I said on my first day in this new job that five years in to the longest period of austerity the Health Service has ever seen, the stakes for the NHS have never been higher.
So far our main response to NHS budget pressures has been an enormous and successful collective effort to keep the show on the road, doing what we’ve mostly always done, but considerably more efficiently.
That’s been vital in sustaining the results that matter for our patients. So we owe a huge debt of gratitude to the staff of the NHS for what has been achieved, under often difficult circumstances.
None of which is to say, of course, that there aren’t still opportunities where we can do even better – as persistent quality and cost differences across the NHS make plain.
But as NHS managers we’re not just in the business of performance; as NHS leaders we’re in the business of change. As the legendary Peter Drucker put it: ‘There is nothing so useless as doing efficiently that which should not be done at all.’ That means constantly asking: why are we doing it like this? Is there a better way?
My argument is that’s necessary not just because of the obvious economic pressures. It’s because all industrialised countries face profound and defining health care choices over the coming decade – about how to respond to the new possibilities opening up in medicine, in technology and social transformation. Will we hunker down and try and fend them off, or will we embrace them and harness them?
King Canute against the tides, or surfing the waves of change – that’s our strategic choice.
If that analysis is right, the implication is this. It’s not just funding that will shape the future success of the NHS. As important will be our capacity for improvement and change. Today I want to talk briefly about the kind of leadership that’ll need.
Of course down the years there’ve been many wise pronouncements on this topic. Sir Roy Griffiths’ short and pointed 1983 management letter has probably had more impact, per word, than any other contribution.
His central claim that high performing health services need great managers continues to inspire new generations of talented young people.
In one of the largest surveys ever, published a fortnight ago by The Guardian UK300, NHS management was ranked first in the nation as the most popular graduate employer – well ahead of Google or Facebook, the BBC or the Civil Service fast stream, JP Morgan or McKinsey, Amnesty or Oxfam, BA or M&S. It’s great to see that Generation Y ‘get it’.
Because while managing health services is never going to be easy and our work is often misunderstood, NHS patients need top quality managers working on their behalf – now more than ever. In saying that, and at a time when there’s bound to be heightened public scrutiny of NHS management, I hope we can avoid the twin dangers of hubris on the one hand or defeatism on the other – and instead couple modesty with ambition.
Start with modesty. To those of us in health care management roles – whether as career managers or as clinicians – let’s always remember we’re here for a social purpose, and not as of right. The ultimate test of everything we do has to be: does it help improve the health and care of the people we serve?
But let’s also have self-confidence and ambition. To those armchair naysayers who assert that good management is a luxury the NHS can do without, let’s remind them that the evidence is now clear. Quality of care, staff fulfilment, and wise stewardship of resources all go up when great health care managers get to work. And by the way, as someone who has spent the past decade working in health care around the world, I can tell you that in England our spending on health care management and administration is now far leaner than just about any other major industrialised country.
I think it was former ICI chairman Sir John Harvey Jones – one of a long line of outside gurus given a review panel or a TV show to look at how the NHS is run – who once said that if the Victorians were still around they’d be erecting statues to honour NHS managers, just as they did years ago for industrialists, municipal leaders and public figures in Manchester, Birmingham and Liverpool.
But to those of you who fancy the idea – don’t hold your breath. Statues are out of vogue, and miss the point. It’s not a few heroic individuals in the mould of Thomas Carlyle that we now need, it’s a different type of leadership and a more nuanced range of management skills and behaviours.
Today’s new Kings Fund report on collective leadership makes that case well. I’m not going to repeat their analysis, or try and set out here a comprehensive manifesto for NHS leadership. What I am going to do is offer a few thoughts on how some of our current ways of working might evolve.
An NHS of the people, by the people and for the people
Ipsos MORI have just released their latest survey of what makes our fellow citizen most proud to be British. And the answer is: it’s the NHS – ahead of the armed forces, the Royal family or the BBC. In fact we are prouder of the health service now than we were two years ago shortly after the Olympics.
So if the NHS is not just a repair and care service, but also a social movement, what does that imply for health care managers?
Partly it’ll mean trying to catalyse communities’ own renewable energy – building on the under-appreciated contribution of volunteers, carers and patients themselves. That in turn will often mean thinking of decision making power not through the conventional lens, where if one person, or one organisation or one profession has it, then someone else doesn’t. But instead running with Hannah Arendt’s alternative conception: power not as zero sum but positive sum. Power as the unleashing of creative energy, and the mobilising of collective action.
This will be easier when the leadership of the NHS better mirrors the people we serve. It can’t be right for example – as Roger Kline’s recent research has pinpointed – that ten years after the launch of the NHS race equality plan, while 41% of NHS staff in London are from black and minority ethnic backgrounds (similar in proportion to the Londoners they serve) only 8% of trust board directors are, with two-fifths of London trust boards having no BME directors at all. Similar patterns apply elsewhere, and have actually been going backwards.
Yet diversity in leadership is associated with more patient-centred care, greater innovation, higher staff morale, and access to a wider talent pool. In my own career, I reflect on the fact that down the years I’ve benefited from having had three black bosses and a woman as my line manager, but in each case that’s been when I’ve been working outside the NHS. That needs to change.
We also know that the NHS does best when it listens hardest. Most major quality failures have been linked directly or indirectly to a failure to listen to patients, carers, and frontline staff. And, by the way, some of the most energising conversations I’ve had as I’ve been out and about around the NHS over the past month and a half have been not only with our patients, but with our frontline nurses. I’d take this opportunity to underline the importance of ensuring they’re properly supported, and that all hospitals do meet their commitment to start publishing ward staffing levels online by the end of next month.
That’s all part of the new culture of openness and a new focus on patient safety of the sort advocated by Robert Francis, Don Berwick and many others. Honesty about where we are; about what needs to change; and the trade-offs in getting there.
In some parts of the country that’ll mean taking a new look at some of those local trade-offs in deciding how services develop. Often these judgements are shades of grey. So within the locally sustainable funding envelope – which is the critical caveat to what I’m about to say – we need to give careful weight to communities’ own values and preferences for access versus specialisation.
Having seen a variety of models working well in dozens of countries round the world over the past decade, let’s take a look at whether some of them might work here. Medical historian Roy Porter once summarised the NHS’ founding organisational principle like this: ‘consultants got the hospitals but GPs got the patients’. I doubt that’s a durable organising principle for the decade ahead.
Getting movement will mean winning hearts and minds. But I also want to use this opportunity today to restate the importance of technical management skills and the necessity of strong operational disciplines. Yes we do need inspirational leadership in the NHS, with all that implies. But we also need strong management skills, and one does not substitute for the other.
So in our commissioning processes, let’s have rigorous use of quantitative analytics, empirical modelling and well-designed controlled experimentation.
In our whole-system working – be it the Better Care Fund, or the redesign of urgent care services – let’s have more rigour in planning and in execution.
And in our provider services, let’s not undervalue the need for well-run hospitals, community and primary care services. Outpatient departments where the phone is answered and appointments Clinics where tests and investigations are all synched up. Accurate waiting list management with PTLs as routine. Patient discharge information in the hands of GPs on the day someone goes home – if not before. We know how to do this, and most places do it well. It makes an enormous difference to patients.
Of course what’s sauce for goose is sauce for the gander. These are the same sort tests we’re applying to ourselves at NHS England. I’ve been greatly encouraged by is the quality of the people I now have the chance to work with. One year in to the new organisation, we’re taking the opportunity to take stock on what’s working well, and what needs to evolve. How we focus on our distinctive commissioning responsibilities. How we align our teams internally and externally. And how we build capabilities in foundational functions.
In doing this, I’m committed to ensuring that NHS England plays its part in shared system leadership that is both purposeful and coherent. Where the various national bodies are more than the sum of their parts. And where, when it makes more sense for someone else to do something, we reassign responsibilities accordingly.
We’ll also be advertising and filling several important national roles at NHS England shortly, including Director of Specialised Commissioning, which with a budget of around £14 billion is one of the biggest jobs in the NHS. We’ll also be filling our vacancies for Director of Commissioning Strategy and Regional Director for the South of England, along with several other fantastic opportunities for some of the most skilled and experienced leaders in Britain!
So I’ll end where I began these remarks with the observation that if it’s the NHS’ capacity for change that is central to its future, then the quality of management and leadership has never been more important. We need leaders drawn from the clinical professions, from Third Sector organisations, from local government, from overseas, from the private sector, but we also need to nourish and invest in home-grown NHS leadership too. And wherever our leaders come from, we’re looking for people…
- who respect our history, without being a hostage to it
- who inspire for the future, while juggling in the present
- who understand both that “The devil is in the detail”, and “Where there is no vision the people perish”
- who create unconventional partnerships to generate non-obvious options
- who find win-win solutions while challenging emperors-with-no-clothes
- who lead by example, but make the unpopular call
- who blend rigorous experimentation with the courage of their convictions, and
- who think like a patient and act like a taxpayer.
That’s just my opening list. Now you know why head-hunters get migraines when I tell them who we’re after in the NHS.
To which my reply is – Yes, these are some of the toughest leadership roles in the world – but also some of the most worthwhile.
It’s a huge personal privilege to have the chance to work with you all. Thank you for all you do.