Peter Homa explains the personal and organisational characteristics that are most vital in getting acute trusts through difficult times

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In times of adversity it is critical we remain true to our leadership values. Tough challenges provide visible tests of leadership authenticity.

When Nottingham University Hospitals Trust had a significant problem with high numbers of cancelled operations in winter 2011-12, we did not waver from what was most important – we remained utterly patient centred, open, transparent, accountable and navigated our way using the trust’s values as guides.

‘How we as leaders conduct ourselves when times are tough influences the confidence we instil in our patients and staff’

This was at a time when we faced much external scrutiny – and rightly so – because we had let down many patients, their loved ones and staff.

Yet we sought to understand the scale of the problem, apologised publically to patients and their families, honestly described what we were doing to tackle the problem and showed a determination to learn how we got there and make changes to significantly reduce numbers of cancelled operations.

We took the decision to publish all cancelled operations (on the day and prior to the day) because this was the right thing to do for patients and the only way of presenting the full picture to those we serve.

How we as leaders conduct ourselves when times are tough influences the confidence we instil in our patients, partners and staff.

Our colleagues look to us for guidance, leadership and reassurance that we are in control of the situation and have carefully thought out plans to address the problem.

A recent example of the importance of organisational values was last year when the trust was judged by the Care Quality Commission to be a “high risk” organisation.

The day I learnt of this was the lowest point of my career; not because I was being defensive, but because even allowing for all of the complexities and imperfections that come with running one of the country’s largest acute teaching trusts, knowing the 14,000 staff who work at our hospitals, this was a description that I did not recognise.

After the initial disappointment, our approach to our inspection was to see it as a further way to improve our patient care.

Our strategy included briefing staff across the organisation over a number of months to describe what we knew about the forthcoming inspection and also why we were considered to be “high risk”. And our efforts paid off, with the trust being judged a “good” trust by the CQC in February.

Diagnosis of organisational challenge is critical

Be clear with staff about your expectations of them, especially during the early stages of major change.

The appropriate depth and breadth of analysis must be done to diagnose the scale of the problem. However, the key is not to become paralysed by analysis, instead getting the balance right between diagnosing, analysing and resolving.

Give close attention to listening to the views of patients and staff at every step of the way. Very often the best ideas and solutions come from them.

‘A key component of high performing organisations in times of big change is a well informed and engaged workforce’

Our nationally recognised Just Do It scheme proves this point. Staff suggestions are central to our journey of continuous improvement, which involves enhancing quality, safety and value for money for the benefit of patients and staff.

We launched Better for You, our trust-wide transformation programme, in 2009 anticipating the significant financial challenges that lay ahead.

Believed to be the biggest change programme of its kind in the NHS, it has become our template for designing change to support all improvement programmes across the trust. Listening to and acting upon patient and staff views and ideas is central to its success.

Clarity and authenticity

Ensure the “critical guiding coalition” of clinical, managerial and trade union leadership is in place.

It is essential there is trust board oversight and that board members collectively and demonstrably back the direction of travel and are willing to make difficult decisions themselves. This is exactly what we did with cancelled operations.

Our trust board made a commitment that we would have a zero tolerance to repeat cancellations.

With our financial challenge we are clear from the outset that the answer is not about fewer staff doing more, but about changing the nature of work by redesigning how we do things. One example of how we can achieve this is by intelligent use of new technology.

‘When facing a challenge one of the keys to turning things around is a community pulling together’

It is important that you go above and beyond the communications you would normally do with both staff and external stakeholders as you seek to describe the problem, next steps and expectations.

A key component of high performing organisations in times of big change is a well informed and engaged workforce.

At our trust at the time of writing we are working our way through a deficit for the first time since 2006-07. We have reached out to the whole workforce to ensure the gravity of the challenge is understood and colleagues know what they each need to do to help us turn the corner.

Rigorous management

Equally important are clear expectations and timescales for delivery with the senior management colleagues who are accountable.

Clear reporting and governance must be in place to ensure that progress can be assured and problems promptly resolved. This gives visibility to all projects and enables escalation, support and intervention as required, minimising the risk of delays in project progression and delivery.

It is important to identify the additional support, training and expertise that may be needed – including mentorship to better equip colleagues with the skills and expertise required to make a step-change.

External input may also be required to bring wider learning.

Teamwork and personal renewal

The power of a high performing team far exceeds that of individuals. When facing a challenge one of the keys to turning things around is a community of colleagues pulling together in the same direction with a desire to achieve excellent results.

However, simultaneously we are also in charge of our own personal development, which involves identifying opportunities for personal improvement and mastering.

We should never allow ourselves to stand still, or those we work with.

The impact of learning

It was reassuring that we were already aware of the areas the CQC identified we need to make quicker improvement. Our recent inspection provided additional valuable feedback from our patients and staff about what more we can do to better the experience of our patients and colleagues.

‘I defy anyone to tell me that they would recreate their service as it is today. There is always a better way’

If we aim for a 2-3 per cent improvement we will not make the required change. However, if we go for a 50-60 per cent improvement we will likely achieve nearer 30 per cent.

We should not be afraid to think big when confronted with challenges. “Noble failure” provides valuable learning. If we have a good plan thoughtfully implemented and we still do not get the desired outcome we should learn from it.

This approach will help us to do better job next time rather than repeat our mistakes.

Realising there is always a better way

“If your service didn’t exist, how would you create it?” When we embarked upon Better for You, this was the question we asked our staff.

Colleagues at the trust have truly embraced this challenge by redefining their services to find better and more imaginative ways to improve the quality, safety and value for money.

‘Leaders should aim to recruit colleagues more able than themselves’

I defy anyone to tell me that they would recreate their service as it is today. There is always a better way. Our challenge is to find it.

This involves talking to and listening to colleagues and patients often outside of the health service to learn from national and international best practice.

Appoint exceptional people

Leaders should aim to recruit colleagues more able than themselves.

Rather than a threat, it makes for a powerful and successful team in my experience.

It is essential that you set these colleagues clear objectives and support their progress.

One of my previous mentors suggested to me that work should be regarded as a life long “learning laboratory”.

I keep a diary to log my reflections and learning and refer to this regularly when working through difficult problems to help inform my decision making.

The section that I read most frequently is called “What have I learnt?”.

Peter Homa is chief executive at Nottingham University Hospitals Trust