How should we lead the NHS in this increasingly difficult context?

Chris Hopson profile picture

07 November 2017

Chris Hopson
Chief Executive


Hello, good morning and welcome to the NHS Providers annual conference and exhibition. Our flagship annual event and the single biggest gathering for provider board members in the NHS calendar.

This event couldn’t happen without the support of our sponsors and I’d particularly like to thank our overall event partners Newton and Hempsons; our strand partner Allocate; and both the GMC and NHS England who are delivering our breakfast sessions tomorrow morning.

Can I please encourage you to support all our commercial partners and spend as much time as possible in our exhibition which you’ll find in Hall 3

Can I also thank you for coming. I know how busy and stretched you are and how difficult it can be to take time out. But I hope you will agree with us that it is important to take time to review our challenges and develop and share solutions.

How do we lead the NHS in this context?

This is my sixth annual conference and exhibition speech. I’m beginning to feel like a veteran. I normally cover a range of topics but this year I want to cover just one. It’s this. How should we lead the NHS in this increasingly difficult context?

I address the issue with some humility. I’ve never run a frontline trust so it’s not my place to tell you how to do your job. And when we talk about good leadership, there are bound to be different opinions and mine is just one.

But my time is equally divided between talking to you, local trust leaders, and to our national system leaders – ministers, civil servants and those running the arm's-length bodies. So I get to look at that national/local leadership relationship, day in day out, and study it in detail.

And that’s what I want to talk about today. How should our national system leaders interact with frontline trust leaders to ensure the NHS delivers the consistently high quality of patient care that is our collective ambition and endeavour?

The current NHS context – the best of times and the worst of times

The obvious place to start is the current context. I was listening to Sir Bruce Keogh the other day when he described the current position, drawing on Dickens, as both the best of times and the worst of times.

The best of times

It’s the best of times because, when we look back in 25 years, we will realise that we were on the edge of a remarkable technology driven revolution that dramatically improved health outcomes.

We know that personal mobile technology, artificial intelligence, robotics and genomics will transform healthcare.

Genomics, for example, will enable us to predict who is at risk from certain diseases. It will enable us to take preventative action to prevent disease developing in many people in the first place. And when disease does occur, genomics will enable precision treatment. We are about five years ahead of any other country in beginning to integrate genomics into our routine pathology services.

As Alan Milburn, one of our NHS Providers lecturers reminded us, however difficult the strategic context, we must always remember to balance the challenge with these opportunities. We have some extraordinary opportunities to improve patient care in front of us and we need to seize them with both hands.

And there are two other reasons why it remains the best of times.

One is the enduring power of the key principle behind the NHS. The idea that great patient care should be provided to everyone, free at the point of use, based on clinical need, not ability to pay.

A principle that has given us one of the fairest, most equitable, most efficient healthcare systems in the world, with some of the widest population coverage, as the Commonwealth Fund reminded us just a couple of months ago.

No wonder then, that the NHS consistently remains the single biggest reason why people are proud to be British. For them, the NHS is a bigger source of national pride than our history, the royal family, our democratic system, our armed forces or the BBC.

The NHS consistently remains the single biggest reason why people are proud to be British

Chris Hopson    Chief Executive

And when many of those other institutions have faced considerable criticism, pride in the NHS endures. Rightly so.

And, of course, it will always be the best of times to work alongside our frontline clinical colleagues. Since we were last together in this hall, we have seen so many examples of the bravery, commitment and professionalism of NHS staff.

From the Westminster Bridge and Borough Market terrorist incidents to the Manchester Arena bombing and the Grenfell Tower fire. Ordinary people doing extraordinary things 24 hours a day, seven days a week, 52 weeks a year.

Not just the immediate things like running towards life threatening danger, not away from it, in the first hour of an incident. But providing the ongoing back up and support in the community in the weeks and months after. Great patient care that is just as important but is often overlooked.

The worst of times

But it’s also, in some respects, the worst, the most challenging, of times.

We are in the middle of the longest and deepest financial squeeze in NHS history.

We’re seeing real pressure on our mental health and community services with a particular public focus on our inability to meet the rapidly growing demand for child and adolescent mental health services.

For the first time since they were introduced, despite best efforts, last year the NHS missed all four of the long standing acute and ambulance performance standards. The four-hour A&E standard. The 18-week elective surgery standard. The 62-day cancer standard. The ambulance response time target.

We also have prolonged, significant and widespread workforce shortages that are making it increasingly difficult to provide services where, when and how they should be provided.

Running the NHS permanently in the red zone

To me it sometime feels like we are in the middle of an old World War Two film.

I see the NHS as a Royal Navy destroyer crashing through a stormy sea being buffeted by wave after wave of surging demand. Fuel is running low. The captain calls for more power. The needle on the engine room pressure dial goes above 100%, and becomes stuck deep in the red zone.

After ten minutes of running at absolute maximum power the engines falter and the ship shudders. Nervous glances cross the bridge. How much longer can the ship stay in the red zone?

Excuse the dramatic licence, but we are now trying to run the NHS above its sustainable limits, well into the red zone. And there’s a danger we’re trying to do that permanently, not just for a short, temporary, period.

There are red zone warning signs wherever you look.

We are now trying to run the NHS above its sustainable limits, well into the red zone. And there’s a danger we’re trying to do that permanently, not just for a short, temporary, period. There are red zone warning signs wherever you look.

   

An enduring, underlying, provider sector financial deficit, estimated by the Nuffield Trust to be around £3.5bn, that the National Audit Office has described as a long way from sustainable.

59% of NHS staff working unpaid overtime each week. A level of effort that it’s reasonable to ask for every so often. But not day in day out.

And, in perhaps the most apt example of the red zone, running too many of our inpatient mental health and acute wards at too high a capacity level too often. For example, mental health inpatient facilities running at occupancy rates of over 100% as we have to put patients into beds at the weekend when other patients are on weekend leave.

Overstretched district nursing services that can only meet the demand they face by squeezing the time available for individual appointments, making the provision of compassionate care much more difficult.

Key public health services like drug and alcohol addiction and sexual health services trying to keep up with rising demand and avoid more serious, costly, hospital referrals on ever decreasing budgets.

Trusts in the red zone

Running the NHS permanently in the red zone also has consequences for individual trusts and their leadership teams too.

The key principle used to be that a well run trust should be able to meet its performance targets and deliver a 5% financial surplus to allow for investment in new treatments and vital maintenance.

When I took up this job five years ago, the vast majority of trusts were achieving that standard. Now, despite working at full stretch, none are.

However hard trusts try and however good a job their frontline staff do, providers are finding it increasingly difficult to hit their performance and financial targets. Only able to make their finances work by delaying capital spend, adjusting the accounts or selling land. Nervously watching as the backlog maintenance bill balloons and the estate starts to crumble.

And a growing, tangible, frustration that the hard fought gains of the 2000s across a range of measures – for example, waiting times and single sex wards – are starting to slip back at increasing pace.

Once every so often you get one of those emails that captures the picture perfectly. This one, which arrived about six weeks ago, was from one of our longest serving and most respected trust CEOs. In their words:

 

In the last 18 months I have seen a reversal of what has been a long-term improvement trend. In 2016/17 we saw the first year-on-year increase for 10 years in mortality rates in our hospital and cases of hospital acquired infection. We failed the A&E target for the first time in eight years and our true financial position was a record low of just £100,000 above break even. This year the mortality rate is stabilising but infections continue to increase, our A&E performance continues to deteriorate and it will be a miracle if we break even in real terms. All of this supposed ‘poor performance’ is with the same team of managers and clinicians who have won the trust a large number of awards and who are still making herculean efforts to keep our services safe, effective and caring. I feel as though I am the captain of a much-loved but slowly sinking ship whose crew are bailing out water faster and faster to stay afloat but cannot continue to do so indefinitely.

   

Herculean efforts is about right. As is the fact that more and more trusts are finding it difficult to keep their heads above water.

Providers deliver

I think, given this context, providers have done some amazing things over the last two years.

Stabilising provider finances and reducing a ballooning deficit from £2.5bn to £800m in a single year.

Developing, at real pace, a significantly increased focus on mental health including introducing the world’s first mental health access standards.

Coping with increasing demand levels a long way above what the Five-year forward view ever predicted and ensuring performance hasn’t fallen off a cliff edge.

Cutting the agency staffing bill by 20% - £750m - in really short order.

Realising £3.1bn of annual cost improvement programme gains, a whopping 3.7% of spend.

Taking the lead in many local systems to develop STPs, pioneer new ways of delivering care and deliver the Five-year forward view transformation.

It’s been an extraordinary performance.

The issue, as Jim Mackey succinctly put it, is that we have do it all over again this year and next year too.

So my question is how can national system leaders help trusts sustain this level of performance year in year out? What can they do to support trusts to keep performing at this level this year, next year, and the year after that? What is the give and the get in the system?

What we need from our national leaders

I think we need four things from our national system leaders.

Recognition of how difficult the context now is.

A deliverable task.

Trust and respect.

And more support.

Let me take each of those in turn. And then I’ll more briefly set out what I think the get from trust boards might be in response for this national level give.

Recognition of the difficult context

The first ask of national leaders is explicit recognition of the difficulty of the current context.

That a financially squeezed NHS, with growing workforce shortages, is finding it increasingly difficult to keep up with increasing demand and expectations, even though it’s running at absolutely full stretch.

It worries me that, at the moment, we seem to have a rapidly increasing gap between the national system level view of how the NHS is faring and the view from the frontline.

The frontline view is as I have described. That we’re trying to run the NHS permanently in the red zone and that the current position is not sustainable.

The system-level view stresses how more money than ever before is being invested in the NHS and how many extra staff the NHS now has.

Yes, the NHS budget and staff numbers are growing.

The question, though, is whether they are growing fast enough to allow the NHS to keep up with demand, preserve care quality and meet the performance standards the government has committed to. They currently aren’t.

When distributed delivery systems like the NHS come under the degree of performance pressure we are currently under, one of two things tends to happen.

Either the system pulls together to address the challenges it faces.

Or it pulls apart with national and local leaders blaming each other in an escalating cycle of recrimination.

National leaders blaming local leaders for not trying hard enough or doing their job well enough.

Local leaders blaming national leaders for setting them an impossible task.

If we are to pull together as a single system, we need a single, shared, evidence-based, objective view of our strategic context and where we really are.

A deliverable task

A closely linked, second, requirement of national leaders is a deliverable task. Ensuring that what national leaders ask of local trust leaders can genuinely be delivered.

We must return to a position where well run trusts can consistently and sustainably succeed, year in, year out, in the task they have been asked to deliver.

At the heart of this is a core requirement for all public services – to match the service provided and the funding envelope.

As I argued last year, the NHS faces a particular issue here as, unlike any other public services, we have a set of detailed, clearly defined, highly scrutinised, constitutional performance standards that need to be met.

Reinforced by a rigorous, well resourced and all encompassing CQC inspection regime.

The NHS can’t, as other public services have done, cut staff, reduce opening hours, change service eligibility criteria, reduce service quality or close services altogether to fit the money.

But we have now reached the point where it is no longer possible to meet those NHS constitutional performance standards on current funding levels.

That’s not a particular surprise given that we’ve had seven years of NHS demand and cost rising by 4% a year on average but NHS funding only rising by an average 1% a year.

It’s particularly not a surprise when you realise, as the Nuffield Trust has recently shown, that between 2010 and 2015, trusts have had annual year on year cuts of 4% to the prices they are paid for treatment through the tariff and through linked levels of block contract spending.

So if, in 2010, a trust received £100 to treat or care for a patient, in 2015 they only received £92.50 for exactly the same treatment or care.

But it’s actually even worse than that. Costs have risen in the meantime. So, by 2015, that 2010 £100 had fallen in real terms to just £80.00.

Trust leaders are clear what they want. They want to meet the standards. But they are equally clear they can only do so if they have the funding and staff required.

So we’re in danger of getting stuck in an impossible trap. There isn’t enough funding or staff to meet the standards. But there are still too many who think the standards are deliverable if only providers tried harder or did their job better.

So we’re in danger of getting stuck in an impossible trap. There isn’t enough funding or staff to meet the standards. But there are still too many who think the standards are deliverable if only providers tried harder or did their job better.

   

It’s why the forthcoming Budget is so important. It’s our one chance, right at the beginning of the new parliament, to ensure the NHS has a deliverable task. That we match the NHS delivery ask with the funding available.

The argument for extra funding for the NHS is clear and we’re proud to have led that argument.

We even had that arch disciple of fiscal rectitude Sir Oliver Letwin arguing for more money for health and care on the Today Programme last week.

The simple point is that if we want the best care, we have to pay for it. UK health spending would need to be around £24bn, or 13% higher, to match current German or French levels of health spending.

If we wanted to spend as much per head of population as the French do, we’d need to be spending £300 a year more per person. To match the Germans we’d need to be spending a whopping £900 a year more per person. Sobering figures which show that in the end, as my Dad used to say, you get what you pay for.

But, equally important, and much less focussed on, is the need to ensure that what is asked of the NHS matches the funding available.

We’ve seen over the last 18 months how corrosive it is for the NHS to over promise and under deliver.

To create a delivery plan that is based on far too optimistic a set of assumptions about how we can supposedly rapidly reduce demand despite a growing, older, population…

… how we can supposedly realise savings levels that no other advanced Western health systems has ever realised…

…And how we can supposedly deliver at record pace across a huge range of widely dispersed priorities.

So whatever funding settlement comes out of the Budget, we must create a delivery plan that has a reasonable set of priorities.

With a realistic and deliverable performance trajectory for each priority.

With complete and total alignment between all key system leaders on those priorities and trajectories.

And genuine involvement of frontline leaders so they can assure that the plan is deliverable and can feel genuine ownership of what’s being asked of them.

In short, a deliverable task, with appropriate stretch, that trusts have a realistic chance of achieving. So we can restore everyone’s confidence that the NHS can and does deliver on its promises.

Trust and respect

The third ask of national leaders is that they trust and respect that local leaders are doing everything they can to maximise performance within their trusts.

I’m going to be blunt and challenging here because I think the situation deserves it.

One of the more difficult aspects of my role is hearing some of the things that are said at the national level about trust leaders. I’ve alluded to some of it already.

That providers aren’t trying hard enough. That they could and should be doing a lot more to hit their performance and financial targets.

That, as a cadre, top trust leadership is poor, substandard or inadequate. That there are only 40 or so good trust chief executives in the country.

That when providers leaders raise legitimate concerns about their ability to deliver what’s asked of them, they are just complaining and trying to avoid their responsibilities.

All things I have heard over the last 12 months.  

I don’t believe any of them.

All the trust leaders I meet are stretching every sinew to deliver the outstanding patient care to which they are passionately committed.

There is absolutely no evidence that NHS trust leaders, as a group, are any less capable than their local government, education or prison service leader colleagues.

There is a simple but important truism. If a few trusts miss their targets when all others are meeting theirs, it’s likely to be a local trust or local system problem. But if almost every trust is consistently missing their targets, as is now the case, it’s likely to be a national system level problem.

There is a simple but important truism. If a few trusts miss their targets when all others are meeting theirs, it’s likely to be a local trust or local system problem. But if almost every trust is consistently missing their targets, as is now the case, it’s likely to be a national system-level problem.

   

Some will interpret this as the providers’ trade union arguing that poor performing trust leaders should not be held to account. It isn’t.

Normal distribution alone suggests that, in a class of 230, some will inevitably struggle, particularly as the chief executive role becomes more difficult.

And the success of the aspiring CEOs programme we have created with NHS Improvement and the NHS Leadership Academy shows the power of investing in the development of trust leaders.

But if we end up thinking that the current performance problems in the NHS are largely due to systemic poor trust leadership, I fear we are in danger of losing the plot.

There is a particular issue around chief executives in the most challenged trusts – the places where senior leadership performance is likely to be under the greatest scrutiny.

The NHS has a poor record of unreasonable impatience here.

These trusts usually have long seated, intractable, problems – often of geography, workforce gaps and system weakness. Failure to meet targets in these trusts can often be as much due to system level failure – in social care or general practice – as the failure of individual providers.

And it’s no coincidence that many challenged local health and care systems often have other public services that are failing too.

Chief executives in many of these trusts have been on a merry go round, with the HSJ showing recently that the average tenure of chief executives in the most challenged trusts is just 11 months. Surprise surprise, the average tenure for chief executives in CQC outstanding rated trusts is seven years.

It also cannot make sense for eight of the most challenged trusts to have had four chief executives in the last three years, as the HSJ also found. That way lies continued failure.

The success of Lesley Dwyer at Medway and Claire Panniker at Basildon, to quote just two examples, shows that when we give the right chief executives the time and air cover to match their talent, they will succeed.

But there is a risk that as the performance pressure on the NHS mounts, the merry go round will speed up once again.

Removing trust leaders should always be a last resort. And our national system leaders should be wary of trying to form their own judgements on which chief executives should go and which should stay.

Removing trust leaders should always be a last resort. And our national system leaders should be wary of trying to form their own judgements on which chief executives should go and which should stay.

   

It is the task of trust boards to reach an evidence-based, rounded, judgement on where a chief executive is failing and where a new chief executive is needed and to then effect the required change with respect and dignity.

Either we trust and respect chairs and non-executive directors to performance manage their trust leadership teams or we might as well not have them at all.

Trust and respect also means our national system leaders wanting to genuinely listen and understand local leaders’ perspectives and then work out how the national system can support them more effectively.

Twelve months ago the entire NHS senior leadership, NHS Providers included, signed up to the new NHS national improvement and leadership development strategy.

At its heart is the concept of compassionate leadership. Defined, and I quote, as “paying close attention to all staff; really understanding the situations they face; responding empathetically; and taking thoughtful and appropriate action to help”.

That wasn’t how it felt to the chairs and chief executives of the trusts with the most challenged A&E performance who attended a meeting with system leaders seven weeks ago.

The issue wasn’t just that some trust leaders were asked to chant “Yes we can”, patronising, inappropriate and parent/child though that was.

It was a perceived lack of willingness among some national leaders to listen and try to understand the situation that trust leaders face on the ground. To respond empathetically. And to work out how national leaders could take appropriate action to help, not just issue a blunt “improve your performance or else” warning.

As the performance pressures on the NHS mount, it is incredibly important that we all stay true to the values and behaviours of compassionate leadership that we all signed up to 12 months ago. With trust and respect at their heart.

Support

Which brings me neatly onto the fourth ask of national leaders - more support please.

The only way the NHS will meet the significantly increased performance challenge it now faces is if national system leaders significantly increase their support for local leaders.

We all know what can happen at a national level when performance pressures mount in the NHS.

Arm's-length bodies scurry around in ever-decreasing circles gathering more and more information; checking what’s happening at the frontline more and more frequently; and exhorting that frontline more and more strongly.

Often just to demonstrate that they, as arms length bodies, are on top of the situation and doing all they can.

A lot of this activity is wasted effort. Worse than that, it’s usually counter productive as the frontline has to respond to this frenetic blizzard of activity, diverting valuable time, energy and resource from where it’s actually needed - delivering frontline care.

It becomes particularly difficult when multiple different layers of multiple different arm's-length bodies ask for effectively the same information in multiple different formats covering multiple different time periods.

What we need to do is to invert the current top down, check and control model of arm's-length body activity into a bottom up, serve and support the frontline model.

Don Berwick has a great story about what’s needed. It’s stuck with me ever since I first heard it though I will, admittedly, embellish and paraphrase it a little.

Imagine a group of student hikers out for a long hike. It’s towards the end of the day. The night is beginning to fall, bringing potential danger. But a couple of the hikers, through no fault of their own, are beginning to fall behind. How do the group leaders respond?

Is it to berate the stragglers for failing to keep up and telling them to look at how well the rest of the group is doing?

Is it to keep telling the stragglers the speed they need to go at, asking them to report their actual speed every five minutes and then keep checking they are meeting the required pace, with the group leaders assuring themselves that this checking process is being done correctly?

Is it calling the group together to lecture the stragglers on the need to increase their speed or else they will be thrown out of the group altogether?

Or is it, perish the thought, calling the group together and asking it to chant in unison “we can do it”.

It is, of course, none of the above.

It’s about asking those who are struggling what help and support they need. Listening carefully to what support they ask for, with no preconceptions of what support the group leaders think they should have. Doing everything possible to offer the requested support. And, where possible, the rest of the group rallying around to provide what support they can. Trusting and respecting that the stragglers will do their absolute best.

That is what we need our arm's-length bodies to do – provide more support for frontline leaders. And it will require a significant change in how they currently do business.

The ask of local leaders

So if the ask of national system leaders is recognition of how difficult the context now is; a deliverable task; trust and respect; and more support…

…What is the ask of local leaders? What’s the local get for the national give?

It’s not my place to make commitments on behalf of the sector but it does feel right and proper to briefly highlight four areas where local leaders will also need to step up to the plate to meet the challenges the NHS faces.

First, it is vital that the sector continues to believe that, however difficult the strategic context may be, the right management actions can make a difference.

One of the big dangers of the current context is that providers become powerless victims of the deteriorating context believing, as I’ve said, that however hard they try, they cannot succeed.

That’s why the CQC’s report in June of eight case studies of trusts who’ve increased their rating – five trusts by two ratings, three by one rating – is so important. It shows that systematic improvement is possible, even in the most challenging of contexts. If you haven’t read it, I would urge you to do so.

Provider leaders need to continue stretching every sinew to deliver as well as they can – for patients and service users, for local communities and for their staff.

Provider leaders need to continue stretching every sinew to deliver as well as they can – for patients and service users, for local communities and for their staff.

   

Second, and closely allied, we need to retain the right balance of realism about the current context – calling it as it is – and optimism – believing that, despite the scale of the current challenges, we can continue to deliver outstanding patient care. I know I personally find it difficult to consistently strike that balance at the moment. But it’s vital we do so, particularly for our staff.

Third, that we remain committed to the idea of reasonable performance stretch. It would be easy as the pressure mounts to lower our ambition – for example to just concentrate on the increasingly difficult operational delivery task and put transformation on the backburner when, in reality, we have to do both.

And, fourth and perhaps most importantly of all, recognising that our staff are our single most important asset and our single most important task is to support them to give of their best.

It’s clear they are increasingly feeling the performance pressure. It must be our task to shield them from that pressure as much as possible, enabling them to concentrate on what they do so well – providing outstanding care.

The staff survey data also tells us that we have some big issues to address – on bullying, for example, and ensuring that we better support our black and ethnic minority staff.

I’m particularly struck by how many trusts are now successfully putting workforce issues centre stage, recognising that the solutions to today’s growing workforce challenges lie not just at a national but at a local level and in the right national/local partnership.

Points we make particularly strongly in our new workforce report which we’re launching today and which, again, I hope you will read.

United we succeed, divided we fail

Let me finish by saying that I am optimistic that the current challenges can be met. The NHS has an uncanny knack of not just enduring but delivering despite all that is thrown at it.

But let us all be clear that as national and local leaders in the same system, we have to do this together. United we succeed, divided we fail.

Thank you and I hope you enjoy the rest of the conference.

 

 

Chris Hopson spoke exclusively with the HSJ ahead of our annual conference and exhibition and warned that NHS leaders' careers are at risk over “impossible targets”. Chris warned that there was an unprecedented gulf between the expectations of system and political leaders, and the reality faced by trust managers, and without significant additional funding, the current performance targets were unachievable, and left leaders “stuck in an endless cycle of not being able to succeed”.

About the author

Chris Hopson profile picture

Chris Hopson
Chief Executive
@ChrisCEOHopson

Chris Hopson is the chief executive of NHS Providers. He joined in September 2012 after a career in politics, commercial television and the civil service. Read more

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