Imperial College Healthcare trust chief executive Steve Smith tells Alastair McLellan how the new academic health science centre allowed a radical cultural shift to clinical leadership

“If you wanted to create a system that was best designed to prevent improvements in patient outcomes, you’d create the system we have in this country.”

So says Steve Smith, chief executive of Imperial College Healthcare trust, England’s largest hospital trust and the organisation that has provided much of the impetus behind establishing academic health science centres.

It has also pioneered a generational shift in the power relations between managers and clinicians.

Professor Smith lays out in stark terms the problem that needed to be resolved. “It had been clear for about 25 years that the structure in the UK wasn’t working. The academic [health science] sector was delivering in terms of discoveries, [but] the service side was not delivering in terms of outcomes.

“Service people were only interested in targets and financial difficulties. Universities wanted nothing to do with improving outcomes. It was a dialogue of the dead.”

The result was an NHS that was slow to change and innovate. The health sciences community in west London initially pinned its hopes on developing the Paddington health campus. When the project failed, senior clinical academics at Imperial College London - including now health minister Lord Darzi as well as Professor Smith - began to explore alternatives.

The question they asked themselves was: “Could we kick-start the mechanism of NHS management with the aspirations of a globally competitive university?”

They settled on the AHSC model - a coming together of leading hospitals and the clinical departments of prestigious universities. The best known example is Johns Hopkins University in Baltimore, USA. But Imperial’s research found European countries, particularly the Dutch, had taken the idea even further.

Driven by the “complete mayhem” of having to deal with two competing NHS institutions, Imperial championed the merger of Hammersmith Hospitals trust and St Mary’s trust.

Attention then turned to establishing the AHSC. The trust and university had to remain separate legal entities since no academic institution would take on the liabilities of a major hospital. Therefore, Imperial adopted the Hopkins model where authority is delegated to a joint chief executive.

Defining moment

“I had to persuade 850 consultants this was a good idea,” says Professor Smith. It was at this point that Imperial took a gamble that could become a defining moment in the management of the NHS. Clinicians were given the opportunity to take charge of the new trust in “a complete revision of the managerial/clinician relationship”.

Seven clinical programme groups were created, with annual budgets ranging from £40m-£108m. The group director posts were open to all, but crucially candidates were required to demonstrate they had the confidence of clinical colleagues. Every clinical programme group director chosen was and is a doctor.

The director is supported by a head of operations, just as at specialty level the clinical chiefs of service work with a senior general manager. Each group also has a faculty of medicine lead, plus individual heads of finance, education, nursing, research and HR.

It is an approach reflected at the top of the organisation, where Professor Smith works alongside managing director Claire Perry - former chief executive of Lewisham Hospital trust.

The rise of the clinician manager or “physician executive” is in Professor Smith’s view a necessary corrective to the mistakes of the past 25 years.

“In the UK, we’ve created a culture of [NHS] management that, if not actively anti-professional, sees professionals as a workforce to be worked and has little interest in academic endeavour or innovation.”

He acknowledges the rise of general management has to be seen in the context of the mid-1980s: “You did have a health service that was managed by doctors in an amateur fashion. You needed a great input of management.

“The management that came in introduced a much sharper structure, but it [also] excluded the professionals from the process. So you ended up with a disenfranchised and angry clinical workforce that managers had very little control over.”

Professor Smith says that culture has been re-engineered at Imperial. “At the start clinicians were completely unbelieving. They’d say to me, ‘you’ve got to do this or that’ and I’d say, ‘I don’t have to do anything, you’re in charge now’.”

One of the keys to the success of this approach is that all clinical programme group directors must remain active clinicians. “We’ve been careful to ensure clinicians who become managers are not seen as having gone to the dark side”, he explains. “The minute you stop practising, you lose credibility with clinical colleagues.”

“Only clinicians can deliver real change,” he adds, pointing to the impact on the trust’s accident and emergency performance. Before the merger, up to 10 per cent of A&E attendees were waiting more than four hours to be admitted.

Among the major changes were increased consultant ward rounds. “As a manager, telling a consultant to do a ward round every 12 hours is next to impossible. As a fellow professional, it’s much easier.”

The Imperial chief executive admits he was worried about sending the wrong message to managers - “that they would lose control now that these ogre clinicians were in charge”.

However, he says the new arrangement has created an even greater focus on their contribution. “Managers in the health service are actually very good project managers”.

Professor Smith says that Imperial has a ferocious commitment to outcome measures and patient satisfaction, and ensures that each of the professional groups knows how it will be “judged”.

He stresses that this is not about appropriating blame. Instead, he says: “We ask the clinicians why something is not working and what they think the answer is.”

Smith calls for truce with private practice

Professor Smith has another of the health service’s hottest topics in his sights: private practice.

“We’ve got a schizophrenic view of private practice in the NHS. It has produced several unfortunate consequences. The first is that the power of the paying patient doesn’t exist in the NHS.

Another “consequence” is that in other countries income from private practice is used for the benefit of the state, while in the UK it “goes to the shareholders of private agencies. “At places like Johns Hopkins a very substantial part of their research activity is driven by profits from private practice.”

Professor Smith regrets that the NHS and private practice have become “deadly foes” locked in competition.

“If we can change that - then we could see private practice [in the NHS] as not a bad thing, which I don’t believe it is. Secondly, we could ensure the [NHS] organisations that employ the doctors who do the private practice could gain some profits.”

He stresses these revenues would come from charges normally levied by private health providers, not from doctors’ fees.

“We think there is a win-win. Providing care for all your patients in one facility is a much safer way of doing it. I think clinicians needs to stand up and say that, while private health providers will lose money, the NHS will gain.”