I’m a surgeon by training. I spend most of my professional life thinking about risk, outcomes, flow, capacity, and decision-making under pressure. Until this MBA, accounting sat firmly in the “important but someone else’s problem” category.
The Accounting and Accountability module changed that.
Not because it turned me into a finance expert — it didn’t — but because it gave me just enough fluency to understand how performance is constructed, defended, and sometimes quietly distorted. That matters a lot in the NHS.
This wasn’t really about accounting. It was about accountability.
Yes, we covered the fundamentals:
balance sheets, profit and loss, cash flow, accruals, ratios, valuation, sustainability.
But the underlying theme was consistent throughout:
How do organisations demonstrate that they are productive, well-run, and in control — and who decides what “good” looks like?
That question is uncomfortably familiar in healthcare.
The NHS talks a lot about productivity: theatre utilisation, waiting lists, length of stay, outpatient activity, cost improvement programmes. What we often talk about less is how those numbers are constructed, what assumptions sit underneath them, and what behaviour they incentivise.
Accounting forces you to confront that.
Accruals: the NHS parallel nobody spells out
One of the most useful concepts for me was accrual accounting.
At a basic level, it’s about matching income and costs to the period they relate to — not when cash moves. But in practice, accruals are where judgement lives:
provisions, depreciation, revenue recognition, year-end adjustments.
Those aren’t just technical decisions. They are managerial choices.
Once you see that, it’s impossible not to notice the parallels with NHS performance reporting:
- activity recognised now, consequences felt later
- benefits counted this year, costs deferred
- “non-recurrent” adjustments that quietly recur every year
Understanding accruals doesn’t make you cynical. It makes you precise. It lets you ask better questions without assuming bad intent.
Productivity vs performance: a familiar NHS trap
A recurring theme in the module — and one that landed hard — was the difference between:
- activity
- productivity
- performance
- and sustainability
You can be busy and still be inefficient.
You can increase output and still worsen cash position.
You can hit short-term targets while quietly building long-term risk.
That maps exactly onto NHS productivity conversations.
We often default to counting “things done” because they’re easy to measure. Accounting frameworks force you to ask whether those things are:
- properly funded
- repeatable
- creating downstream cost or risk
- aligned with the organisation’s purpose
That shift in thinking is directly applicable to theatre productivity, clinic redesign, virtual models of care, and workforce planning — without needing to be overly technical.
The residential business simulation: learning the hard way
The highlight of the module was the residential business simulation.
In teams, we ran a company over multiple cycles — making decisions on pricing, investment, borrowing, dividends — while managing profitability, cash flow, and the balance sheet.
It was competitive, occasionally chaotic, and brutally instructive.
You could make what felt like the “right” operational decision and still end up with a deteriorating financial position. You could look profitable and still run out of cash. You could chase growth and load hidden risk onto the balance sheet.
That experience crystallised something that resonates strongly with NHS leadership:
Good intentions don’t guarantee good outcomes if the system design is wrong.
Productivity without financial and operational coherence is just deferred failure.
NHS accounts: suddenly more readable
One unexpected benefit of the module is that NHS accounts now make more sense to me.
I don’t mean I suddenly enjoy reading them — but I can follow the logic:
- why deficits and “break-even” aren’t the same thing
- how capital, depreciation, and backlog maintenance interact
- why cash support and revenue support tell different stories
- how sustainability and long-term viability are increasingly part of the narrative
That matters for clinicians in leadership roles. If we don’t understand the language of accounts, we can’t effectively challenge or shape the story being told about our services.
What I’m taking forward into NHS leadership
Three practical shifts for me:
- I interrogate productivity claims more carefully Not to block progress, but to make sure gains are real, repeatable, and not just accounting artefacts.
- I see governance and finance as enablers, not obstacles When done well, they protect services, staff, and patients from short-termism.
- I’m more confident operating at the clinical–financial interface I don’t need to be an accountant. I do need to understand enough to ask the right questions.
Final reflection
I went into this module as a surgeon learning the basics of accounting.
I came out of it seeing accounting as a practical tool for understanding productivity, sustainability, and accountability — especially in large, complex systems like the NHS.
And honestly? I enjoyed it more than I expected.