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Patients not profits



An edited version of this post was published on The Guardian’s website on 30th July 2014

Pen pushers, bean counters, faceless bureaucrats, stuffed shirts, spreadsheet monkeys, grey suits……all phrases that, at various times, I’ve heard levelled at the National Health Service’s finance staff. I’m one of the bean counters and until recently it was largely a case of sticks and stones for me. We’re an easy target for vote hungry politicians keen to show how they can save a few bob for the public purse. But peer beyond the lazy rhetoric and it’s possible to appreciate that although we might not be the ones caring for patients, we have a crucial part to play in ensuring that a vast organisation faced with rising demand and a finite level of funding uses its resources wisely. It can be the difference between whether some patients get the care they need or not. To me, that’s an important role and one to take pride in. Lately though, I’ve begun to wonder.

The NHS is in the final year of a four year “challenge” to save £20 billion by 2015. This is dressed up as “efficiency savings” and “cost improvement programmes” but in reality it means cuts to services, staff pay freezes and pensions “reform”. That’s not enough for NHS England though who estimate that, faced with rising demand and an ageing population, the NHS needs to find a further £30 billion of savings by 2020-21. In the meantime, the government has the cheek to pretend that NHS funding has somehow been ring-fenced.


Sadly the NHS, an internationally renowned health service that cares for the sick and some of the most vulnerable people in our society, continues to pay a high price for the banking crisis of 2008. Whilst it was considered unthinkable not to bail out the banks who caused the financial crash, six years on it appears perfectly thinkable to make NHS patients, staff and other public sector workers pay for the greed of the bankers. Morally this is indefensible. In the meantime, the NHS’s finance function unquestioningly busies itself with finding more and more ways to save money. Cut, cut, cut and then keep on cutting. Surely patients, not profits, should be the primary concern of any health service?

It hasn’t always been this way. Back in the autumn of 1990 I was interviewed in a portacabin in Cambridge for a place on the East Anglian Regional Health Authority’s financial management training scheme. Only a few months out of university and full of youthful idealism, I assured the two man panel that I wanted to work in the NHS because of its public service ethos. I was clueless when it came to career ambitions but I did know that I definitely didn’t want to spend my working life grafting to generate profits to make the rich even richer. There was a sense of social solidarity about the NHS that really appealed to me. Everyone, regardless of wealth and status is treated equally when they enter a hospital or surgery in the NHS.


Over the last twenty four years I’ve been lucky enough to work with a wonderfully diverse range of staff in many different parts of the NHS around the country from substance misuse services for heroin addicts in Scunthorpe to maternity services for women in Kensington and Chelsea. I’ve provided financial advice to a host of doctors, nurses and service managers and guided them through baffling spreadsheets and often impenetrable jargon in order to enable them to best use the resources at their disposal (time, money and human beings) to deliver the highest quality of care for their patients. Although I’m not directly involved in providing patient care I’ve always tried  to maintain an empathy with the doctors, nurses, therapists and other healthcare professionals who are in the frontline. And never to lose sight of the fact that the NHS exists, not to make a financial return, but to improve the health of the patients who require its services. Sadly, I’ve never felt so disillusioned with my own profession as I have over the last twelve months.

Since the Health and Social Care Act of 2012 the NHS is steadily being chopped up and packaged off to private health companies. Between April and December 2013 over £5 billion worth of NHS services were put out to tender with 70% of the four hundred contracts awarded to a private sector provider; from cancer services in the East Midlands (yes, it seems that it is possible to make money out of cancer services) to psychological therapies in Barnet. The health service as we know it, with its strong public service ethos, is being demolished piece by piece. Soon it will simply be a brand under which a multitude of providers will ply their trade. In short, we are witnessing the privatisation of the health service, something which goes completely against my main reasons for joining the NHS in the first place.


Yet finance managers appear reluctant to speak out about the changes. There is a fightback by doctors, nurses and other healthcare professionals that is gathering momentum. The National Health Action Party, led by consultant oncologist Clive Peedell, will field candidates in next year’s general election. The party is aiming to oust those Members of Parliament who supported the Health and Social Care Act. In August, a national March for the NHS will commence from Jarrow to London organised by a group called 999 Call for the NHS. The wonderful Keep Our NHS Public group campaigns to protect the NHS as a public service that is free at the point of use. The superb book NHS SOS written by Dr Jacky Davis and Raymond Tallis demolishes the propaganda behind the Tory NHS reforms. Meanwhile across the country public campaigns to save Accident & Emergency departments, maternity services and other services from closure are in full swing. The NHS is “unaffordable” is the oft-repeated justification for these cuts. It’s not though. Nowhere do I hear one of the NHS’s highly paid Finance Directors speaking out about the damage done by these financially-driven reforms.


I’ve struggled to grasp the reasons for this apathy amongst finance staff. Have we swallowed all the rhetoric about how the introduction of “clinically-led” commissioning will offer “choice” to patients? Are we accepting the myth that has grown since the banking crisis of 2008 that the NHS is unsustainable? Are we afraid of speaking out and rocking the boat? Do we just want to get on with our jobs without really having to concern ourselves with the details of government policy? Or have we become so immersed in our own world of numbers and spreadsheets that we’ve ceased to care anymore? Why have we been so quiet on the damage that is being wrought by the Health and Social Care Act?

A recent survey revealed that 39% of finance staff feel that clinicians don’t value their contribution. Perhaps we ought to start earning some respect by properly supporting them in providing high quality patient care. Somewhere the public service ethos that I love has gradually faded to be replaced by a hard-nosed business oriented approach to managing finances that is focused on making cuts. Barely a year after the Francis Report into the tragic events at Mid Staffordshire Hospital identified that cost cutting was a major factor in the breakdown in the quality of care at the hospital. At what point do we say that we simply can’t cut anymore without compromising patient care?


Service Line Reporting was hailed as a major advance in how the NHS manages its finances when it was introduced eight years ago. It represented a more business-like approach to managing finances by treating different specialties and services as separate “business units” and measuring their Earnings Before Interest Taxation, Depreciation and Amortisation (EBITDA) or profitability. Each service or business unit would be asked to demonstrate its long-term financial viability or face the axe. Millions of pounds were spent on implementing SLR, much of it pocketed by the management consultancy firm McKinsey, yet eight years on there is next to nothing to show for this. You see, it’s just not that simple to apply hard-nosed business economics to services that care for often severely ill people and whose demand is unpredictable.


The corporatisation of the NHS can similarly be witnessed in the increasingly cold and cynical language employed by NHS managers. Phrases like “frequent flyers” and “bed blockers” are bandied around to describe some of the most seriously ill patients that the health service has to treat. Changes that can often lead to people losing their jobs are referred to as “transformation”. A local reorganisation of hospital services that results in the closure of Accident & Emergency departments, beds being closed and buildings possibly being sold off for luxury apartments is referred to as “shaping a healthier future”. A 2009 report by McKinsey that identified how the NHS could save between £15 billion and £20 billion over the four years to 2014-15 was called “sizing the opportunity”. An opportunity for who exactly?

We are perhaps best placed of any NHS staff group to appreciate the epic scale of the current reorganisation of the NHS. Unlike doctors and nurses in the front line of delivering healthcare, finance staff could make a stand without it directly affecting patient care. We could speak out about the scandalous waste of money that is the Private Finance Initiative and call for the renegotiation of PFI contracts to at least claw some of the money back. We could refuse to implement charging for health services for migrants. We could stop wasting money on management consultants when there are talented, dedicated staff within the health service who could fulfil the same roles. We could be critical of the shambles of SLR. We could point out the dangers of removing the cap on the amount of income that hospitals can earn from treating private patients. We could bring to the attention of the public the privatisation of the health service and how that results in a flow of money out of patient care in the form of profits for private health companies.


There is the real prospect of austerity stretching way beyond 2020. It’s time that the finance profession found its voice on the state of NHS finances and what it means for patients and services. We can’t go on pretending that taking £20 billion and more out of the NHS will have no impact on the quality of the service that it provides. In a recent interview Margaret Hodge, the chair of the Public Accounts Committee said of the NHS “it’s the public service most under threat, yet everyone’s in denial”. Professional organisations like the Chartered Institute of Public Finance & Accountancy (CIPFA) and the Healthcare Financial Management Association (HFMA) should be honest with the public about the state of the finances of the NHS and what it means for them.

I don’t want to be part of a fragmented health service that places financial considerations above the clinical needs of patients. As the founder of the NHS Nye Bevan famously said “the NHS will survive as long as there are folk left with the faith to fight for it”. Let’s show that we’re capable of more than pushing pens and counting beans. Let’s show that we really care about our health service and the patients that use it. Let’s demonstrate some social solidarity and join the doctors, nurses, therapists, other healthcare workers and members of the public fighting to save our NHS.




From → NHS, Politics

  1. Gonzalez permalink

    Spot on.. well said. let’s set up a breakaway splinter group, called “the real HFMA” to tell it like it is..!

    • Thanks, the thought had crossed my mind about an HFMA splinter group, it’s not as daft an idea as it initially sounds. For me, the HFMA is fast losing credibility as the voice of NHS finance staff.

  2. Michael C Lyndsell permalink

    Well said Sir. Any efficiency savings made will go straight to the bottom line in profit, the tax payer gains nothing from this, It’s efficient PROFITEERING.

    • Thanks for your comments. PFI and the creeping privatisation of health services are the biggest scandals in terms of redistributing public money to the private sector.

  3. Gemma Williams permalink

    Clive Peedell is a consultant at the trust where I work now Jono. I will join a splinter group!

  4. Keep fighting the good fight young man!

  5. Reblogged this on Big Up the NHS and commented:
    Really delighted to be able to reblog this. Please read and share.

  6. Katy Drummond permalink

    Hi, I found your post through the Health Services Journal website today.
    I also read a few other essays on your blog site.
    On Myers-Briggs Personality Inventory, I am on the divide line between Introvert and Extrovert so can see both points of view and sympathise with your
    need to want others to listen to you when what you see doesn’t square rationally with what makes sense.
    In reading I saw that you got your first job with the NHS in 1991.
    That was the same year I went on a training course run by the Kings Fund for doctors about to become consultants. I had done my Higher Specialist Training in Psychiatry at Guy’s Hospital,
    London and we were a pilot site for Griffiths-type analysis of costs generated by doctors.
    One important theme of the course was the “attack” on the clinician’s traditional role by the
    “managerial” culture. We were warned that our focus would have to shift to accomodate the
    “business” model. We all agreed that the NHS faced issues which could be described in a
    reductionist way as rationing of staff skills, activity and cost (as money). However “Health” is not an entity which can be treated as an economic transaction in the market place. Also the NHS
    organization is a very top-down driven juggernaut with the patient lost in the system. Also much activity was spent re-organizing the deck chairs on the Titanic or creating a Brave New World
    which could only ever be a mirage. Activity is better than thinking and agreeing with others on a sensible plan.
    We all had a scientific training so we knew that you had to decide what question you want to answer before deciding what data to collect. As junior doctors we had all experienced people gaming the system rather than serving the patient.
    We all felt that it was like the Hans Christian Anderson story “Emperor’s New Clothes” but there was no one brave enough to say
    the leader had been conned and we are all taking part in a farce.
    I think it is because people fear the world will come to an end if they say what they think. It is best understood in Orwellian terms as what humans do when they are in a totalitarian system and fear not only punishment but their basic primal anxiety numbs the ability to think. Your thinking function doesn’t crumble under this assault by anxiety.
    You are finding it hard because your thinking ability is constantly being attacked and your value system makes you challenge the
    dominant GroupThink of the oppressive system. It’s all mad but you are trying to make sense of this madness.
    You are correct in your analysis except you haven’t understood the primal way individuals think and act in dysfunctional groups.
    This process is well described in the theory and practice of Group Dynamics.
    The first person to describe it vividly was a man named WS Bion who fought as a soldier in WW1
    and based his analysis on what he had experienced in the Army.
    I will keep on reading your blogs so please keep on sharing them with us.
    Katy Drummond

  7. JamesC permalink

    Thanks for an inspiring blog entry. I am a clinician who values what goes on ‘behind the scenes, behind the desks’, even though I may not fully understand everything that needs to happen for the NHS to function.

    • Thanks James, much appreciated. I’m sure there will be someone in your own finance department who would be only too willing to help you get a better understanding of any finance issues.

  8. Sharon Robson permalink

    If only had the nerve …….. Why are we all like you! Keep up the good work

  9. Tracey Watson permalink

    Hi I felt enthused when I read this. I am a leadership and organisational development practitioner in a large trust. I work with hundreds of great people in our trust every month. It’s rare I meet a person who doesn’t work hard and have good intentions. I have no front line clinical experience, however I am a service user, a carer. As are most people!
    I care about the NHS ~ we are all customers. I was born in the NHS and I hope I die in the NHS. I hope I serve that purpose for years to come. Support services should be influencing and supporting it’s customer, ie the patient not navigating politics and egos. I fear in these times of worry change and austerity the golden thread of providing care is diluted the further away people work from the front line. My job is to provide a lense to leaders especially those in support services that magnifies that golden thread of service. Your words inspire leadership in the principles of the NHS. We all have our part to play but some are more likely to step up first. Be brave there are others willing to follow, which is a leadership act on it’s own! Xxx

    • Cheers Tracey, really appreciate your comments. This blogpost started off as a bit of a rant so I’m surprised, but nevertheless really chuffed, that people find it inspiring. You’re right, even though we’re not in the frontline of providing care, those of us who work in support services should never lose sight of the fact that the needs of patients should shape our working lives too.

  10. Bean counters of the world unite & take over. Great piece of writing Jonathan. Well said.

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