预算管理(英文原文与中文译文).doc

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英文原文budget management1 introductionthe nhs reforms have had far reaching implications for clinicians of all grades and specialties. among other changes, it has been deliberate government policy that senior clinicians should have more direct management and budgetary responsibility within their own clinical areas. trust hospitals have developed a directorate based management structure and devolved budgets to clinical directors. a&e departments have either become directorates in their own right or associate directorates within larger directorates. a&e consultants who take on clinical directorship responsibilities will have more direct control of spending within their own department. at first this may seem intimidating, but the advantages of having control outweigh the disadvantages of more administrative activity.this article aims to give some guidelines to help make the task less daunting, as well as some tips based on personal experience. i do not intend to cover fund raising activity or the organization of postgraduate education and its funding. brief mention will be made of business planning at the end. and we have outlined what management budgeting is and how it differs from traditional budgetary control systems in health authorities; considered what it aims to achieve; and discussed the participation of clinicians in the management budgeting process and its likely impact on their methods of working.2 what is a budget?traditional budgetary control systems are based primarily on a structure of what are normally termed functional or departmental budgets. in this structure budgets are held by those people responsible for providing a service.there is normally no participation of clinical staff in this budgetary control structure other than the possibility that the budget holders for pathology and radiology might be the consultants in charge. this seems strange given the considerable influence that clinicians have over the use of hospital resources.in any system of budgetary control a key principle is that individual budget holders should be held responsible only for those items of expenditure over which they can exert control. in health authorities this principle does not always apply. an extreme example of this concerns the pharmacy budget, where the pharmacist is often held responsible for drugs expenditure even though he has no direct control over the level of spending.although a budget is a sum of money given to you to run your service (including salaries and wages of all personnel) it is important to realize it is essentially a paper exercise similar to running your own bank account and receiving a bank statement. you will never actually see the money and the nitty-gritty of manipulating the account is done by your management colleagues and the finance department. your role as clinical director is to keep a watching brief on it and to make executive decisions as to how it isspent. there are three broad categories of budget:(1) steady state-you are allocated the same amount of money each year with an allowance for inflation. although it offers predictability for future planning it is inflexible and does not allow for surges in activity or unfunded government and trust lead initiatives. the majority of a&e departments receive their funding in this way.(2) activity based-the amount of money provided reflects the work done. it is accurate, flexible, and is the basis of much purchaser/provider contract activity. it is generally not available until the work has been completed and will vary from year to year.(3) lump sum-the government, region, or trust releases a lump sum of money for a specific purpose (for example, to start triage or audit or to complete a waiting list initiative).this is unpredictable, often comes at short notice, and can rarely be used for long term planning.although the majority of a&e budgeting falls into the first category, lump sum money is available from time to time. an average department seeing 50 000 patients a year may hadean annual budget of approximately one million pounds. when taking on a budget ask these questions:(1) how big is it? who actually controls it?(2) do you really have control of it or is it only theoretical, how often will you receive a statement? who do you speak to make changes with the budget? with whom and how do you negotiate within your institution?(3) ask to be taken through a budget statement and have a clear explanation of all terms, etc. it is normally delivered monthly and although it may look complicated it is easy to master and is really little different from your own bank statement.(4) go through it carefully as mistakes are an occasional occurrence (although they can be rectified retrospective through the finance department).(5) the financial year runs from april to march. the theoretical aim is to make the books balance by the end of the financial year and not from month to month. short term overspends or under spends are not important.(6) a positive (+) sign means an overspend and a negative (-)sign means an under spend.(7) concentrate on the big numbers; do not worry too much about little numbers although they do need to reanalyzed at some stage as savings can probably be made without affecting the quality of service.(8) devolve control of the nursing budget to your clinical nurse manager but be prepared to involve yourself in nursing activities (for example, the development of nurse partitioning).(9) be prepared to negotiate with other directorates about certain items, similar issues arise with funding for anesthetic agents and blood products.(10) use creative accountancy. this is legitimate and will even receive the support of your financial colleagues.a key principle of management budgets is that all users of services should be informed of their costs. this is achieved by means of recharges made between those budget holders who supply services and those who use them. considering domestic and cleaning services again, this would entail a recharge between that departments budget and those of other departments and facilities in the hospital. cleaning costs would then appear on budget reports.in the case of, say, pathology services, consultant budget holders would be charged according to the number and type of tests that they request. such recharges would be based on an agreed price list for tests rather than the actual cost of performing each individual one. this would have the effect of protecting the consultants who use pathology services from bearing the costs of any inefficiencies in the laboratories.it is beyond the scope of this article to describe in detail the revised procedures for setting budgets that would apply in a system of management budgeting. two features of importance should, however, be noted.the first is that all budget holders, including clinicians, would be invited to discuss possible changes in their budgets. such discussions would consider options for service developments if additional resources became available and options for retrenchment should this become necessary as a consequence of reductions in resources. also included would bean assessment of alternative ways of using existing resources to achieve greater efficiency. these reallocations might be made within a specific budget or might mean the movement of resources from one budget to another.linked to these discussions would be several financial incentives intended to encourage good budgetary control. typically, these would permit budget holders to retain a proportion of any planned underpinnings to use in improving the services that they provide.3 who needs budgets?modern companies reject centralization, inflexible planning, and command and control. so why do they cling to a process that reinforces those things? budgeting, as most corporations practice it, should be abolished. that may sound like a radical proposition, but it would be merely the culmination of long-running efforts to transform organizations from centralized hierarchies into devolved networks that allow for nimble adjustments to market conditions. most of the other building blocks are in place. companies have invested huge sums in it networks, process reengineering, and a range of management tools including eva (economic value added), balanced scorecards, and activity accounting. but they have been unable to establish a new order because the budget and the command and control culture that it supports remain predominant.in extreme cases, use of the budget to force performance improvements may lead to a breakdown in corporate ethics. people who worked at worldcom, now bankrupt and under criminal investigation, said ceo bernard eberts rigid demands were an overwhelming fact of life there. “you would have a budget, and he would mandate that you had to be 2% under budget,” said a person who worked at worldcom, according to an article in financial times last year. “nothing else was acceptable.” worldcom, enron, barings bank, and other failed companies had tight budgetary control processes that funneled information only to those with a “need to know.”in short, the same companies that vow to stay close to the customer, so that they can respond quickly to precious intelligence about market shifts, cling tenaciously to budgeting-a process that disembowels the front line, discourages information sharing, and slows the response to market developments until its too late.a number of companies have recognized the full extent of the damage done by budgeting. they have rejected the reliance on obsolete data and the protracted, self-interested wrangling over what the data indicate about the future. and they have rejected the foregone conclusions embedded in traditional budgets-conclusions that render pointless the interpretation and circulation of current market information, the stock-in-trade of the knowledge-based, networked company.4 business planningthis is a new concept in the nhs but is well recognized in private industry. you will probably be asked to write on each year, a task which is not as tedious as it may sound. a good plan will help:(1) priorities future activity(2) predict financial needs(3) develop departmental team spirit(4) convince others of your “vision” and enlist their cooperation(5) give support in times of change and uncertainty.metho