Most community nursing staff will be well aware of the escalating demand upon their limited resources and the increasing expectation of improved delivery from patients, clients, relatives and the general public. In order to survive and develop services in such a rapidly changing environment that is shaped by improved technology, rapid scientific advances, the increasing incidence of moral and ethical dilemmas and evolving patient/client management, budget managers and prospective budget managers must recognise and reconcile three fundamentally contradictory pressures that affect the way in which funds are used:
- Constantly rising levels of expectation and demand for improvement.
- Significant increases in patient/client dependency and numbers.
- A permanent climate of scarcity in the availability of resources.
Funding and budgets
Many people mean money when they speak of scarce resources. Actually money is merely the facilitating factor that enables us to buy the essentials that keep the service going. And it is important to note that the Budget Manager’s key role is to spend money (as opposed to saving) or otherwise authorise expenditure, so that the very best value is obtained.
In addition to the physical resources that we all recognise and use, there are a large number of extremely important non-tangible assets that may increase or diminish according to the way in which the service is managed. These include, goodwill in the form of gifts, donations, sponsorship and the ability to generally manage the external environment, staff morale in the face of scarcity, volunteer services and the degree to which there is cooperation with other service providers, (for example social services.)
As far as funding is concerned, it is interesting to note that in overall terms, around eight per cent of the total health and social services annual day-to-day budget goes to community health and around 15 per cent is spent on social services. Although there are constraints, the major responsibility for day-to-day, or revenue spending is delegated to local level through a system of budgetary management where, in theory at least, managers individually or collectively are best able to decide the spending priorities that are fundamental to their particular patch, group, or specialty.
Perversely, managers often worry when a budget is consistently under-spent as this signifies an overprovision of funding. This can be especially depressing in cases where there are staff shortages. The net effect of this may be a redistribution of funds which in turn may lead in later periods to a tendency towards overspending.
The close connection between budget, workload, and quality, cannot be overemphasised, but lack of clarity when budgets are set can lead to confusion. For example, a budget manager may be happy with 10 staff to do 100 units of work to be performed to a certain standard, but a reduction to nine staff, whilst it might be borne for a short time clearly will have consequences for wither work done or quality. But how would 10 staff cope with 101 units of work or 102 units?
As money is allocated according to a fairly strict calendar, timing expenditure can also cause problems especially when the time limit is expiring. Other familiar complications arise from the need for expensive replacement items, new equipment, the repair of building fabric or the identification of an entirely new service. Keywords in all these problem areas are competence in managing the external environment and negotiation at appropriate levels. All these aspects will be dealt with in later papers.
Physical resources
Although the availability of funds is a crucial consideration, it is not the primary answer to the filling of vacancies where the degree of expertise required is itself in short supply. Similarly, replacement buildings or equipment or major repairs will all have a final delivery date that money alone will not reduce. Managers must become intimate with the condition of their own internal environment. They must be able to assess the state of their current resources in terms of consumption, the degree of depreciation, and the need for renewal or refreshment (this includes staffing).
Physical resources can be categorised as being goods and services including drugs and dressings, transport and travel; expertise or staffing; equipment which is self explanatory; systems including computerisation; estate which usually covers the building envelope, grounds, roadways and car parks.
Because our services are very labour intensive, directly employed staff account for by far the largest portion of budgets. Depending upon type, in hospitals this represents between 70 and 75 per cent of the total running cost of which up to 40 per cent of the total can be attributed to nursing staff. In the community the staffing ratio is much higher.
Non-tangible assets
Whilst managers are generally competent in at least recognising resource problems in their particular domain, frequently they encounter difficulties in handling and mobilising relevant elements of the external environment, for example, local support groups, key political contacts, possible partners in care provision, staff organisations etc. Often this is because managers do not perceive this facet to be either within their control or to be amenable to their influence but inept management can inadvertently lose goodwill from the community at large.
In both instances, however, the relative effective use they make of both the hierarchical structure and lateral connections will be reflected directly or indirectly in their ability to acquire and utilise resources. For example repeated failure to meet payroll deadlines will cause resentment and annoyance at all levels including a loss of morale. Similarly, a mistake or negligence in managing resources can result in physical loss together with time and other resources wasted in correcting the error.
One way of diminishing this kind of waste is through the introduction of process quality. That is to say, implementing a system by which they aim to do the right thing, first time, and everytime. By this means, managers can measure and enhance the standard attained in their degree of cooperation and profile across the range of relationships needed to guarantee the continued stability and supply of resources.
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