If I Were On The Board Of An NHS Provider, Here Are Three Questions I Would Be Asking

The NHS has never been under more financial, operational and workforce pressure. Providers are expected to deliver more care, more quickly, with fewer resources.

Waiting lists are stubbornly high, staff morale is low and deficits are growing. National policy talks of “recovery” and “productivity gains,” but at the level of individual providers, the reality is often firefighting.

So if I were sitting on the board of an NHS provider, what would I be asking?

Not for more glossy strategies. Not for more fire drills to meet the latest national target. But three simple, commercial and pragmatic questions:

• What do we make money on?
• What do we lose money on (and what do we need to cross subsidise)?
• What might we be able to stop doing or subcontract to another provider?

These aren’t the kinds of questions NHS boards are always comfortable asking. But in a world where financial sustainability is existential, they are unavoidable. And the answers, if properly explored, create a roadmap not just for survival but for transformation.

Moving Beyond Turnover – Profit And Cashflow Reality

Boards often take comfort from headline turnover: “We delivered £1.2 billion of care this year.” But turnover alone tells us very little. In the commercial world, there’s a well-known mantra; turnover is vanity, profit is sanity, cashflow is reality. That’s as true in the NHS as anywhere else.

• Turnover tells you what you did.
• Profit (or margin) tells you whether you broke even or made a margin on what you did.
• Cashflow tells you whether you can keep going long enough to do it again.

The NHS rarely talks about profit in these terms, but it should. Some services generate surpluses that keep organisations afloat. Others haemorrhage money. Most rely on fragile cross subsidies. Unless boards understand this in detail, they can’t make rational decisions about what to expand, what to fix, and what to stop. And if you can’t stop it, how do you plan to cross subsidise?

Discovery Before Design – Understanding The Pathway

In my new book, Embedded, I make a central point that you must do discovery before design. Before you can fix a pathway, subcontract a service or decide to stop something, you have to understand the current state.

That means mapping, in detail:

• Every step of the patient pathway – who does what, where, and how long it takes.
• The true cost of delivery – not just the tariff but workforce, estates, consumables, admin and opportunity cost.
• Bottlenecks – where patients get stuck.
• Backlogs – where activity piles up and spills into neighbouring services.
• Patient flow – the routes people actually take, not just the ones in a policy document.
• Money flow – which steps cost more than they generate.
• Hand-offs – every transition point that risks delay or duplication.
• Workarounds – the unofficial fixes staff use to keep the system functioning, often masking deeper inefficiencies.

Without this discovery, boards risk tinkering at the edges rather than redesigning care where it matters most.

The Left Shift – Doing Less In Hospitals

Policy is clear. The “left shift”, moving care from acute hospitals into community, primary care and digital settings, is the direction of travel. But for Trust Boards, the left shift is not just a policy imperative; it’s a financial one.

You can read more about the left shift in my blog here.

Every hospital board must ask, which services are tying up resources unnecessarily? Which clinics could safely be delivered elsewhere? Which pathways should we stop holding onto, not because they’re unimportant, but because others can do them better, cheaper and closer to patients?

The NHS template subcontract for 2025/26 provides a practical mechanism for this. Providers can subcontract services to other organisations under a standardised, compliant framework.

Done well, this enables hospitals to concentrate on complex, high-value care while freeing capacity, reducing deficits and improving flow.

An Indepth Look At The Three Core Questions

1. What Do We Make Money On?

Every provider has areas where services are not only clinically important but financially viable. These might be high volume elective procedures with decent margins or specialised services where the Trust has particular expertise.

Boards must identify these areas and protect them. That means ensuring:

• The pathway is efficient with minimal delays and cancellations.
• Workforce is optimised so skilled staff are not wasted on avoidable admin.
• Estates and theatres are used to full capacity.

Example: Elective orthopaedics

Orthopaedic surgery is often a profitable service line when managed well. Theatres are expensive but when throughput is high and cancellations are minimised, the margins are strong. Trusts that run dedicated orthopaedic centres or “cold sites” often find this a stable source of income.

Opportunity for pharma, medtech and device companies:

• Robotics and navigation tools can improve efficiency, reduce revisions and increase throughput.
• Prehabilitation programmes (supported by digital apps or remote monitoring devices) can optimise patients before surgery, reducing cancellations.
• Enhanced recovery pathways, supported by medicines and devices, can cut length of stay.

2. What Do We Lose Money On?

This is where it gets uncomfortable. Some services are structurally loss making, either because tariffs don’t cover costs, demand outstrips funding or inefficiencies swallow margins.

Common examples include:

• Urgent and emergency care – a constant pressure point with insufficient funding.
• Long Term Condition management in hospitals, where patients could be managed more effectively in community settings.
• Follow-up clinics, often a legacy of outdated models rather than genuine need.

Example: Outpatient follow-ups

Many Trusts lose money on routine follow-up appointments that add little clinical value. Patients stable on treatment for conditions like hypertension, diabetes or asthma may attend multiple follow-ups that could be replaced by community monitoring.

Opportunity for pharma, medtech and device companies:

• Remote monitoring devices that allow safe community follow-up.
• Medicines with proven outcomes in reducing admissions (e.g. SGLT2 inhibitors in cardio-renal-metabolic conditions).
• Structured nurse-led review models, supported by pharma or medtech partners, to reduce unnecessary hospital visits.

3. What Might We Stop Doing (or Subcontract)?

The most radical but necessary question. Providers often continue delivering services out of habit or fear, even when they are unsustainable. Boards must have the courage to say: “We shouldn’t do this anymore.”

Example: Spirometry

For years, diagnostic spirometry drifted into secondary care. Hospitals struggled with backlogs, underfunded tariffs and slow turnaround. Yet spirometry can be delivered effectively in primary care by trained nurses, with digital reporting back to GPs and consultants.

Opportunity for industry

• Pharma can fund or co-develop nurse training programmes.
• Device companies provide portable, accurate spirometry equipment.
• Medtech solutions integrate results into GP systems and ensure consistent interpretation.

Example: Wound care

Chronic wound care consumes huge amounts of time in both hospitals and General Practice, often without standardisation. Subcontracting wound care clinics to dedicated community providers, supported by medtech imaging tools, dressings and digital triage, can deliver faster healing and reduce re-admissions.

Example: Mental health digital tools

Secondary care often carries the burden of referrals for mild to moderate depression or anxiety, when digital CBT tools could support patients earlier in their journey. Subcontracting delivery to community providers or federations can shift activity left while maintaining safety.

The Role Of Industry: From Supplier To Partner

For pharma, medtech and device companies, the implications of these questions are profound. Your value is not in selling a standalone product. It is in helping NHS providers answer the questions boards should be asking.

• Where do we make money? Show how your product strengthens profitable services by improving efficiency, throughput or quality.
• Where do we lose money? Demonstrate how you reduce costs, admissions or follow-ups in fragile pathways.
• What can we stop or subcontract? Position your solution as a safe enabler of care closer to home, in line with NHS subcontracting models.

The NHS is not structured to buy products in isolation. It is structured to commission and deliver pathways. Industry partners who align with this reality, who show how they improve flow, reduce cost and support sustainability, will move from supplier to trusted partner.

Case Studies In Practice

Fracture Liaison Services (FLS)

Pharma companies with osteoporosis treatments often struggled to gain traction until they reframed their offer around pathway redesign. By co-designing fracture liaison services that systematically identified fragility fractures, ensured treatment and audited outcomes, they turned a drug into a catalyst for a whole service.

Lesson – Don’t push the product; redesign the pathway.

Digital Mental Health Tools

Digital CBT tools faced resistance when pitched as “apps.” But when reframed as a subcontracted service that reduced waiting lists, supported GPs and delivered Core20PLUS5 goals, they gained traction.

Lesson – Align with system pain points, not product features.

Wound Care Services

Variation in wound care creates inefficiency and poor outcomes. A medtech enabled pathway that standardises assessment, integrates digital imaging and provides community based review clinics transforms wound care from a time drain to a measurable quality improvement.

Lesson – Tackle variation with data, devices and pathway support.

This Is The Way To Move From Product Hawker To Valued Partner

If I were sat on the board of an NHS provider, my questions would be simple:

• Where do we win?
• Where do we lose?
• Where can we let go?

Answering them requires courage. It means facing uncomfortable truths about where services are unsustainable. It means rethinking what hospitals are for. It means embracing subcontracting and the left shift.

But it also opens a door. For pharma, medtech and device companies, this is the chance to stop being product vendors and start being transformation partners. If you can help providers answer these three questions with practical, pathway aligned solutions, you will be in the room when decisions are made and you’ll stay there.

Because the NHS really doesn’t need more products. It needs partners who understand flow, finance and the reality of delivery. And those partners will be the ones who shape its future.

At www.scottmckenzieconsultancy.com, we work directly inside the NHS, supporting provider organisations, commissioners and system leaders to implement real change. We then help pharma, medtech and device companies interpret what’s happening, so they can engage the right stakeholders, align with NHS priorities and get their innovations embedded into care pathways.

With more than 20 years working within the NHS and Pharma, medtech and devices companies, Scott brings a unique dual perspective, now captured in his book, Embedded: How Pharma, MedTech, and Device Companies Can Get Their Products into NHS Pathways and Stay There, which distils everything he’s learned into a practical playbook. Whether you’re launching a new product or trying to unlock stalled adoption, Embedded shows you how to reframe your offer, align with NHS priorities and make change stick.