Caroline Clarke

Shoe size 6

Produced by Eleanor McDowall

When people ask me what I do, if it's in a taxi, I might just say I work in the NHS and then I might get a response “Are you a nurse, love?” - that's happened to me a few times.

I once said I was a brain surgeon and then the man said “Oh I'm seeing somebody, I'm under so and so at this particular hospital.” So I've never lied since, because, obviously, lies have short legs and that was a very stupid thing to do. I had two parents who were sick when I was quite young. So I think that that might have dictated me coming into the NHS I think most people have some kind of story. Did an economics degree and wanted to do public service and I wanted to join trade unions, actually, but it was at a time when union membership was declining, so I don't know if you remember, it was in the Thatcher years. I often think about what would have happened to my mum, who had a stroke more than twenty years ago, and lived quite a long time after, but didn't live very well, so you kind of think health care has changed and definitely having a kid colours how you think about things, you know I went to vote this morning, I took her with me because it's really changed the my thoughts on voting, and I was kind of really "Women have died for this you know, you’ve got to come and look". She's six, I don't think she quite got it, but, you know.

OK, so my name is Caroline Clarke, I'm the chief financial officer and deputy chief executive at the Royal Free in North London. We are currently sitting in my office on the second floor of the Royal Free Hospital in Hampstead, which is one of the three hospitals that we operate. I didn't really want to be an accountant and I thought accountants were a bit dull, bean counters. I didn't really know any accountants - the ones I did know were just kind of grey and largely blokey, but I didn't want to be a general manager either, I thought I needed a profession and had I been more practical, I might have done plumbing - but I’m not very practical, and so I did finance and then the graduate scheme sort of promoted through the NHS , so I've done kind of every, every sort of job in the NHS , and then, about seven or eight years ago, I took a couple of years out. I went to work with KPMG, one of the big accounting firms, and kind of learnt what it was like in the commercial sector, which, it turns out, is very interesting, and the dark side, as people on my side of the fence call it, is actually full of really nice people who have similar values and are just working with a slightly different profit motive. And it's very different. It's different if you're working in an organisation where the main determining feature of your success is money, it's much easier. In this world, it's saving lives. One of the reasons why I work in a hospital, rather than in a kind of planning bit of the NHS or NHS England or these clinical commission groups, is because I think you need to stay close to patients. You know, people like me must spend time on the ward, so we are all compelled to go out on the wards and see staff and patients and talk to them. You know, we talked a bit about my parents, actually I've been a patient a number of times and I have MS, so I'm treated in a different hospital. Diagnosed while I was working in this job by colleagues, which was quite difficult for them.

I think they did it really nicely and really elegantly and I had to make a decision about whether to speak about it or not. I still struggle a bit with that, because I'm in a leadership role and people need to see me being strong and resilient and making good decisions and MS is a disease which affects your brain as well as your physical health. So I took a decision to be really open about it, because people need to see and make up their own mind really. As it happens I am well with it, but, you know, who knows what the future brings? But I'm being treated in another hospital, because at least I can be a patient there. One of the things that we do in the NHS is we provide people with long term conditions with a clinical nurse specialist, so you don't always go and see a doctor, if there's something wrong you can ring up someone who's very, very experienced in looking after people with your condition. And it turns out that that is a really, really important thing to have if you're a patient ,you know, I mean, I, you know, it hasn't happened to me particularly yet,

but I know that if I have a new symptom I can ring this person and say this thing's happened and I don't know what to do about it and I know that she'd have the answer or she'd put me in touch with somebody and that is fantastic. At all hospitals we have to reduce our costs, and there are fairly conventional ways of reducing your costs in hospitals, and, you know, some of it is about reducing waste and making sure we don't do things twice. And some of it is about redesigning people's roles, so that less expensive people do more. It’s sort of a slightly facile way of describing it. And one of the things you often see on people's kind of cost-cutting lists, because you have a list, is clinical nurse specialists. And I've seen that quite a few times in my career, and the reason why clinical nurse specialists are often seen as a kind of target area to cut costs is because, of course, they don't see patients in a conventional manner, where the patient, you get paid for it. So every time you come into a hospital you generally get paid for the thing that you do to a patient. It’s called, the system's called ‘payment by results’ and the clinical commissioning groups, our commissioners pay us for the treatments, but when you ring up a clinical nurse specialist, of course, that's just a phone call or chat, you don't get paid for that. So their costs kind of get covered by everything else, so they're almost seen like an overhead. That is a problem, and I think my personal experience has definitely made me see that quite differently and...We've got loads of clinical nurse specialists here and I, you know, I'm sure there's stuff we can do differently and we can improve the patient experience and make it more efficient but my view of them is definitely different. And I'm sure it's the same for everyone and it's why you’ve got to have really diverse groups of people making decisions, so, you know, around the board table, unique groups of commissions, you need one or two people like me but you need a diversity of thought.

I'm always interested in space and I've got enough space - other empty offices that we can recycle, you'll see that the infrastructure here isn't as good, so this is, this isn't clinical space, this is the medical school, they haven’t modernised so this is pretty much original 1970s.

You could argue that every period in NHS History has been difficult, but I think this one is quite unique. So it's got a number of features that are very difficult at the moment, so the money just is, there may be enough money but not for this particular set of services. You cannot have universal health care for everybody at the quality that we want it and the money that we're willing to pay. I absolutely accept that the NHS can get more efficient and part of my job is to make it more efficient, but I can tell you now that my hospital here is one of the most efficient trusts in the country by every kind of measure that you use, and yet we have a deficit, so our costs are greater than our income by about five percent. I had a deficit once in 2005/6 and we turned that around and it was OK, but it was hard, but we did it, but I haven't, that hasn't happened since. And I feel terrible about it, so you know, I'm not as anxious as I was when I was twenty or thirty. But that really does keep me awake at night, and I don't I know that in the longer term... I have a range of solutions that can solve it. And we've got a great clinical workforce here and I'm pretty sure that over the next five years our plans will get us back to where we need to be, but it's going to take much longer than an electoral cycle. So will the politicians kind of give us the time and space? We’ve had a few conversations with politicians who, of course, are having of necessity to work on the electoral cycle, and they say, “Well why can't you get to scale really quickly? Why can't you take ten hospitals over kind of tomorrow”. And I'm like, “Well, we took two over two years ago and it's really hard,” and we're really trying to make it work and we said it would take us five years to get them back into a financial position that worked, and so these things do take a long time, and so, you know, we're living through exactly this conundrum of, you know, fix it now versus the long term. The day that you stop being frustrated and stop thinking that you can improve, is probably the day to retire. As long as we all burn slightly with that irritation, that's good.