Open any newspaper, on any day, and you are likely to encounter stories describing how the National Health Service is in a cycle of financial decay ­ in a system that leaves millions of pounds unspent one year and then huge deficits the next in an endless boom and bust merry go round.

This picture makes it is easy to imagine NHS finance directors as frazzled damage limitation specialists rather than stewards who steady the finances and make long-term plans to invest in healthcare services and technology.

Jane Tomkinson, FD of the Countess of Chester Foundation Trust, blows that stereotype out of the water. Her trust has 580 beds, employs 3,000 staff, provides care for 400,000 patients annually but still manages to generate steady surpluses every year.

Countess of Chester banked £2.7m in 2006/07 and £2.6m 2005/06. Over the next three years, the trust plans to continue generating modest annual surpluses of £1.6m. Financially, organisations don’t get more stable.

Tomkinson joined the NHS in 1990 and was appointed as deputy FD at Countess of Chester in 1998 and FD in 2002.

She played a key role in helping Countess of Chester become one of the first NHS foundation trusts in 2004. It is an achievement she believes was crucial in securing the financial stability it enjoys.

‘Becoming a foundation trust gives you the freedom to manage healthcare locally without the constraints of central government or the Strategic Health Authority. There is the financial freedom to generate surpluses and then invest that money into the healthcare needs of the local community,’ Tomkinson says.

Trust model

There are now 89 foundation trusts in the UK, the first of which were established in April 2004. They are organisations that operate as independent public benefit corporations and provide healthcare according to the NHS princip les of universal care. But they have the freedom to generate surpluses a nd borrow money as they see fit in order to improve services and innovate for the particular needs of their communities.

‘This is the only way to invest and it is right that there should be a financial surplus. It allows for better planning for future risk and there is no reckless spending. The foundation trust takes ownership of providing care to its community,’ says Tomkinson.

She is adamant that this is the best way to provide quality healthcare and is superior to the traditional tariff-based system. ‘A tariff system can cause imprecise costing and there are areas of apportionment which results in inefficiency and constrains effective business decision making,’ she says.

‘A foundation trust mirrors the private sector far more closely. There is more flexibility. You look at financial indicators and monitor risk metrics. You look at the balance sheet, assess what cash you have and plan how you will invest that in the future. These things would just not be explored otherwise,’ Tomkinson says.

But acquiring foundation trust status is not easy and requires applicants to demonstrate a high likelihood of generating a sustainable net income surplus after three years, maintain a reasonable cash position, and certify its financial reporting procedures are satisfactory, with external opinion to back the claim.

It must also have a robust board structure. Countess of Chester is managed by a board consisting of a non-executive chairman, five executives and six non-executives.

As Countess of Chester was one of the first organisations to acquire trust status, Tomkinson found herself at the forefront of introducing these changes in structure and implementing the new system of financial management.

‘It was completely new. This had never been done before so there wasn’t much guidance to follow and it was iterative.

‘We had to change our thinking. We were almost creating a system from scratch, but at the same time keeping the day-to-day business of the hospital running. We set the agenda. It was very challenging but hugely exciting,’ Tomkinson says. Just under four years since achieving trust status, Tomkinson says she still finds the job exciting and stimulating. One of the reasons for this is the diversity of her role. In addition to finance, Tomkinson also takes responsibility for corporate performance management and IT.

One project she led was the introduction of a COA Solutions eProcurement system that has created £5.2m in efficiencies.

She also enjoys analysing the services to private patients that the hospital offers. These services generate valuable income for the trust and Tomkinson is responsible for ensuring that the right private patient services are available and that they are profitable.

‘The modern NHS FD has to have financial management skills, understanding of the operational issues of healthcare, strong financial management skills and technology knowledge, as well as empathy with people. It gives a real edge to the role,’ Tomkinson says.

One part of her job that she finds particularly energising is her daily interaction with doctors and therapists. ‘If you are going to have any credibility as an executive working in healthcare, you have to have medical knowledge. I meet daily with the clinic’s consultants and I have to know what resource we have and where it needs to go.

‘For instance, you have to be able to weigh up the costs of surgery versus drug therapy, but also have an understanding of which treatment is the most appropriate in different circumstances. Healthcare is complex and the story is not as straightforward as it seems. You need to understand that as an FD,’ she says.

Indeed Tomkinson can’t simply focus on the bottom line and cut costs at the expense of quality care. The key challenge she faces daily is balancing the importance of financial prudence with the key objective of providing the very best quality healthcare.

It is a balance she has struck well. While Tomkinson has kept generating surpluses, the hospital treated an extra 7,500 patients in 2006/07, reduced waiting times by 17% and reduced MRSA infections by 44%.

‘Finance is the foundation for delivering good healthcare,’ Tomkinson says.
But it is more than just the variety in her role that has kept Tomkinson committed to a career within the NHS and immune to offers of a higher pay package in the private sector.

She says that over the years she has worked for the NHS she has seen ‘a fair degree of drift’ of colleagues to the private sector, but has never been tempted herself.

‘Money is not a key motivation for me. It is how we deliver services and improve healthcare that is rewarding,’ Tomkinson says. ‘The reward is not instantaneous but when you invest effectively over a long period of time and you see healthcare improving because of that, the payback is immense.’

Positive attitude

If there is one thing that irritates Jane Tomkinson, the FD of the Countess of Chester NHS Foundation Trust, it is the negative way the NHS is portrayed to the public.

Over the last year Tomkinson’s foundation trust has treated more patients, reduced waiting times and still managed to deliver a surplus of £2.7m for future investment.

It is an achievement of which Tomkinson is proud, and she believes there are many more examples of good financial management and excellent healthcare provision in the NHS that are not acknowledged.

‘I do feel that there is vast negativity towards the NHS. Health is such a hot issue that sometimes political reaction can be knee-jerk. I also feel that the media seem to love a bad news story rather than focusing on the good things,’ Tomkinson says.

She believes better education is the key to changing perceptions and wishes that reporting on the NHS could be ‘less emotional and more objective’.

‘The NHS is a very positive healthcare system. Yes, things are not perfect, but the percentage of NHS patients who have a negative outcome is minimal and that needs to be put into perspective,’ she adds.