Alwen Williams joined Barts Health Trust as interim chief executive in June 2015 – shortly after it had been rated inadequate and placed in “special measures” by the Care Quality Commission. In October that year she took on the role permanently.

Barts is one of England’s largest NHS trusts, formed from a challenging three way merger in 2012, and operates from multiple sites including five hospitals.

Ms Williams’ time at Barts has not been plain sailing, with the size of the underlying financial problem larger than anticipated, and major waiting list issues among the difficulties faced. But moving to a “group” management and leadership model combined with drives on staff recruitment and engagement resulted in Barts being upgraded to “requires improvement”, with none of its individual services now rated “inadequate”. The trust hopes to lose its “special measures” tag soon.

Prior to joining Barts, Ms Williams served two years as the NHS Trust Development Authority’s director for London. Before that she had worked as a manager on Barts’ east London patch, including as chief executive of the top rated Tower Hamlets Primary Care Trust, then of PCT clusters across East London. She also in the past worked in more junior roles at the Royal London Hospital, one of the main sites.

This interview is part of a series being published exclusively for HSJ Membership subscribers. It covers:

Approaches to turning around a large trust with quality and finance problems; developing and running a hospital “group” or “chain”; the benefits of forming a large hospital “group”; supporting senior leaders when their organisations fail.

Taking on a troubled trust – and reducing the “human cost” for leaders

Ms Williams said having already worked extensively in east London meant “quite a lot was familiar” when she joined Barts and that this made it easier to “work out what I would need to do in the substantive role.

“It’s very important when you take on an organisation with that scale of challenge to be very honest with yourself about, ‘am I capable of this? Do I understand what the challenge is? Do I know what I would need to do as the chief executive of this organisation?’

“So, when I applied for the post substantively, I was able to position my considered view as to what I would then need to do as a chief executive.

“You need to be able to step in and articulate – to your interview panel, to your board and your chair, but [also] to yourself – ‘I know I can add value to this organisation because I have a sense of what is needed. This is what I would bring as a chief executive in terms of my leadership style, the way I do the job, [and] these are the critical milestones and priorities.’”

When trust chief executives run into problems, is it because they lack or lose this insight?

“It is difficult to answer generically. I’ve sat on quite a lot of interviews for chief executives… It has to be a contract [about what can be expected] between the organisation and the individual.

“We can all think of examples where people have stepped into chief executive roles and were not successful, and some of that might have been, did they have sufficient insight when they took the role on? Were they sufficiently tested within the interview and recruitment process?

“But sometimes it’s that these roles are difficult and the context shifts, at times chief execs find themselves trying to cope with very difficult wicked problems which they weren’t expecting. Because you won’t know everything when you take on a chief exec role.

“There is a personal responsibility… it would be irresponsible for someone to step into a chief executive role without feeling they have the wherewithal to do that job.

“But there are circumstances where that judgement is spot on, and one or two years down the line, the context and issues [change].”

When senior leaders are publicly sacked and deemed as failed, Ms Williams said, you should “not underestimate the human cost of that”. She argues support is lacking for senior NHS leaders who run into serious problems, saying support networks were weakened by the 2010-13 reorganisation and have not recovered.

What should change?

“The commitments we’re now hearing from NHS Improvement that there is going to be more done to support and protect chief executives [are welcome]. Because I do worry that as I talk to colleagues in the NHS people are saying, ‘Why would I want to be a chief executive?’

“I’d like to see the NHS as a totality support an organisation, senior teams and senior people [with serious problems] – finding ways in which they can be supported – maybe to do other roles for a period of time and thinking about training and development.

“In the past [there has been] a sense of you either succeed or you fail – that’s too polarised.

“I’ve seen very good colleagues who have found themselves in difficult circumstances but then have been, a number of years down the road, in other roles, entirely successful.

“We talk a lot in the NHS about this kind of culture of compassionate care to our staff… [and] the NHS at large could do more to enact those values as it relates to senior people, who give so much of their lives to these leadership roles.

“The other area [for] NHS Improvement or the new NHS England/Improvement arrangements is just to facilitate more what I call ‘communities of practice’. We’ve lost a bit of groups of chief execs coming together and learning and supporting each other. [This is] one of the opportunities now, if you take London for example, we will have a London regional director [to bring people together]. (Sir David Sloman has been appointed to the post since this interview was carried out).

“Those of us that have been in these roles for a period of time… we also have to support people that are newly appointed a little bit more.

“[We should ensure] people know if they step into something and it goes wrong, that they still have a career ahead of them.”

Approaching a huge turnaround: Management, governance, recruitment and engagement

How did you approach what seemed a huge and potentially very daunting task?

“I remember when I came in as an interim chief executive in June 2015, within about a week or so I’d constructed a view about what the top six or seven key immediate objectives and priorities were, and I was able to describe those to the board and corral the organisation to take things forward.

“Some were pretty significant – one of the first decisions we took was to restructure the entirety of the organisation. (This is explored in more detail below in the section on group structures.)

“We brought in hospital leadership teams [as opposed to a senior structure which spanned the whole trust] and we effectively reorganised something like 200 senior leaders from the previous management structure into the new structure.

“The judgement I took in June was that unless we did that very quickly, over the summer months, we didn’t have the wherewithal to deliver improvement.

“I knew it would then take another period of time to start to make real improvements. You have to be very open and honest about what you can do quickly and what will take longer.

“[Initially] we were building the organisation… appointing corporate directors, appointing staff permanently into key critical leadership positions… It was really from 2016-17 onwards that we were able to then demonstrate improvement.”

Another priority from the outset was seeking to improve quality and efficiency by changing staff engagement and motivation.

“We knew from the staff survey data that team Barts was a bit down in the dumps and demoralised. It had been put into special measures and had lost all of its senior leaders.

“We started a quite dynamic and proactive staff engagement programme. Because I was appointing senior leaders into the organisation, [we needed to focus on] how did we connect with the front line, how did we connect with the organisation, and how did we start to drive a culture where staff felt empowered and enabled to make change and improvements?

“We had a debate about whether we should do all the structural change first and then think about culture change. But I think the judgement was right to actually do both at the same time.

“We did a lot of work resetting our vision and values [with] a huge amount of staff engagement, communication and involvement, like focus groups. We had lots of ways in which we were trying to build a consensus about what really resonated with people working in Barts and [with] patients.

“We have awards - Barts heroes - and what’s been fantastic over the last few years is the number of staff and patients who are nominating individuals and teams has increased significantly…

“That’s a real barometer, that people working in the organisation want to nominate their colleagues for fantastic services and improvements staff have made for the benefit of patients. That’s a real testament to [what] we’re starting to see in terms of a culture change.”

A new quality strategy in 2015 drew the strands together, and has been refreshed several times since, reflecting on what has improved and setting new ambitions.

“It’s important when you’re newly appointed to listen. I always remember my first medical council meeting and there were about 70 consultants in the room, and they said to me they felt the organisation had only talked to them about money.

“They started to say what they wanted and valued were conversations around quality, and we started a process at that meeting which effectively translated into… our first quality improvement plan in 2015.

“In 2015 [the aim] was to get ourselves out of “inadequate”. The quality improvement plan was focused on quite a lot of basics – we had to get the right governance in place, the right leadership in place, and fix some of the basics.

“If I look back to when I came to Barts – and it’s an interesting case study about how you manage when you are in financial distress – the organisation had stopped recruiting to some extent, [it] was holding vacancies. But all that had happened was it had to employ agency staff, and that had cost even more money.

“We put in a quite ambitious programme to recruit permanent staff.

“We brought in something called ‘drive 95’ which was to get ourselves to a 95 per cent fill rate, and we’re doing really well on that.

“We’re now over 90 per cent, and about third best in terms of retention in London. So that’s starting to yield a lot of benefit and the more you’ve brought permanent staff into the organisation, [the more] you start to build stability in teams who can then work together to improve quality and reduce cost.

“We published the third edition [of our quality strategy] in March of last year, and we called that ‘to good and outstanding’. If I published anything in 2015 which was about good and outstanding, people would have said ‘We’ve got a slightly deluded chief exec here.’

“Each year we celebrate the success [so far] and then we reset the bar.”

Why the Barts merger was worth it – and how to run a hospital “group”

Barts Health Trust was formed in 2012 by a merger of three predecessor trusts, creating a provider running five hospitals, including three full service acute sites. This was unprecedented then, and Barts remains one of the three largest NHS providers. The major quality and finance problems of its first years led many to judge the merger as a mistake.

One of the first things Ms Williams did on taking up post in 2015 was scrap the single trust wide structure and reintroduce strong, separate senior management teams for each of the hospitals – a model now being used at other “groups” and providers running multiple major hospitals. Having strengthened the sites’ individual management and accountability, Barts has also introduced cross cutting group clinical boards responsible for “strategy and standardisation”, as well as group corporate teams and shared services.

“The NHS understands better now how to run a group of hospitals… Barts was probably the first or one of the very first [mergers of this scale].

“The learning is that you can’t run five hospitals and pretend it’s a single site or two site teaching hospital model. We’ve had to design something that’s more sophisticated to do that.”

Having introduced strong site leadership, in response to major quality and finance problems, is there enough benefit to having a single group to make the merger justified?

“There’s huge benefit. If we think about the drivers for change at the time of the merger – and I know Barts went through a difficult initial few years – preceding the merger, each of the three NHS trusts that came together had financial and quality challenges…

“The benefits are significant in my view.

“[It has changed] the way we’re conceiving of delivering care to the population. St Bart’s Hospital, which is the largest cardiac centre in Europe, is really thinking about its role in delivering cardiac services at Whipps Cross. We have a networked service, delivered by St Bart’s Hospital [staff] but at Whipps Cross.

“We have joint appointments so we’re able to bring talent into the organisation. People rotate [between sites] in a number of services – we’ve got a great story on nursing rotations in A&E and other hard to fill roles.

“We get the benefits that we’re able to bring in some real talent to lead on some of these critical bits of infrastructure that the hospitals draw down. If you imagined Barts being three standalone organisations, they are never in my view going to have a fully equipped business intelligence service [which they now do].

“And we can make sure that we standardise. We’ve now got a single patient waiting list across the organisation so patients can be fast tracked into the single orthopaedic centre.

“We have a network of our 35 orthopods all working together and looking strategically about how do we best deploy that asset; how do they work together with trauma services at the Royal London. Our aspiration next year is to create a centre of excellence at Whipps Cross for fractured neck of femur.

“We’re doing the same in surgery, we’ve already done it in cardiac. If we look at patient outcomes and quality from the strategic reconfiguration perspective, you can implement that further and faster in a group than if you were trying to do that across three separate organisations with sovereign boards.

“I’m very very confident that a group model concept gives us much greater opportunity in the future in terms of improving services and delivering improvements in care.

“The other benefit is to the overall way providers increasingly will step more into the space of system leadership and improvement [across east London].”

Overhauling business intelligence was very important in moving to strong hospital level management, governance and accountability, Ms Williams explained.

“We had to do quite a lot to make sure that all the different component parts had the right data and information and intelligence so that we could make sure… the person accountable had all the right reports on quality, performance and finance.

“People often say to me, ‘As the group chief exec, how do I stay in touch?’ I say, ‘Well, we have performance reviews with every hospital every month and big generated dashboards and reports will highlight, for example, for every hospital site, which ward I have to worry about around the issue of pressure ulcers or falls.

“So, we have really good reporting which means we can collectively ensure the leadership teams intervene where that might be required.

“What has helped me [in] being a group chief executive is that when I was chief executive of, for example, the north east London commissioning organisation, I had relationships with seven PCTs and local authorities, and three or four NHS trusts. In many ways I was managing a system of care, which is what Barts is.

“When I was working for the TDA I had 22 NHS trusts [to oversee]. Now the relationship is different, my accountabilities are different, but in the way, you conceive of a system of care – there are lots of lessons and similarities.

“In many ways. I think I’ve been able to step into that probably more straightforwardly than perhaps if had I been the chief executive of a small district general hospital wanting to make sure I was in A&E every day. Certainly, Barts isn’t going to be successful and deliver outstanding care if it relies on the group chief executive being everywhere all the time.”