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We should expect more questions than answers from good leaders

The conventional wisdom is that greater competition is needed in the NHS to drive out the inefficiencies that some believe are inherent in sectors dominated by publicly owned providers.

It is also assumed that anybody championing increased use of the private sector in supplying NHS-funded care will have a vested interest in pushing the change – either financial or, if a commissioner, greater control over established providers.

Gareth Goodier’s views, reported in HSJ this week, provide a welcome corrective to this lazy thinking. Dr Goodier runs Cambridge University Hospitals, one of the NHS’s best known foundation trusts, and as chair of the Shelford Group he represents the country’s 10 largest teaching trusts.

Dr Goodier rejects that notion that the NHS is “inherently inefficient”, while recognising the need for it to rethink how it operates in response to growing and changing need. But rather than suggesting the existing set of providers is sufficient, Dr Goodier wants to see private providers supplying a much higher proportion of NHS care.

He suggests that only when around 30 per cent of NHS-funded hospital care is provided by non-NHS players will we see the benefits of scale, with “big brands” competing to “keep the price down and quality up”.

His view begs many questions, most notably where these “big brands” might come from. The UK private healthcare sector remains underpowered and continues to struggle for financial stability.

But Dr Goodier’s opinions also raise another question, which is what do we expect from NHS leaders?

This week brings the second report from the King’s Fund’s authoritative and welcome study of NHS leadership. It stresses – correctly – how leaders, many of them clinicians, will need to adopt a style which embraces more staff and public engagement.

But engagement does not automatically mean agreeing with what staff and the public expect or even, in some cases, want. It is also about using the privileged viewpoint that leadership brings to challenge and to stimulate debate.

Private sector providers are very unlikely to secure the market share Dr Goodier calls for – and there are good reasons for that. But in stressing how significant change is needed to meet future challenges, Dr Goodier, on his departure from the UK, is leaving a great example for the next generation of leaders.

Readers' comments (5)

  • phil kenmore

    There are some good points here especially relating to the nature of leadership and public/patient expectations and wants. One of the big leadership challenges facing new CCG leaders will be distinguishing between public perceptions of what is wanted and population health needs - many of which may be different and not necessarily on the minds of the majority.

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  • David Dalton

    Dear Alistair,
    I'm on the train reading your 'Editor's opinion' challenge: that leaders should question and not answer. I have been pondering on some questions on my mind and wondered what the answers might be:
    Questions on a Train
    1. Tolerating excellent and poor performance and doing nothing about either reinforces mediocrity. Why don’t we positively reinforce good performance by rewarding those organisations that consistently deliver high results?
    2. Within an organisation we find normal distribution of staff contribution to goals and values – with poor, average and excellent contribution. Why don’t we use the freedom of Agenda for Change arrangements to introduce robust assessment and assure that access to the 3 ½% incremental pay advancement is directly associated with contribution rather than provided on the anniversary of appointment?
    3. Organising the management of knowledge is difficult. Getting best practice reliably into practice requires a change in traditional mindset and relentless discipline to assure adherence. We have limited experience and even less success at doing this. What new skills will leaders require for this?
    4. Providing a two tier service (weekday and weekend) harms patients and traps inefficiency in our systems. Do we have the courage to set new service standards for patients so they can have highly reliable services – any time of the day and any day of the week? Do our senior managers and clinical leaders act as role-models by routinely working at weekends as part of their working arrangement?
    5. Variance of practice leads to variance of outcomes. What are the effective governance arrangements which the NHS should have for assuring consistently high standards of primary care practice?
    6. Improving our health care systems requires a new understanding or measuring (not benchmarking) for improvement. Do Boards really understand the difference in data sources and how to read run charts/statistical process control charts to drive improvement?
    7. Better care, better outcomes and lower cost will follow from hospital provision being organised to serve populations of c.1m. How do we change the incentives and create win–win opportunities so that Trust CEOs embrace change positively rather than defend the status quo? Isn’t it odd that there are so few models and experimentation of joint venture SPVs for Trusts to share benefits of rationalisation of scale and scope of services?
    8. Too many patients still experience avoidable harm within our systems. Will organisations be bold enough to publish, at the beginning of the year, what improvements to patient safety they will make and then report publicly their improvement in their annual quality accounts – rather than congratulate themselves on what they have done without saying what they had intended to do?
    9. The tsunami of alcohol related admissions (77% increase in 10 years) is having deep impact on our health systems and our society. Do we have the will, ideas and disciplined method to change this?
    10. Most sustainable ideas for change are found deep inside an organisation – and few are found at the top. The same is true for the NHS as a whole. How do we encourage both deep engagement with staff inside organisations as well as supporting organisations to network with like-minded ones to test new ideas and implement change together - rather than accept the ‘wisdom’ from above?

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  • Presumably Dr Goodier can produce some good evidence supporting his assertion on the use of the private sector. He will have an antipodean opportunity to put the theory into practice. David Dalton makes the usual careless mistake in thinking that contribution can be measured and rewarded in a collectivised culture in a purely individual and exclusively monetary form. When will management geeks learn about human nature.

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  • Hello Patrick, I'm a different poster to all of the above. This isn't meant as a facetious question, I'm trying to learn. What do you mean? Are you saying that using A4C gateways linked to IPRs don't work to improve organisational performance? I know that e.g. nurses in the private sector get other "rewards" like child care vouchers and so on, or flexible working arrangements etc and it's not all about monetary bonuses. Please could you expand your thinking, I'd be interested to hear more. Many thanks!

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  • Maryam Omitogun

    Yes, A good leader is expected to ask question more than answering. This is a good step and will bring more advantages to any organisation thus create avenue to make ways for development especially in health sector. I think the most reason responsible for poor care in nursing homes and hospitals are the fact that the leaders are not ready to say the truth and actually ask questions from workers either to find out their opinion about the working conditions and their own personal life probably this will help in giving quality care. A good leader should be able to observe and carry out regular inspection and by doing this he/she will be able to detect the performances of staffs and know things that are necessary to do in terms of recruiting correct employees, monitor the Managers performances in each departments and take steps in making correction.
    Recruiting care assistants to work in hospitals and Nursing homes should be addressed more seriously as I presumed this contributes to poor care performances. They should be properly trained and let them be aware of what they are employed to do (job descriptions) make sure they have interest to carry out the task not just for the purpose of earning money. The work of care workers are generally to see to the personal hygiene of the patients,feeding,cleaning etc. this should be stressed making sure they are actually ready to do the work and must do it truthfully.

    Maryam Omitogun.

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