At the first of three events linked to HSJ’s Top Chief Executives list, healthcare leaders gathered to discuss the ever increasing need for collaboration across organisations, writes Alison Moore
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The old certainty that their primary focus should be the interests of their own organisation is beginning to break down as trusts increasingly collaborate across wider areas in a variety of new frameworks and their leaders are required to take and implement decisions which are for the greater good.
Suddenly system leadership is the order of the day. But are leaders being enabled to function across health economies and wider areas?
The first of three roundtables linked to the HSJ top 50 chief executives list brought together some of these top chief executives and others to discuss this changing landscape.
HSJ deputy bureau chief David Williams, who chaired the event, pointed to the vanguards and sustainability and transformation plans as two examples where trust leaders were being asked to overcome problems in a way they had not done before. In an increasing number of areas, chief executives were being asked to run more than one trust and chains of linked trusts were emerging.
“There is a question in my mind about whether people have the capacity, training and skills, and support from the centre, to evolve in to system leaders,” he said. He pointed out that the leaders in these new collaborations still had to do “the day job” as well as leading systems.
What we have been told with STPs is come up with a plan which works and is affordable within existing resources. It is debatable about whether that is actually possible
“And if we are moving towards something like system leadership does the regulation and system framework underlie it? Is it possible to work around it?”
All of the chief executives around the table were actively involved in STPs but some led trusts which were engaged with more than one and could see differences emerging. Tracy Taylor, chief executive of Birmingham Community Healthcare Foundation Trust, is involved with two STPs – one covering central Birmingham and the other in the Black Country.
“In one STP we have a number of organisations that are more aligned so the number of senior leaders has reduced. I think that has had a positive impact on our ability to sit round a table and start to have a different conversation that I don’t think we would have been having before.”
This Birmingham STP also had an independent chair in Stephen Dorrell, the former health secretary. “That has helped. The chair has been able to challenge us individually in a constructive way but has laid the gauntlet down by saying put your money where your mouth is.”
However, she added, implementation of some of the ideas was yet to come and tensions could occur around this.
The bigger picture
At the moment, the participants were able to have open conversations with the city council involved and putting in resources. A “big vision” was developing and “it feels like the STP has been a catalyst”.
“In the other STP relationships are good. There’s a greater number of leaders and the conversations are not yet where they are in Birmingham. The ambition does not feel as big. We are still having the conversations about, say, let’s focus on orthopaedic pathways. The conversation has not yet risen up. I think that will come but at the moment we are in a different place,” she said.
However, she said that this did not really mean that a smaller number of organisations “trumped” good relationships in terms of STP development – it was more around timing. While relationships had not been so good in the past in Birmingham, the STP process had required everyone to “swallow hard” and think about the bigger picture.
In an increasing number of areas, chief executives were being asked to run more than one trust and chains of linked trusts were emerging
In Leicestershire the STP covers a relatively straightforward landscape with one key acute provider, three local authorities and three clinical commissioning groups. John Adler, chief executive of University Hospitals of Leicester Trust, said there had been a history of work around system redesign, reconfiguration and changing pathways, which had come out of being a challenged health economy. “Migrating into STP land is relatively straightforward,” he said.
“We are just starting to get to the stage of feeling we need to do something much more different. In terms of state of planning and jointly owned plans we are probably better than many. In terms of game-changing design we may be further back than many. We are trying to push on but we are not clear what integration looks like and precisely what we mean by it.”
But, talking about the bigger funding question, he added: “What we have been told with STPs is come up with a plan which works and is affordable within existing resources. It is debatable about whether that is actually possible. That issue [of affordability within resources] has been pushed aside.
“It does not make sense to me to be talking all the time about integrating systems and not have an integrated system above us. But I think NHS England and NHS Improvement have got better at singing from the same hymn sheet.”
However, NHS organisations still sometimes got different imperatives from different regulators over money and, although they were keen on unified control totals, it was hard to see how those would work with the different regulatory systems. “The tension is built in. It seems an unnecessary complication to me,” he said.
Ambulance services typically have to work across multiple STP areas which can give them an unrivalled view of how they are operating in different locations. Anthony Marsh, chief executive of the West Midlands Ambulance Service Foundation Trust, said his trust was involved in six STPs, one of which was its “lead” STP and the other five where it was an associate partner: this obviously raised issues of capacity.
“I think relationships are generally good. Like everywhere there are relationships in some areas that are better than others,” he added.
What does this new system leadership concept unlock or allow us to achieve which those existing systems can’t?
He said some ambitions laid out by the STPs had been around for a long time and had not yet been tackled. “There are some real opportunities for integration or better alignment of services. To reduce duplication would be very helpful.”
But he raised some more fundamental questions about how the NHS was run and organised, asking whether if it was a company the owners or shareholders would run it in this way.
“We see enormous variation in the way in which many of our hospitals provide services and organise themselves. That’s true of the ambulance sector as well. It’s often called local flexibility – but are the local needs of the population so different between Leicester and central Birmingham and rural Herefordshire?” he said.
“Of course there are some differences but I genuinely think there is too much variation. We need to find a way of reducing that. I’m not saying that one size fits all but we have variation on a scale where we can do the right thing and reduce variation and improve services for patients and make us more efficient.”
He said that some of the changes which are happening – chief executives running more than one trust and STPs – were a good way of reducing variation. Smaller groups of senior leaders might help clarity. And, as a chief executive with experience of running more than one trust, he felt this could be part of the solution. But were there too few great leaders or too many organisations?
“It does beg the question of if we were running this as our organisation would we have this many acute, community and ambulance services as we have now?” His personal view was that there were too many ambulance services trusts.
NHS organisations still sometimes got different imperatives from different regulators over money and, although they were keen on unified control totals, it was hard to see how those would work with the different regulatory systems
Fiona Dalton, chief executive of University Hospital Southampton Foundation Trust, described relationships in her area as positive with a desire to work together. However, she cautioned that there was a danger of moving into “motherhood and apple pie territory” with everyone agreeing and getting on.
Her STP had 18 statutory organisations involved. “It is really hard to work with that number of people and get a consensus,” she said. She questioned how, if genuine disagreements arose, they could be resolved.
“Do you vote? Do you have a majority STP and a minority STP? Is NHS England or NHS Improvement going to decide? We have not got to the point where individual organisations are willing to hand over that autonomy,” she said. “There is a lack of clarity about where decisions get made now.”
There was also a question about the capacity of leaders to engage with the STP. “I was really struck by something I read about how the manager of Leicester City was at every training session,” she said. “I always felt that was how we should run a hospital.”
But there was a tension between doing that and being able to be in an STP meeting with 18 senior people in the room. However, some of the others felt that operating on this level was now the day job for chief executives.
In West Yorkshire, the STP covers 11 CCGs, six acute trusts, multiple local authorities and a 2.6 milllion population with very diverse needs. Ros Tolcher, chief executive of Harrogate and District Hospital Foundation Trust, posed the question: “What does this new system leadership concept unlock or allow us to achieve which those existing systems can’t?”
The challenge was to raise the level of thinking, cut through the complexity and unleash something even better than the local vision.
But the process bit should not be the main event: it was what made a difference to the population that mattered, she said.
At the same time as dealing with the more immediate issues, there was a need to keep an eye on the long term – the early interventions and prevention. “There’s a risk that all we can do is hold the flames off and don’t get to the source,” she said.
She suggested that the demands for very senior leaders to be involved at this pan-organisation level means they needed to unlock the next layer of talent in their own organisations. Ms Taylor agreed that the chief executive’s role was looking much more like a system role, with other leaders within their organisation keeping the day job going.
I think the system leadership challenge is being able to have that perspective – that regeneration, population perspective
With the vanguard she was involved in, it was “two steps forward and one step back” despite a shared clear vision, said Dr Tolcher. “Getting to the stage of actually making things different has been really complicated,” she said.
“As soon as you start talking about the money, given the current regulatory framework, it becomes much more difficult to talk about change.” For example, different funding streams did not make it easy to implement the pathways they wanted – although they had developed locality teams.
There were particular issues with primary care which needed to make a “leap of faith” and was still struggling with this.
Ms Taylor added: ‘Unless we start to look upstream we will still be having the same conversations in 10 or 15 years’ time.”
Professor Judith Smith, director of the health services management centre at Birmingham University, said the healthcare system had been torn asunder by the Health and Social Care Act and was being pragmatically patched together. This had been given momentum by the development of STPs and also devolution.
“We have a model of leadership which is really about running your own organisation and having a heroic leadership model. None of that changes when you are sat around a table with 18 people,” she said.
There was a question around how leaders could enable others in a “distributed” leadership model as they started to work in different ways with interactions with a large number of other organisations. They needed to see their day job as working together but without setting up lots of complicated governance structures.
The demands for very senior leaders to be involved at this pan-organisation level means they needed to unlock the next layer of talent in their own organisations
This led on to questions about long term sustainability, she said: there were enormous differences in continuity of leadership across the country - and there was a question of whether system leaders were going to be given space and time to do the job, not to mention how what they were doing now would fit into a longer timescale covering 10, 20 or even 40 years.
Professor Smith pointed out that High Speed 2 had a 67 year business plan; there is nothing comparable in the NHS. “We may say that we can’t plan for that length of time: but why?
“I think the system leadership challenge is being able to have that perspective – that regeneration, population perspective. But, she added, there was also the financial side to consider.
Having leaders with the resilience to work and perform in this environment was a real challenge for the NHS. She welcomed the suggestion that those who took tough decisions about closures and service changes would be given “safe havens”.
The acid test would be whether the centre “walked the walk” on supporting leaders through this.
Capsticks partner Sharon Lamb said it was important to be clear about who had the levers to bring about change, and whether system leaders had the power to implement.
“There needs to be clarity about what the difficult conversations are and who is in control to make these decisions capable of being implemented in a meaningful and efficient way,” she said. Otherwise six months down the line nothing would have moved forward.
But do STPs need a stronger leader, with increased powers, to help them tackle some of the difficult decisions around implementation? Dr Tolcher said there was an assumption that “leadership would make it happen” if people were put in a room together: but, at the same time, STPs had not been designed with a single point of leadership.
“The STP concept that says we bring people together to tackle some of the wider problems is right but we can’t assume that putting the leaders in the room opens up the way to do that.” The person at the top was not being given any authority – or even accountability – around the decisions which would have to be made.
One of the reasons why the vanguards were not further along might be that there was no metric they were measured against, no agreed savings – and people could walk away
“Somehow magically system leadership like smoke or fairy dust will disperse across the region. Could we be failing to create the conditions for success because we don’t have an accountable officer for the system?”
Ms Lamb pointed out that one of the reasons why the vanguards were not further along might be that there was no metric they were measured against, no agreed savings – and people could walk away.
However, there was also little room to try something new: some leaders had had experience of trying to develop new types of contracts only to have NHS England try to impose the “standard” model.
Professor Smith questioned whether there was too much focus on having good relationships, which could mean difficult questions – especially around implementation – were not tackled.
She asked: “How will conflict be dealt with? We should not always be looking for consensus – conflict can be a way to get through it.” It might be about not always getting to the lowest common denominator on these questions and that might need a different kind of support from the centre, she added.
There was no lack of appetite in the room for working in a different way to meet the challenges of the future: but also no doubt that the centre needed to do as much as possible to help local leaders deliver this.
Read more about the HSJ Top Chief Executives 2016: http://bit.ly/29BH1Jx
- John Adler, chief executive, University Hospitals of Leicester Trust
- Fiona Dalton, chief executive, University Hospital Southampton Foundation Trust
- Sharon Lamb, partner, Capsticks
- Anthony Marsh, chief executive, West Midlands Ambulance Service Foundation Trust
- Professor Judith Smith, director of health services management centre, Birmingham University
- Tracy Taylor, chief executive, Birmingham Community Healthcare Foundation Trust
- Dr Ros Tolcher, chief executive, Harrogate District Hospital Foundation Trust
- David Williams, HSJ deputy bureau chief – roundtable chair
- Birmingham Community Healthcare NHS Trust
- East Midlands
- HARROGATE AND DISTRICT NHS FOUNDATION TRUST
- Integrated care
- NHS Improvement
- Policy and regulation
- South Central
- Sustainability and transformation plans (STPs)
- Top Chief Executives
- UNIVERSITY HOSPITAL SOUTHAMPTON NHS FOUNDATION TRUST
- UNIVERSITY HOSPITALS OF LEICESTER NHS TRUST
- West Midlands Ambulance Service NHS Foundation Trust
- Yorkshire and the Humber
Into the great wide open: looking beyond your organisation
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Into the great wide open: looking beyond your organisation