NHS finance staff gather in a basement meeting room to discuss changes. Two finance departments are to integrate after our merger with another hospital and it’s an anxious time. A guest speaker advises us on how to cope with change but, for most in the room, restructuring and reorganising has been an almost constant feature of our jobs for many years. We’re still dealing with the fallout from the 2012 Health and Social Care Act.


I attend a meeting with colleagues from local clinical commissioning groups (CCGs) to review outstanding payments from the second quarter of this financial year, which ended five months ago. All the patients that go through the hospital are recorded and the finance department attaches a price to each for the treatment he or she received. This time, a CCG is challenging £9m of the £27m we have billed it. Many disputes rumble on for months, exacerbated by the financial pressure on both parties. CCGs are reluctant to pay for any activity they don’t consider their responsibility or that they deem clinically inappropriate, while cash-strapped trusts are eager to protect their revenue streams. The meeting, scheduled for one hour, lasts for nearly three.

Afterwards I work through my list of challenges. Often that means looking at details of the care individual patients received, and it can be a laborious process. One query relates to a charge for a patient’s bespoke dental prosthesis, which cost several thousand pounds. Dental services should be paid for by NHS England – not CCGs – hence the query. I discover the item in question was used in a maxillofacial (jaws and face – not dental) procedure and, after an exchange of emails, the CCG accepts the charge. Behind the numbers, someone has undergone a life-transforming procedure. Amid the byzantine system of financial flows that reduces hospitals to mini-businesses and occupies far too much of our time, it’s easy to forget the important things.

If the way the NHS is organised seems absurd, that’s because it is
Polly Toynbee
I write a brief report for the board summarising the trust’s monthly income. November was the busiest month of the financial year so far for our A&E department, with a higher than expected number of emergency admissions. Perversely, with our accounting goggles on, we tend to view more patients turning up at A&E favourably as it boosts the trust’s income. It’s absurd that we end up thinking like this. Surely the emphasis should be on reducing the number of patients visiting A&E? Organisations end up looking inwards to protect their finances, when patients need us to look outwards at the whole system.

I receive a call from a clinician working on a business case for developing cardiac services after the merger. Part of the case involves forecasting the impact on the trust’s income over the next few years, and he needs help in understanding how the trust is reimbursed for its activity. I compile some income projections and run through them with him.

Guidance on the national payment system for 2016-17 drops into our inboxes. It includes draft prices for the next financial year and means we can begin income planning. Prices will rise but, simultaneously, the health service is expected to deliver an additional £20bn of efficiency savings by 2020, which many chief executives and finance directors acknowledge is nigh on impossible.

Most satisfying moment: Advising the clinician on the financial aspects of changes that will improve the quality of care for patients with the centralisation of expertise and equipment on one site.