Roger Spencer has been chief executive of The Christie Foundation Trust since 2013, and has led the trust to an outstanding Care Quality Commission rating. He previously served for seven years as director of delivery and as chief operating officer, during a period in which the trust tackled poor performance, cultural problems and board level governance issues. The Christie has participated in a national new care models vanguard exploring collaboration on cancer services, and is working with other organisations in Greater Manchester under the regional devolution programme.
This interview is part of a series being published exclusively for HSJ Membership subscribers. It covers:
The impact of system pressure on innovation; devolution; collaboration and partnership working; and staff engagement.
- How system pressure is making leaders turn inwards rather than innovate together
- Is devolution aiding integration of acute services in Greater Manchester?
- Why collaboration is more effective than structural tinkering
- Partnering with private organisations can be easier than working with NHS trusts
- Engaging clinical staff to turn around an unbalanced culture
Managing pressure: Leaders are turning inwards rather than innovating together
“When the pressure is on, when the heat is on, then whilst people talk about the need to work together and be more collaborative… actually what happens is people almost revert to a situation where it’s much more a ‘traditional management’ approach.
“So they’re less likely to work as collaboratively or in as joined up a way… which is counter intuitive to the ‘burning platform’ question, isn’t it?”
Often it is argued financial and operational pressure will cause people to collaborate more than they would have needed to otherwise.
“I think the opposite is the case, particularly where innovation is concerned.”
What things could be done that are not happening because people are reverting to traditional, inward looking management?
“The classic examples are where you have an innovation or a change that you might want to make that is in the gift of one organisation, and a benefit – the improvement or the efficiency – might come out in another area or part of the system.
“In my area, the classic example might come in the 62 day pathway… where the way you will improve the performance that’s allocated to one organisation is by innovating or doing something different in another part of the pathway”
Joint working: Is devolution aiding integration in Greater Manchester?
“One of the things it is doing is trying to integrate the leadership of health and social care – primary care, social care and secondary care – changing the way those things are led.
“That’s progress, isn’t it? But it is only in that area and my observation might be that there are other leadership challenges in the system that are equally as important.”
Has devolution in Greater Manchester fostered collaboration on acute pathways?
“That’s certainly something we can do more with, or we would like to do more with.
“Imagine you’ve got an area that is doing outstandingly well on the majority of things in a specialist area. Why wouldn’t the rest of the system – which is keen to see improvements in that particular specialist area – why wouldn’t the rest of the system lend responsibility to where that leadership was available and getting good results, so the whole system pathway would get results that could be the same?
“Here’s the example – the 62 day pathway – even the simple ones have a whole load of primary care and secondary care and some specialist diagnostic and other services in that pathway.
“The real question is: why aren’t you getting the leadership of that whole system and pathway vested in the bit that is really good at it?”
To answer the question, it comes back to people choosing organisational self-interest over best clinical practice?
Is that being driven more by leadership choice or the way the system is set up?
“My observation is that when the pressure increases… the ratio swings to the individual.”
Do you observe the tendency to look after your own organisational priorities when the pressure is on at The Christie?
“I think that’s generally true in times gone by, where there’s been areas of potential conflict or difficulty in the system, then most of the reaction is to try to retrench. [But] often the answer or the solution or the best thing for patients is to not do that but to find a way to work across the system or with partners.
“And yet the behaviour is often this retrenchment behaviour, isn’t it?”
How difficult is balancing constant improvement with operational pressure?
“In a lot of organisations you’ll find that the innovation immediately becomes second, third, fourth, fifth order stuff when the pressure is on [see above] from a financial point of view, and the target delivery of the standard treatment is the priority.
“[Yet] many of the things that are to do with this research are the things that will give you the step change in performance that you want to see.
“That has been the story of The Christie forever. That’s where the culture comes from. I am interested, all the time, in this improvement – what’s better, where’s the innovation.
“But the pressure in the system often is entirely focused on operational delivery.”
Collaboration: It is more effective than structural tinkering
There is currently lots of structural rewiring going on in Greater Manchester – particularly on the commissioner side.
“I wouldn’t say it’s a directly competing activity but that [restructuring] going on means there’s less space and bandwidth to have people as engaged in the sorts of things that I might really want them to be engaged in.
“There’s a lot of progress that has been made in working in partnership in Greater Manchester anyway. Providers have been working really quite well together in the development of new provision models.”
For example, The Christie is the only radiotherapy provider for the region and runs chemotherapy services in Wigan.
“The real question is: can we move that into an even more joined up system across this whole integrated pathway? And that’s one of the things that it proves harder to test. We can do it in some areas but… we might be pushing very hard because we think there are benefits to patients in testing those things but the opportunities are competing with the other priorities that [people in other organisations] rightly see and are trying to grapple with.”
Partnering with private organisations: why it can be easier than working with NHS trusts
“There are a lot of people who believe you have to have [a particular kind of] organisational ownership as a prerequisite to be able to make the change on the ground.
“I’m not sure we’ve ever really believed that’s the case. We have a range of different sorts of relationships in a number of different areas in the NHS, with other NHS partners, with private sector partners and third sector partners, where working together we can deliver something that’s more than the two of us might be able to deliver on our own.”
For example, your private patients joint venture with HCA. Why are they easier to work with than NHS trusts?
“I’m not saying exactly that but for a partnership to be very successful you’ve got to be entirely clear about what it is that you’re both trying to achieve.
“The second thing you’ve got to do is be really crystal clear what it is you’re going to do – what the inputs are that are required from you and what the inputs are that are required from your partner.
“What often happens is that we get together with people and think it must generally be a good idea – and start working together and are then surprised when we don’t actually get as far as we want to get. That’s because often we’ve not spent our time understanding those factors. And when you work in a commercial arrangement it’s often easier to be much more precise about those things.
“That’s not to say you can’t do it, we’ve done it successfully – for example The Christie at Wigan, the chemo delivery service – but equally there might be another NHS partner where it’s very difficult to make the level of progress we’ve made there.”
Are you looking to collaborate on very niche treatments or general cancer services?
“We’re particularly looking at the moment with colleagues who may be struggling with the normal major questions like sustainability… and work together in a way that doesn’t require them to worry about being taken over, or all those other organisational artefacts.
“Because we do believe you can achieve some good things without…
…being part of an enormous organisation?
Engaging staff: Balancing innovation with performance
In 2006, when you joined The Christie as director of delivery, the first job you faced was to focus clinical staff on improving performance against waiting time targets.
“The innovation culture probably predominated, which was a very good thing for this organisation because its whole history is built on the innovation of seeking new treatments.
“But that in itself leads to things being less coordinated, effective, efficient, joined up, et cetera.
“So the first job really was to try and shift that whole approach – probably the backbone of the great performance in recent times has been the full engagement of everybody in that endeavour… having them involved in saying ‘this is part of our plan’. And understanding how they could do it and being empowered to do that, having a very clear set of arrangements about how they could make decisions – some very clear governance arrangements.
“We had some very challenging financial and performance targets that weren’t being met, and at the time [commissioners] were saying to the newly appointed chief executive that either you need to make this work or they’ll be off looking for other organisational solutions.
“That’s the kind of circumstance when you can engage people, can’t you? ‘Let’s try and do this because the alternative is something else’.”