining the main healthcare reforms that will be introduced in the comingyears as key building blocks for the introduction of Universal HealthInsurance in 2016.The economic crisis has had a profound impact on public services in Ireland.The Government’s efforts to manage public expenditure in line withcommitments made to the Troika has seen budget reductions in Health of 3.3bn (22%) since 2008.Future Health seeks to support innovative models of care delivery and inparticular integrated care pathways. All this must be achieved under themost stringent fiscal constraints experienced for decades and cognisant ofhealth trends and drivers of change such as:3CONFIDENTIAL – between PA and The Health Service Executive
Demographic change; Effectiveness of decision support being compromised by time spentvalidating and manipulating data to meet information requirements ofcustomers; New medical technologies, health informatics and telemedicine; Rising expectations and demands; and A lack of shared ownership of transaction processes – finance, HR andprocurement results in duplication and inconsistency in processes and alack of integration; Spiralling costs of healthcare provision. Health services in Ireland face the dual challenge of reducing costs whilstimproving outcomes for patients. In these circumstances the need forstrong, effective financial management is of paramount importance. Significant under-investment in technology which has compromised theability of finance to improve current working practices; Weak accountability for actions and recognition that financialmanagement is a corporate responsibility undermines the controlling roleof finance; andThere is a clear consensus for the need for changeThe review of current financial management arrangements securedconsensus amongst the finance community that the current operating modelis no longer fit for purpose. There are three distinct drivers for change in thefinancial management practices within the health system in Ireland, andthese are considered below: A lack of investment in training and development of both finance staffand budget holders to ensure that they discharge their financialmanagement responsibilities effectively.The current financial management framework does notsupport the CFO’s responsibilities and accountabilitiesThe current operating model is no longer fit for purposeReports by Ogden and PA during 2012 identified significant weaknesses infinancial management practices.The Health Service Executive (Governance) Act, 2013 strengthens theaccountability arrangements between the HSE and the Government. Therole of CFO was introduced to support these new accountabilityarrangements.We have worked closely with the finance community to understand currentways of working and have found many examples of good practice, achievedin spite of variations in processes, multiple financial systems and limitedengagement with the voluntary sector.The CFO’s appointment sends a clear statement of intent to stakeholdersthat steps will be taken to improve confidence in financial managementpractices and to achieve greater financial control.However it was clear that current practice was not fit for purpose and ischaracterised by:The CFO has accountability for financial management across the entirehealth system. To discharge that accountability the CFO must ensure thatthe financial management framework enables him to deliver against all fourfacets of his role: Inconsistency in the level and standards of service provided to differentcustomer groups across the system; The extent of financial management activity being supported by teamswith no direct accountability or responsibility to the CFO; Stewardship and accountability: ensuring the compliance framework is inplace to provide a true and fair view, that builds trust in the financialinformation provided; The extent of process variation, inconsistent data definitions and multiplefinance systems in place inhibit the ability of staff involved in decisionsupport and compliance to make best use of their skills and expertise;4CONFIDENTIAL – between PA and The Health Service Executive
Financial Management: ensuring practices across the system informdecision making, promote probity and value for money and a culture ofcost consciousness and continuous improvement;Whilst finance has traditionally found innovative solutions to newrequirements, the consensus reached is that the current operating modelcannot effectively respond to these changes. The success of health reformis fundamentally dependent on having a transformed approach to FinancialManagement. Corporate Leadership: as a Board member providing strategic direction,effective corporate governance and building strong relationships; and Professional Leadership: driving professional standards, leading theprofession and building capability across the system.The scope and scale of change required presentsa significant challenge to the system The current operating model does not provide the CFO with theadequate tools to discharge this responsibility.It is important to recognise the flexibility, professionalism and commitment ofthe finance team in the way that they work within current structural andsystems constraints to support financial management across the system.The fundamental changes in healthcare heralded by FutureHealth bring new requirements which current practicescannot supportPhase 1 of the Finance Reform Programme has made a significant impact intackling specific challenges in service planning, budgeting and costcontainment, and it should also be recognised that this added to theworkload of an already stretched finance team. There is tangible evidence ofchange fatigue in the system which will potentially impact on the pace ofchange.The long term changes in Ireland’s health system, as described in FutureHealth have significant implications for finance.The introduction of Money Follows the Patient (MFTP) and ultimatelyUniversal Health Insurance (UHI) will fundamentally change the financingsystem requiring:The challenge facing the HSE is how best transform financial managementduring a period of unprecedented change across the healthcare system. The creation of new organisational entities to support commissioning,tariff setting, pricing & payment and service regulation;There is a need to build on what has been achieved in recent months and todeliver an approach to financial management that secures medium termstability and cost containment while allowing sufficient flexibility to supportthe reforms under the vision for Future Health. A fundamental change in the relationship between the Department ofHealth, these new organisational entities and Health and Social CareProviders (HSCPs); A change in culture and behaviour amongst HSCPs particularly infinancial management, so that they understand the cost of serviceprovision by procedure, and have the ability to operate effectively in acommissioning environment which defines services to be provided andthe payment streams for these services, andCritical to success will be: The development of a new relationship between the Insurance sector inIreland and the Health system together with a supporting infrastructure tounderpin the mechanics of UHI. Resourcing the programme properly using key finance staff and externalsupport where required. Demonstrating intent and ability to deliver; Securing timely approvals for any investment; Addressing workforce issues effectively; and5CONFIDENTIAL – between PA and The Health Service Executive
A new operating model for Finance will drive realchange over an extended periodThis report defines a new Finance Operating model for Health in Ireland,which addresses the challenges of current financial management practice,and is capable of meeting the future needs of a dynamic and complex healthenvironment.This will fundamentally transform finance from being a reactive, disjointed,reporting function into a proactive, coherent decision support capability,adding value at all levels of the business at a significantly reduced cost.The model builds on leading practice principles to ensure the CFO’sresponsibilities and accountabilities for financial management are delivered,and the desired changes in behaviours amongst both finance staff andbudget holders drive the improvements in financial management practicesrequired. The CFO will: Operations Excellence: the ‘finance engine room’ which will ensure thatthe infrastructure is in place to deliver financial reporting and transactionprocessing effectively and efficiently; Define the financial management framework to be followed ; Provide trusted and timely information to support decision making, in astandard and consistent way Finance Specialists: deep technical skills and expertise providing asingle point of contact for expert advice; and Inform strategic and operational decision making through trustedprofessional advice, insightful analysis and decision support; and Business Partners: supporting financial management decision makingand promoting a culture of financial responsibility across the system byworking closely with the business at a strategic, national and operationallevel. Ensure expected standards are maintained through effective complianceand performance management.The model is underpinned by a commitment to develop the financialmanagement capability of both finance staff and budget holders to build acost-consciousness culture and change behaviours across the system.Process, Governance and Controls to demonstrateeffective financial management practicesA service delivery model reflecting leading practiceFinance will provide a consistent and appropriate level of service to all usersreflecting user requirements and focused on improving the quality offinancial management and enabling informed decision making.The CFO will define the financial management framework which ismandated across the health system. This will define the process,governance and controls required to demonstrate effective financialmanagement practiceThis will be achieved through a service delivery model comprising threedistinct components as illustrated in the figure below:6CONFIDENTIAL – between PA and The Health Service Executive
In practice that means:There is a requirement to invest significantly in building skills andcapabilities to support these changes. Processes are standardised, simplified and automated wherever possible Clear line of sight from a national consolidated position to a functionalbusiness unit level is possible for all areas of expenditureIn practice this means: Controls and rules are embedded within systems and guidance on theirapplication is available in a user friendly format online Continued Professional Development (CPD) compulsory for all financeprofessionals Governance and controls are mandated CFO “head of profession” to improve standards and quality of financialadvice Skills and capabilities mandated for key finance roles The CFO owns all end to end financial management processes Learning and development for both finance professionals and nonfinancial managers to be recommended and supported by CFO.Information systems providing trusted management informationWe recognise that technology is a key enabler of change and the successfulimplementation of the new model is dependent on technology.The model will be supported by a high level organisational structure asfollows:In practice that means: A single financial management system supporting HR, Procurement andFinance processes will be deployed across the health system A national system to support patient level costing and tariff pricing Information and data governance to be owned by CFO A single version of the truth Trust in data Information to be collected once and used many times with financialreporting and data analytics being delivered in a standardised, consistentway to all users through Operations ExcellenceA commitment has been made to introduce new financial systems for Healthwithin the Memorandum of Understanding between Government and theTroika. Our plan to implement a new operating model for Finance providesthe means to deliver against this commitment.Developing the Skills and Capabilities of all our peopleThe necessary changes in financial management practice rely uponchanges in behaviours from those involved across the system.7CONFIDENTIAL – between PA and The Health Service Executive
The diagram below illustrates the implementation strategy.An incremental approach to changeThe future operating model for Finance is only achievable if the followingcomponents are in place: A single financial management system providing line of sight andsupporting embedded controls, standardised processes and facilitatingeffective self-service principles; Trusted financial management information which supports effectivedecision making; and Budget holders who are supported in undertaking their financialmanagement responsibilities and appropriate performance managementarrangements which reward good practices and provide sanction whereappropriateThe Finance Reform Programme will deliver these components over time,but is a need to change the structures and operating model for Finance tosupport the system during this transition period. This will support the deliveryof the Finance Reform programme whilst ensuring that systems of financialcontrol remain robust and effective during transition.This is particularly important given:Step 1: Interim Structure Many commissioned reports, including the C & AG Audit show that thecurrent financial systems are not fit for purpose;An interim structure will be introduced from 1 October 2013 for a period of6-9 months. This will enable the CFO signal to the system that changes areunderway, and will allow the Finance Specialist and Operational Excellencefunctions to be established. It will also support the consolidation of regionalfinance operations into two units as an initial step towards BusinessPartnering. The move to Step 2 can take place when the followingconditions are in place: The recent establishment of ‘National Directors’ and the immediatenecessity to prepare financial systems to support their requirements; and The overall transition, in the next few months, from the current reportingstructures and the need for continuity of financial reporting through thischange, while ensuring financial integrity. ISA review outcome is known; Interim BI reporting solution in place; New system requirements defined; and The future role of Shared Services is confirmed.8CONFIDENTIAL – between PA and The Health Service Executive
Step 2 – Transitional Operating ModelThe Implementation ChallengeThe Transitional Operating Model is designed to support the implementationof the key change initiatives required to deliver the new Operating modelover time whilst continuing to support business as usual.The scope and scale of the implementation challenge should not beunderestimated, and it is important to recognise that the Future Healthmilestones will drive the pace of change.The Business Partner model will be introduced, and decision supportservices to support commissioning and performance management will bedeveloped; and the implementation of financial management arrangementswithin HSCPs supported.Our work has secured significant consensus amongst the financecommunity both of the need to change, and that the proposed model is theright one to deliver the changes in financial management practices sought.We have secured commitment and buy-in to make these changes a reality.The transitional operating model will be supported by the following high levelorganisation structure:A quarterly milestone plan to support the next twelve months has beendeveloped as part of a three year change programme.The plan identifies the need for significant and positive action in theimmediate months ahead and the success of the overall programme willlikely be defined by these actions.Key activities include: Initiating Phase 2 of the Finance Reform Programme and mobilising thedelivery teams; Developing the business case for managed service to provide a singleintegrated financial management system; Designing common chart of accounts, data standards and definingsystem requirements; Developing interim BI reporting; The design of transitional and final organisation structures, roles andperson specifications; and Initiating procurement of managed service to provide a single integratedfinancial management system.These are key leadership roles within Finance and those in these posts willhave clear responsibilities for both service delivery and reform. They willhave a clear change management role, and will need supported anddeveloped to deliver that role effectively.9CONFIDENTIAL – between PA and The Health Service Executive
CONTENTSEXECUTIVE SUMMARY3The future sustainability of healthcare funding remains a keyGovernment priority3There is a clear consensus for the need for change4The scope and scale of change required presents a significantchallenge to the system5A new operating model for Finance will drive real change over anextended period6An incremental approach to change8The Implementation Challenge91INTRODUCTION141.1Background and context141.2The Finance Reform Programme141.3How an operating model will support the scope and scale ofchange required151.4Our Approach161.5Structure of the report162THE CURRENT SHAPE OF FINANCE182.1The Current Finance Operating Model182.2Information and technology242.3Inconsistency in support levels and standards2710CONFIDENTIAL – between PA and The Health Service Executive2.4The provider landscape272.5The cost of finance282.6Strengths to build on and areas for development323HOW FINANCE NEEDS TO CHANGE333.1Drivers of Change333.2How Finance functions in other organisations are transforming463.3Requirements for change across the finance operating modelfor health in Ireland514OPTIONS APPRAISAL544.1Our approach to options appraisal544.2Defining the Financial Management Framework544.3Delivering effective transaction processing554.4Addressing line management and accountability in BusinessPartnering564.5Conclusion and recommended way forward575NEW FINANCE OPERATING MODEL FOR HEALTH INIRELAND585.1Purpose585.2Vision and Design Principles585.3A new Finance operating model59
6IMPLEMENTATION STRATEGY69C.3Steps towards a new operating model1166.1Essential components of the new operating model69C.4Dublin East1176.2An incremental approach to change706.3Step 1: An interim organisational structure706.4Step 2: A transitional operating model706.5Implementation success factors76C.6Dublin North East1196.6Implementation plan78C.7Dublin Midlands1206.7Planned Outcomes: Year 186C.8West / North West1216.8Critical Success Factors89C.9Mid West1227CONCLUSIONS90DCASE STUDIES123D.1Business partnering123D.2Shared services126D.3Big Data126EOPTIONS ransaction processing137E.4Business Partners143117C.5South / South West118118APPENDICES91ASHAPE OF FINANCE92A.1Introduction92A.2Process analysis93A.3Duplication of process activities94A.4Fragmentation97A.5Activity profile of core processes97A.6Cost Analysis98A.7Grade Analysis104FORGANISATION DESIGN145BTRAINING NEEDS ANALYSIS111GBUSINESS INTELLIGENCE148B.1Introduction111HCEMERGING HOSPITAL GROUPS115SENIOR FINANCE TEAM VIEW OF CURRENTINFORMATION SYSTEMS150C.1Introduction115KEY STAKEHOLDERS CONSULTED151C.2The emerging group structures115I11CONFIDENTIAL – between PA and The Health Service Executive
FIGURES AND TABLESFIGURESFigure 16The interim organisational structure70Figure 17The transitional operating model for Finance72Figure 1:Finance Operating Model16Figure 18Transitional Management Structure73Figure 2:The Current Operating Model20Figure 19High level road map79Figure 3:The current shape of Finance in the HSE22Figure 20:WTE by core and non-core finance processes93Figure 4:The variation in support across the statutory andvoluntary sector27Figure 21:The Current and Future shape of Finance93Figure 5:The Role of the CFO37Figure 22:Compliance94Figure 6:The differing roles of operational and financialmanagers in the context of budgetary controlFigure 23:Transaction Processing9438Figure 24:Decision Support96Figure 7:The Emerging Landscape40Figure 25:Decision Support97Figure 8:The Commissioning Wheel for the NHS42Figure 26Compliance98Figure 9:The planning and operational processes that couldfollow from the MFTPFigure 27:Transaction Processing9844Figure 28:Cost versus time as a % total (excluding non-core)100How leading organisations have transformed theirfinance operationsFigure 29:Analysis of grade by process10446Figure 30:% of time spent on activities (by grade)105Figure 11The new operating model for Finance60Figure 31:Business Partner – Manager113Figure 12:The New Service Delivery Model61Figure 32:Business Partner - Team Member113Figure 13:Business Partnering Roles65Figure 33:Operations Excellence - Manager114Figure 14:Organisation Structure66Figure 34:Finance Specialist - Manager114Figure 15The transition steps towards a future operating model70Figure 10:12CONFIDENTIAL – between PA and The Health Service Executive
TABLESTable 1Phase 1 of the Finance Reform Programme15Table 2:Current skills and capabilities26Table 3:Cost by Finance Service (excluding non-core financeprocesses)28Table 4:Cost by Finance Activity29Table 5:Changes required in financial management practices52Table 6:Delivery Options and Evaluation Criteria55Table 7:Roles and Responsibilities within the TransitionalOperating Model74Table 8:Critical Success Factors89Table 9:Cost, WTE and number of locations by activity99Table 10:Cost by grade and process100Table 11:WTE numbers by grade and process104Table 12:Analysis of Respondents by Grade112Table 13:Analysis of Respondents by Age, Qualifications &Experience11213CONFIDENTIAL – between PA and The Health Service Executive
1 INTRODUCTIONSince the Health Service Executive (HSE)’s establishment, the Financefunction has worked hard to support financial management across thediversity of the HSE’s services despite the challenges of multiple systemsand many manual, non-standard processes which add complexity and a lackof transparency and flexibility in reporting.A fundamental change in the way that financialmanagement operates across the health system in Irelandis essential to underpin the reform envisaged in FutureHealth and to address recognised weaknesses in currentfinancial management systems and infrastructure. Thischange goes beyond the need for new systems andprocesses and requires a positive response from bothfinance professionals and non-financial managers,recognising new roles and owning their budgetmanagement responsibilities. A new operating modelprovides the blueprint design to shape that changeensuring alignment with desired outcomes.1.1It has become clear that the current financial management arrangementswill no longer meet the needs of the emerging health system and thestructural change required to support it.The establishment of hospital groups, new structures for primary care andcommunity services, the development of formal purchaser / providerarrangements and the establishment of a Healthcare CommissioningAgency (HCA) will bring new requirements for financial management, as willthe changing funding arrangements arising from Universal Health Insurance(UHI). It will also bring about a change in the role of the Department ofHealth in the wider health landscape, and a need to build and develop newrelationships across the system. These new relationships will bring newrequirements from a financial management perspective.Background and contextThe Health Service in Ireland has embarked on a major programme ofchange. Future Health: A Strategic Framework for Reform of the HealthService 2012-2015 sets out the main healthcare reforms that will beintroduced in the coming years, as key building blocks for the introduction ofUniversal Health Insurance in 2016. Future Health will focus on the needs ofthe patient even as difficult decisions on health financing are made.1.2The Finance Reform Programme has been established in response toreports into financial management practice in Health by Ogden and PAConsulting during 2012. This programme is the beginning of a journey ofchange in culture, systems and processes across the organisation that will14CONFIDENTIAL – between PA and The Health Service ExecutiveThe Finance Reform Programme
Table 1transform finance operations. The programme aims to develop moreeffective financial planning and management and build a more costconscious culture across the Health system by:Phase 1 of the Finance Reform ProgrammePMO and Programme ManagementDriving the pace of change andensuring a sense of purpose enhancing financial management knowledge, skills and capability bothwithin Finance and amongst service managers and clinicians;Service Planning, Budgeting andCost Containment securing ownership for financial performance at inter-departmental,strategic and operational levels by improving service planning, budgetingand performance management and reporting;Greater clarity and confidence in 2013Budget and Service Plan and a newprocess for 2014Performance Management andAccountabilityEstablishing the framework to changebehaviours through improvedperformance management andreporting arrangements evidenced overtime through changed behavioursA new operating model for FinanceBuilding the foundations fortransformationFinancial Strategy, ServiceImprovement and Future HealthBuilding the capability for the future having a better understanding of the cost of service provision across thesystem, which aligns current activity and future demand; adopting multi-annual planning and budgeting to support reform anddeliver cost reduction in a sustainable way; being clear about responsibility and accountability, and ensuring thesystem impact of poor performance is understood and responded to; simplifying and standardising systems and processes; and ensuring financial management support to services is fit for purpose anddelivered by the right people, in the right place, at the right time.1.3PA Consulting was appointed to support the Finance Reform Programme inNovember 2012. PA supported the programme in a number of key areaswith a view to establishing the foundations of the programme which will bedelivered over time. Work on the finance operating model is one aspect ofthis support, as illustrated below.How an operating model will support thescope and scale of change requiredAn operating model describes how each of the components of a function ororganisation will fit together to deliver an efficient and effective service,aligned to new requirements. In developing a new operating model forFinance we will address the weaknesses identified in current systems andprocess, and ensure that Finance skills and capabilities are developed to theextent that the emerging financial management needs of the health systemare met by new ways of working.This work provides insight into how finance is being delivered across thehealth system: nationally, regionally and locally, supporting both statutoryand voluntary service providers. We identify and evaluate alternative optionsto deliver finance services to meet emerging future requirements.15CONFIDENTIAL – between PA and The Health Service Executive
ProcessThe Senior Finance Team acted as a steering group, and a Working Groupwas established to support key aspects of project delivery.GovernanceandcontrolsCulture andbehavioursServicesFINANCEOPERATINGMODELOur approach involved the following logical steps:The operating model is arepresentation of how HSEFinance operates now, and couldoperate in the future in terms of: Understanding the current position; informe
Business Partners: supporting financial management decision making and promoting a culture of financial responsibility across the system by level. Process, Governance and Controls to demonstrate effective financial management practices The CFO will define the financial management framework which is mandated across the health system.
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SECTION - B : FINANCIAL MANAGEMENT Study Note 3 : Overview of Financial Management 3.1 Objective of Financial Management 3.1 3.2 Key Decisions of Financial Management 3.5 3.3 Planing Environment 3.6 3.4 Functions of Financial Management 3.7 3.5 Sources of Finance 3.9 3.6 International Sources 3.13 3.7 Emerging Role of Finance Manager 3.23
Financial Management Practices of College Students from States with Varying Financial Education Mandates . This study uses three categories of financial outcome indicators (financial knowledge, financial dispositions, and financial behaviors) to assess the effectiveness of state policies regarding high school financial education. States were .
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