The Voice of Trusts
Trust chief executives have one of toughest jobs there is
I have been lucky enough in my career to work with a range of cabinet ministers, FTSE 100 company chairs and chief executives and Whitehall permanent secretaries. I believe that being an NHS trust chief executive is just as difficult as any of these roles, if not more so.
It’s a view I know is shared by David Bennett at Monitor, the health sector regulator. Why?
Consider the following factors involved in being a trust chief executive. For a start, you’re running a safety critical organisation − getting it wrong can mean the difference between life and death on a systematic basis and there aren’t many organisational leaders who directly bear that responsibility.
‘It can sometimes feel like you are managing what one chief executive described as a “set of warring tribes”’
Your role is usually subject to the full glare of local and sometimes national media attention. Service failures and service changes are all headline news and there’s often a level of personal vilification involved in the coverage.
Health issues understandably generate strong emotions in local communities and this is often reflected in the way the local debate about healthcare is conducted.
Lack of support
It’s a business model over which you have startlingly little control. You effectively have a compulsory universal service obligation: you must treat whatever comes through the door, to stringent and demanding national standards and targets, such as waiting times and clinical and quality standards.
If someone turns up at your A&E department, for example, because everyone else (eg: all the local GP surgeries) is shut, you can’t do anything about it. Failure to deliver the targets, sometimes due to factors beyond your control, can result in finger pointing rather than constructive support designed to help you improve.
Prices are often centrally fixed and may not reflect the true cost of what’s being provided. Your ability to deliver your service is constrained by the need to operate in a highly complex interdependent system with little or no control over the other system players.
For example, the person who buys your services changes, just after you’d got used to working with them, and you now have to form a completely different set of relationships.
Tribal loyalties
You’re currently required to improve the quality of the service you offer while reducing the cost of your service by 5 per cent every year − right on the edge of what international experience says is sustainably deliverable.
But 65-70% of your costs come from your workforce, with these costs driven by a highly inflexible national pay agreement that can ratchet up annual pay increases, even when there is supposed to be a national pay freeze.
‘Complex leadership challenges like running a trust live or die by their ability to attract, retain and develop the best talent in senior roles’
At the moment, in particular, you’re trying to cope with the consequences of displaced demand that is coming from the rest of the health and the social care system, with the latter under particular strain in some places as local government spending cuts begin to bite.
While you are formally in charge of your organisation, you have to contend, such as if you are an acute hospital chief executive, with the fact that over 100 different bodies ranging from the royal colleges and regulators to health and safety inspectors and local authorities, have the right to come in and demand that you start or stop a particular activity.
Although you may have great and highly motivated staff, it can sometimes feel like you are managing what one chief executive described as a “set of warring tribes”. Some consultants, for example, may have stronger loyalties to their profession and other sources of income than the trust you lead.
Cause for concern
So why does this matter? There is lots of evidence to show that systems with complex leadership challenges like running an NHS trust live or die by their ability to attract, retain and develop the best talent in the most senior leadership roles. I hope everyone would be as concerned as I was when a leading sector headhunter told me the following four facts last month:
- they had struggled to find even one appointable candidate in their last 10 NHS trust chief executive appointment processes;
- over the summer, four trusts had asked them to approach what collectively turned out to be 10 former chief executives to see if they would return to the role. All 10, still working but not in the NHS, many in the voluntary sector, refused. They all cited the pressures outlined above;
- the average length of tenure for an NHS chief executive these days is 20 months and leadership turnover in some of the more challenging trusts is clearly a significant factor in poor performance;
- there were 20 trust chief executive vacancies at one point last summer.
This is clearly a major problem.
What can we do about it? Why don’t we start with everyone in the NHS recognising just how difficult these roles are and offering all the support − moral and practical − they can to those who are sitting in the hottest seats around?
The Foundation Trust Network: you had to be there
People often say that “you had to be there” to appreciate a really good event. And it’s tempting to say the same of the Foundation Trust Network’s first annual conference in Liverpool. But while all those on the ground listened to some great speakers, wandered around the exhibition, and networked like mad, there was a parallel conference going on in the ether.
Tweeters and bloggers beamed out the messages far beyond the shores of the Mersey and the networking was almost as intense as the chatter on the ground. Looking back on some of the tweets and blogs gives a flavour and a glimpse into some of the knotty and complex themes debated and unpicked at the conference - #ftn2012.
One theme to emerge was how delivering high quality patient centred care has to sit at the heart of all that the Foundation Trust movement does. Three priorities were identified here:
- Ara Darzi’s dictum that we need to make quality the key organising principle of how we run the NHS. How far have we really got with this?
- Breaking the logjam around ensuring patient feedback gains traction as a means of driving improved care. Are we doing enough here?
- Ensuring our culture, systems and processes reflect the fact that we operate in a safety critical industry. Are we doing as well others who operate in similar “safety critical” sectors?
I was struck by the overwhelming need to do things differently if the NHS is to meet the significant challenges it faces. And that the FT movement, with its freedoms and relative sense of stability compared to the rest of the service, is in pole position to drive the innovation required. This will require a greater degree of risk and a willingness to embrace disruptive change than all of us will feel instinctively comfortable with…particularly in a safety critical industry.
One of the themes I personally stressed was the importance of celebrating success - particularly when it involves innovative approaches, is driven by front line staff and improves the quality of patient care. I deliberately made one such story the centre piece of my speech - you can read it here.
The ever perceptive Paul Corrigan, in his blog from the conference, highlighted what he saw as the surprising reticence of the Foundation Trust movement to really take advantage of the freedoms FTs have been given. In his words “One of the main questions asked about NHS architecture, post the creation of the first FT in 2004, has been why FTs have not all been much more separate from the NHS hierarchy. Throughout the period Strategic Health Authorities have usually been trying to tell FTs how to operate as a part of the wider NHS - and sometimes that has been intrusive. Why haven’t more FTs told SHAs where to get off?”
He speculated that the reasons for this included a lack of trust that these new freedoms are permanent and that at some date in the near future, they will be taken back and retribution for any overly independent behaviour will take place. He pointed to this as an important example of how strong the dominant NHS culture really is. But, in his words, there was a law which changed the ownership of FTs and it was passed. For eight years FTs have had experience of being a different legal entity. The model has worked. There was no debate in the recent Health and Social Care Act about abolishing FTs. In fact, far from it, the Government has decided that all NHS Trusts should reach foundation status as quickly as possible.
In the words of Earl Howe, the Minister responsible for NHS providers, in his speech to the conference: “[The Government] wants strong, autonomous foundation trust boards that take responsibility for delivering change … There is always going to be a balancing act between the powers of the centre and the autonomy of local providers and commissioners. But this Government’s instincts are to decentralise. And we now have the Health Act to underpin those instincts”
Earl Howe’s and Paul Corrigan’s challenge to the FT movement to grow into and use the freedoms to deliver the change the NHS needs is well made and one that we need to rise to.
C is for Culture - not Control
It is rather apt that the former Culture Secretary, Jeremy Hunt, who has now taken over the Health portfolio, spoke about culture in his first public foray at the Conservative party conference last week.
He was talking about care of the elderly when he said: “I want to be the Health Secretary who helped transform the culture of the system”, but culture change in the health service could, and should, be applied more widely.
Of course it applies to a culture of kindness and caring for patients, and a system that is open to innovation and enterprise. But it goes wider than that, and should apply to the way that the whole NHS runs. As Jeremy Hunt himself pointed out, it is famously the fifth largest organisation in the world – bigger than the Indian railways and just a little smaller than the Red Army.
Our new Secretary of State says that he has a desire to transform the system and ensure that it is not overly centralised. “We will never meet the challenges we face with over a million people trying to meet a thousand targets to satisfy one Secretary of State sitting behind his desk in Whitehall,” he told the party conference. He also, pointedly, said “no to top down bureaucratic procurement”.
He is quite right. A ‘command and control’ culture based on uniformly measuring progress against hundreds of targets is not the way to get the best out of the NHS – something with which even Tony Blair now agrees. It’s been interesting to watch the former Prime Minister’s personal conversion to the same cause as that now advocated by Jeremy Hunt: empowering those on the ground to deliver, making them accountable to local people and service users but also responsible for national standards underpinned by a robust regulatory regime. If this sounds familiar, it should do. It’s the Foundation Trust model.
The Health and Social Care Act has decentralising the NHS at its heart – for example by abolishing Strategic Health Authorities and enshrining the concept of provider (and Clinical Commissioning Group) autonomy throughout. But structural change needs to be accompanied by cultural change to make the decentralist vision a reality.
Paul Corrigan makes the powerful point that despite its stated intention, there is a danger that the Act is leading to more centralisation, not less. He points , for example, to the significant percentage of the commissioning budget that will now be spent nationally by the NHS Commissioning Board as opposed to locally by Clinical Commissioning Groups.
So, as the new national bodies established by the Act begin to assume their responsibilities, they need to ask themselves, which of the two visions of running the NHS do we want to adopt? The one that’s about a million people trying to satisfy a thousand targets or the one’s that about genuinely empowering local organisations to deliver local needs? The way these organisations behave and the culture they adopt will largely dictate the outcome. The argument applies across the piece from commissioning to leadership training and education.
As a final thought, there may also be occasions when the new Secretary of State needs to be reminded of his decentralising instincts. One intriguing section of his speech said: “We have many committed managers in hospitals and care homes. But I need to say this to all managers: you will be held responsible for the care in your establishments. You wouldn’t expect to keep your job if you lost control of your finances. Well don’t expect to keep it if you lose control of your care…I have asked my Department and the Care Quality Commission how we can make sure managers are held accountable for the care they provide, both in the NHS and social care sectors”.
This sparked speculation about a whole new regulatory regime governing managers with some suggesting that managers would be subject to the same type of registration and assessment that characterise the relationship between the Royal Colleges and clinicians.
There is a real danger that this will end up confusing and diluting as opposed to clarifying and strengthening management accountability. It is NHS Trust Boards who must and should hold accountability for the management and leadership of care in their organisations. Setting up a parallel regulatory structure undermines the key relationship between a Board and its managers. If there is a fundamental failure of the board then there are other remedies as recent events at both Mid Staffs and Sherwood Forest have shown.
It’s a good example of how we should subject each new initiative to that basic test – is this about a million people trying to satisfy a thousand targets to satisfy one Secretary of State sitting behind his desk in Whitehall or is it about genuinely empowering local organisations to deliver local needs?
NHS enterprise has been given a freer rein
Ten years ago everyone warned that foundation trusts were the start of privatising the NHS. How wrong they were.
This week, the arbitrary and absurdly tight restraints on the income that these organisations can earn from beyond the NHS have been lifted. The government used to prescribe how much non-NHS income these organisations could earn and, for the vast majority, this amounted to 1 per cent of their income or even less.
These restrictions were put in place to ensure that NHS organisations, funded from the public purse, supposedly stayed true to their core public purpose and weren’t seduced into prioritising private healthcare over public medicine. In practice, this was always a false argument.
Excellence, expertise and enterprise
The restrictions have now been dropped and, in their place, we have a 49 per cent non NHS income limit - a safety catch to show that the majority of these organisations’ work is firmly rooted in the NHS. Given the unique governance arrangements for foundation trusts, they will also need the majority approval of their governors to approve an increase of 5 per cent or more in non NHS work. And they have to set out how their non-NHS income has benefited NHS patients in their annual report. This is something that these organisations will willingly and proudly do because so much of their non-NHS work shows excellence, expertise and enterprise that benefits all patients.
‘Non-NHS income is not a backdoor privatisation of the NHS’
Non-NHS income does not always equal private patient work - although it can do. And it is certainly not a backdoor privatisation of the NHS. Indeed, these foundation trusts are at the very heart of the NHS. Non-NHS activity covers all sorts of activity where someone else pays - this could be employers wanting to pay for their staff to have counselling or other psychological support; trusts providing medical services for British troops abroad for the Ministry of Defence; or specialist care for foreign patients being funded by their own governments.
The Foundation Trust Network, which represents these trusts, argued long and hard that the cash-strapped NHS needs all the income it can find and that trusts should be allowed to compete with the private sector for this valuable income.
International reputation
Some of the beacons of the NHS such as Moorfields Eye Hospital, the Royal Marsden cancer hospital and Great Ormond Street Hospital for Children are those that bring in the most income from beyond the NHS. That is because they have an international reputation and first class specialist services that are valued around the world. That expertise is also fully available to NHS patients. No one would think that these centres of excellence are anything other than fully committed to the values and ethos of the NHS.
The government is keen for the NHS to spread its expertise around the world, for instance, by training doctors abroad and setting up specialist clinics or services. The Moorfields branch in Dubai is staffed by doctors from overseas trained in London. This is not a drain on NHS expertise and has no impact on patient care in the UK, but it does allow Moorfields to earn valuable income from abroad.
Salisbury Foundation Trust has launched Odstock Medical Limited - the first NHS owned limited company in England - to market its specialised service worldwide. So income from its electrical stimulation devices used to treat non-NHS patients with “dropped foot” brought about by stroke, multiple sclerosis or cerebral palsy can be used to develop further leading edge technologies that benefit NHS patients.
The private maternity unit at Chelsea and Westminster Hospital Foundation Trust has a 24-hour consultant anaesthetist who helps out with NHS care when there are out-of-hours emergencies. The private maternity unit generates £2m a year that is reinvested to help the trust provide excellent care for all NHS patients. Some of the income from the private unit has been used to pay for a consultant and an academic working on pioneering research in neonatal medicine.
Leading edge benefits
There are a number of foundation trusts that would not have been able to offer leading edge technology to NHS patients without the subsidy from their private patients, as there is insufficient demand from the NHS alone. For example, one trust has spent £6m of its non-NHS income on tomotherapy equipment providing an advanced form of radiation treatment for cancers. Others have bought a gamma knife to deliver sharply targeted radiotherapy for neurological disorders like brain tumours, and lasers for eye surgery with funds from non-NHS income.
And when the health service does impose a ceiling on the amount of treatment the NHS can supply to individual patients, such as the number of IVF fertility treatments, trusts can offer those patients continuity of service through their private work.
Lifting the cap is not about a wholesale expansion of private patient care in the NHS. But it is about allowing trusts to innovate so they can bring in much needed resources to improve care for NHS patients.
