预算管理(英文原文与中文译文).doc

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 department's 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 it's 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.METHOD:The following is a useful structure for developing your plan:(1) Identify all the activity of your department.(2) Do you wish to stop any activity?(3) Do you wish to continue any activity unchanged?(4) Do you wish to continue any activity with minor change?(5) Is there anything you wish to radically change?(6) Is there anything you wish to introduce which is considered radical or innovative?TIPS:(1) Involve your medical and nursing colleagues; many heads contribute many ideas(2) Use brainstorming(3) Don't forget to involve your clerical staff-they will seething from a very different angle and can contribute excellent ideas(4) Include everything in the first draft (it can be pruned later)(5) If you think an innovative idea is worth pursuing try not to be put off by caution keep pursuing it(6) The actual format of the plan should follow that usedwithin your trust.5 SummaryThe NHS as a whole is constrained to operate with finite resources. Furthermore, each individual district, as a consequence of the cash limit system, has a fixed sum of money available to it each year for the provision of services. These financial facts of life must be recognized by all those who use the service or work in it. From the point of view of the district they lead to two apparently contradictory obligations-namely, to provide the pattern of services that best meets the changing needs of the community as a whole; and to do so within a fixed financial allocation. The provision of services that meet the needs of the community requires constant appraisal of the way that resources are used. This may indicate that growth in a certain area of activity is required. Cash limits, however, imply that growth in one area can only be achieved either through contraction in another or by an overall improvement in efficiency. Management budgeting provides the means to examine and tackle these issues and thus can help to reconcile the conflicting demands that confront districts.Budgetary responsibility gives you more control. Take time to master the fine detail, ask questions of your management and finance colleagues about anything you do not understand (you will not lose face), and develop the skills of lateral thinking and creative accountancy. Even if your budget is repeatedly overspent do not take it personally, ensure that management are aware of it and have a goodnight's sleep. Do not worry about it.中文译文预算管理1介绍国民保健制度的改革措施已经对所有职业和专业医生产生了深远的影响。在其他方面，它已蓄意被政府的政策改变，资深医生在自己的临床领域应该有更多的直接管理和预算责任。医院已经开发出一种信任的预算管理体制和权力下放的临床董事。急症室要么成为拥有自己权利的董事，要么成为联营公司里更大的董事。急症室顾问对临床采取控制的职责将更直接地体现在他们自己的支出部门。起初，这看起来吓人，但似乎有控制带来的优点远远大于更多的管理活动所带来的弊端。本文旨在提供一些指引，以帮助更好的完成任务，以及提供一些基于个人的经验的技巧。我不打算在筹集资金活动或组织研究生教育资金方面展开讨论，只是在最后简要提及“业务规划”。另外会提出什么是管理预算以及在卫生当局它是如何不同于传统的预算控制系统；指出它旨在实现的目标；及探讨了临床医师参与管理预算编制过程及其可能影响他们的方法工作。2什么是预算传统的预算控制系统建立的主要是根据一个什么样的功能或结构，通常被称为部门预算。在这种结构中的预算分别由这些人负责提供某种服务。在预算控制结构以外，通常没有临床工作人员的参与的可能性，病理学和放射学的预算是归持有人的顾问公司负责。这似乎起了相当陌生影响，临床医师可以使用医院资源。在任何预算控制系统里的一个关键原则是，个别预算持有人应只负责以上这些项目的开支，他们可以对这些项目施加控制。卫生当局对这个原则并不总是适用。一个极端的例子，这涉及到制药预算，在那里药剂师通常只是负责药品的支出，尽管他没有对消费水平有直接的控制。虽然预算就是给你一笔钱让你来管理服务(包括薪金和所有人员的工资)。但重要的是要认识到它本质上就类似于纸上谈兵，来经营自己的银行帐户和接受银行对帐单。你永远不会真正看到金钱和事实的真相，操纵帐户是通过你的管理和财务部的同事来完成的。你作为临床主任的作用是保持看简介并作出如何花费的行政决定。共有三种主要的预算大类：(1) 稳态，你分配相同数额的钱每年都有因通货膨胀引起的津贴。虽然未来的规划提供了可预测性但缺乏灵活性，但不允许在今后的活动中或在政府的领导下倡议无资金激增。大部分部门接受以这种方式提供资金。(2) 活动的基础，所提供的资金数额反映所做的工作。这是许多购买者或供应商合同的准确的，灵活的，基本活动。一般而言，它是直到工作已经完成后才使用的，并将于每年有所不同。(3) 分政府、地区包干，或信托发行的用于特定目的的一笔钱(例如，以开始分流或审计为依据来完成候补名单的倡议)。这是不可预测的，往往在短时间内很少被用于长远的规划。尽管大多数预算多数属于第一大类，但包干资金可以一次性供应。一个平均每年症治50000名患者的部门的年度预算大约有100万英镑。当实行预算时会有这么几个问题：(1) 预算有多大？究竟是谁控制它？(2) 你是真的对它有控制，还是只是理论上的？你隔多久会收到一份声明？你说的话能改变预算吗？你会和谁在你的机构内进行协商？(3) 声明需要通过预算报表，对所有条款做出明确说明，这是每个月的正常交付，尽管它看起来很复杂，但它是很容易掌握的，和你自己的银行声明只有一点点的不同。(4) 通过小心翼翼的预算能使错误只会偶然发生(虽然他们可以通过财务部门进行回顾性分析)。(5) 财政年度从三月算到四月。理论目的是使年底收支平衡,财政按年度预算，而不是按月。短期的超支与否并不重要。(6) 正(+)符号的含义是超支而负(-)符号是指未用尽。(7) 集中精力在大数目，关于小数目不要太担心，尽管他们确实需要在某个阶段分析如何节省开支同时又不影响服务质量。(8) 控制下放临床护理预算，给你的护士经理，但也要准备自己参与护理活动(例如，护士发展)。(9) 准备与其他董事谈判某些项目，如麻醉剂和血液制品类似的问题。(10) 创造性应用会计。这是合法的，并会得到你财务同事的支持。预算管理的一个重要原则是，所有用户的服务都应该被告知他们的成本。这是实现预算持有人之间的沟通方式清楚的了解是谁提供的服务以及是谁在使用它们。再次考虑到清洁服务，这将导致该部门之间和其他部门以及医院设施的预算充值。清洁费用然后才出现在预算报告里。比如说，病理服务，顾问的预算根据持有人收取的数量和类型来满足他们的测试要求。这种方式将基于每个个体测试商定的价格清单，而不是实际成本。这将有效的保护那些在实验室使用病理顾问服务的降低效率成本。它详细地描述了超出本文范围以外的设置预算修订的程序，将适用于预算编制的管理制度。有两个重要的特征应该指出并加以说明。首先，所有预算的持有人包括医生，将被邀请参加讨论其预算中可能出现的变化。这样的讨论会考虑选项的服务发展，如果更多资源成为可及期权那么选择裁员就会成为资源减少一个必然的后果。评估还包括利用现有资源的替代方式来实现更高的效率。这些可能是重新分配作出的具体预算或可能意味着资源从一个预算流动到另一个。另外这些讨论旨在