Stephen Eames became chief executive of North Cumbria University Hospitals in January 2016, when it had been in care quality special measures for nearly three years. Cumbria had also been placed in the “success regime” for health economies with multiple serious problems in 2015.

He has led the trust out of special measures and overseen major changes to acute hospital services, following a long and controversial reconfiguration debate. Mr Eames’ CV includes a number of other turnaround and reconfiguration chief executive roles, including Mid Yorkshire and Durham and Darlington.

In September 2017 he was appointed, in addition to the acute job, as chief of the area’s mental health and community provider, Cumbria Partnership Foundation Trust, with the aim of developing a single integrated provider.

In May 2018, the area was named in the second wave of “integrated care systems” by NHS England.

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

Challenges and approaches to turning around seriously troubled trusts and systems; implementing contentious service reconfiguration; and the future of mental health providers as service integration develops.

Key points:

From ‘success regime’ to integrated care system: nursing a fragile flame

“When I came here early in the ‘success regime’ there were a lot of serious concerns right at the top of the shop around some of the quality issues and in some of the services, mortality for instance. Children’s services were in dire straits.

“What the success regime did was create the case and support the process [for] the service reconfiguration here. It created the platform for collaborative working between key partners, which shall we say wasn’t the strongest.

“It’s rather difficult to have done what’s happened here without a crisis. I am in not suggesting to others they should inspire a crisis. But where else was there to go?”

Mr Eames said the response to crisis and spending time on relationships had fuelled the move to an integrated care system.

“It’s those two factors, and at the moment it’s a difficult flame to nurture. It’s very fragile.

“People believe something is going to change for the first time and therefore they are committing [to the process]. That’s picked up pace, because they can see things changing, it’s not just warbling and rhetoric, things are actually changing and broadly speaking people see that’s for the better, particularly the staff and leadership of organisations.”

Reconfiguring: You’re either on the bus or you’re off

Mr Eames has led major acute reconfiguration in Cumbria, Mid Yorkshire, Durham and elsewhere. Most recently in Cumbria, several community hospitals are being downgraded or closed, acute beds being shut, and stroke and paediatrics centralised, while a new model of community-based care and coordination is introduced. Mr Eames says opposition is common, and it’s sometimes necessary to knock heads together.

“There will always be discussions. I have always been of the view, but not always been right, that you need to inject a relentless pace into this sort of change. If you’re making changes that provoke anxiety, the sooner you can get through them the better.

“You have to deal with concern and anxiety about change, from very senior staff. Appropriate concerns about safety and clinical quality. But you also have to deal with quit a lot of myths and sometimes challenge quite vigorously what you call might call traditional practice.

“It’s fear of change, loss of status, loss of influence, it’s all things we would all fear if we felt our world was being threatened, and it manifests itself in lots of different ways.

“But also there are some people who cannot change and in the process of managing big reconfigurations of complex strategic change you have to have strategies for dealing with that, or you won’t get very far.

“Those can sometimes be positive strategies where you can turn those people to what you are doing and make them spokespeople. In the last two years we have done quite a lot of that. In other cases sometimes it’s, ‘You’re either on the bus or you’re off it’.

“But there’s no point beating people up. There’s no point getting people in a room, who have spent the last year tiring themselves out trying to deliver the four-hour standard and berating them for it.

“You need to get them in a room and think about how we can improve things or what we can do to help and support them.”

What can you do as a leader to get staff behind large-scale reconfiguration?

“The first thing you can do as a board, chief executive and leadership team is have a very clear sense of direction: do you know where you are going? Can you articulate it? Because in the end, however unpopular something might be, people want to know rather than be uncertain.

“One of the issues you often find is there are long-standing problems that have never actually been dealt with.

“Therefore it’s difficult to deal with and people find it hard and you have to face up to it. But equally when you do deal with it people say, ‘at last someone is doing something about this’. It creates a sort of momentum which is quite helpful.

“However, there’s an underlying set of pressures on NHS staff, it’s no secret there’s pay issues, though there is some resolution towards that now. There are the huge pressures that people work under in many fragile services up and down the country and every day.

“The irony is, these service reconfigurations are the solutions to some of these [pressures].”

Struggling to win public trust and support

Mr Eames said one of the barriers to service change was a lack of public trust in NHS decisions.

“I don’t think we were able, within the success regime, to break through some of that lack of trust in the NHS locally as a body or nationally as the ‘success regime’ [policy].

“But also the ‘success regime’ was in an environment [locally] where the NHS in particular over a lot of time, probably longer than a decade, had lost trust.

“This is a variety of what I call the Duke of York syndrome, marching people to the top of a hill with a series of changes and then never quite making them happen which is why we got to the ‘success regime’ position in some ways.”

How do you win support or trust?

“There’s an issue with consultations – it’s a zero-sum game.

“We say, ‘here are some options, we think this is the right one’, and [that] immediately creates the type of dynamic [of] an awful lot of difficult, challenging discussions and a huge amount of legwork in the engagement.

“Even having numerous consultations over the years, extremely well and professionally [run] we didn’t break through that trust issue.

“It’s only since [after] the consultation we are starting to address it, although we haven’t cured it, through this big coproduction programme we have got going on.

“It has been helpful that we have some investment supporting the outcomes of the consultation, particularly in cancer developments in Carlisle and community hospitals and of course at West Cumberland Hospital. There are some things for people to rally around.

“That’s helping but we haven’t broken through yet and we often take three steps forward and a couple of steps back.”

Turnaround specialist: Making change from within

“My career path is what you might call turnaround. People often say, ‘why do you keep taking on impossible jobs’.

“I tend to think that large scale change ultimately can only come from within. It’s a bit like with a person, unless it comes from within you don’t really achieve significant change.

“Things like the ‘success regime’ are good for an intervention to get things in place. But you really need to get the leaders and then the wider system owning and developing that change.

How do you get change off the ground?

“There are always fantastic people. If you find those diamonds in the rough [you can then] organise so those people who – even in adversity – have a positive view of life, whose glasses are half full, are in strong position of influence.”

He continued: “To start with it’s just leg work and building relationships. It’s a simple truth, you have got to invest time at this level in building relationships.

“Structural arrangements will never work. Personal arrangements, understanding each other’s worlds, all that territory, we did a huge amount of that [in Cumbria].

“That was externally but also internally… sticking to building the system approach, number one. Number two you have to be prepared to compromise.

“I don’t talk about performance, I talk about improving things. It’s good to try to change the focus.

“It’s probably true of the acute staff, culturally it’s not great to be the best part of four years in special measures. When the trust came out of special measures the change in the atmosphere was palpable. I have never seen that before.

“It’s about talking the language of improvement, celebrating what people are achieving even in the worst circumstances and trying to demonstrate that to others.”

Integrating mental health: Smaller MH trusts will localise while specialists extend their reach

Mr Eames became chief executive of Cumbria Partnership Foundation Trust, in addition to North Cumbria, in 2017, and is working on integrating the organisations.

“If we want parity of esteem there has to be much more joining up of the mental health with the physical agenda.

“We have seen real benefits already. We have seen a reduction in the four-hour breaches attributed to mental health since the teams have been working together. That’s about mental health practitioners training A&E staff.

“On this patch there’s a big development agenda going on in mental health. Around about 70 or 80 per cent of mental health services will be locally orientated and community based as part of the ICS.

“We are building partnerships like with have done with Newcastle Hospitals [for specialised physical health] for the specialised end of mental health, with [Northumberland, Tyne and Wear Foundation Trust] in the north and Lancashire Care Foundation Trust in the south, because we would never be able to deliver some specialist services like specialist eating disorder services.

“To my mind for integrating mental health with not just acute but social care, and community and primary care services, is the way we should go.

“I imagine mental health specialist trusts are just going to get bigger [as they provide across a wider patch]

“What will be happening here is mental health will be an integral part of the services we offer in a place-based locality driven way, with specialist services being provided in partnership with others.”