HUGH TAYLOR
Chair, Guy's and St Thomas' NHS Foundation Trust
and King's College Hospital NHS Foundation Trust
What was the original rationale for the arrangement and what were your reasons for agreeing to the approach?
The rationale for a move to a chair in common was for the two trusts to work in partnership (building on an academic partnership) and to collectively improve operational and financial performance. It also made sense to work together due to proximity and being in the same STP. A merger is not in prospect at the moment for a number of reasons including the need to overcome significant financial challenges.
What were the expected benefits of adopting this approach?
We expected this approach to support each other over time to improve position and provide more integrated services, as well as helping the development of the STP/ICS and collaborative working, including on specialised services. Ultimately, we thought this joint chair approach would also encourage building relationships across trusts at leadership level and throughout the organisations.
What unanticipated risks/issues have you experienced and how have you managed them?
A trust chair doesn't just chair meetings, they are held accountable by regulators which means taking on board a lot of responsibility, managing complex risk and managing a number of relationships – with the support of the team.
While chairing two different governing structures at two trusts is time-consuming and complex logistically – e.g. lots of meetings – there is also a need to rationalise and improve the effectiveness of the governance structures in this new arrangement. Additionally, wider changes within the executive leadership teams of both trusts have presented both an opportunity to develop and support people, and a risk to be managed in terms of loss of corporate memory and continuity. There are new players involved at NHS England and Improvement and also new board members all of whom need to form trusting relationships.
With the benefit of hindsight would you do it again and why?
We would do it again – despite the challenges, having a joint chair signals the potential of better, collaborative working. A clear benefit has been cultural alignment -there are similar values in both trusts with staff on the frontline also holding the same values. There are now two councils of governors, which works well and they hold the chair accountable. Each trust's council of governors is experienced and questions how they fit in the STP model. Going forward, a key concern is maintaining, and indeed improving, quality of care for both trusts. Structural groups, such as boards, will move further away from the operational line due to the workload of two trusts and will need a new regulatory model to manage.
JOE FIELDER
Chair, North East London NHS Foundation Trust (NELFT)
and Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT)
What was the original rationale for the arrangement and what were your reasons for agreeing to the approach?
The regulators approached Joe to consider being chair at BHRUT, as good progress was being made at NELFT and they saw opportunities for further progress. The rationale for there being a chair in common with BHRUT was to help develop the direction of the accountable care organisation where there would need to be more collaborative working between the trusts and wider stakeholders.
Joe was successful in becoming a chair in common, working to develop integration and improve healthcare for the local population, in an area where he grew up and still lives to this day.
For Joe, further personal motivation for becoming a joint chair was to influence the local community to improve patient outcomes, provide more holistic care and improve value for money for the taxpayer. It was also important to be more influential in the collaboration between health and social care and to be able to give back to the public sector, having previously worked in the private sector.
What were the expected benefits of adopting this approach?
It was expected that the benefits would largely be about bringing the organisations together, which would help develop the system – especially as there is so much cross over between the two who potentially needed to communicate and collaborate better in a number of areas. However, from the chair's personal perspective, Joe expected there to be an improvement in patient outcomes in the local population via collaborative working, for fragmented care to become more joined-up and a decrease in unhelpful inter-trust competition. There was also a hope to improve inpatient, outpatient, and mental health services, ICT and staff engagement.
There have been a number of benefits and lessons learned between the trusts, for example:
- there is a more developed volunteer scheme at BHRUT (hundreds of volunteers), something that NELFT needs especially since they are spread over more sites
- the trust charity at BHRUT is established and brings in £600-700,000 of income that is of great value and beneficial to patients, which is another aspect that NELFT could learn from
- BHRUT benefit from having more nurse associates which NELFT aspires to increase
- NELFT is a national leader in WRES and can assist BHRUT with its diversity agenda
- NELFT ICT is strong and well placed to assist BHRUT with the digital agenda.
What unanticipated risks/issues have you experienced and how have you managed them?
BHRUT faced unanticipated, early financial challenges during this process. Leadership challenges were also considerable and external investigations had to be commissioned, which led to some change in leadership. Time was another challenge – the joint chair role was supposed to be two days in each trust but has resulted in closer to a fulltime role, while the NELFT council of governors were concerned about time commitments. The vice chair at NELFT was given more visiting responsibilities to engage with people across the trust as a result, which was then mirrored in BHRUT.
It is important for anyone hoping to become a joint chair to understand the rationale behind the regulator wanting a joint chair for the trusts and the challenges that they might expect. There is a need for the centre to be explicit about the rationale for a chair role and the combined objectives.
Have conflicts of interest arisen and if so how have they been managed?
Where conflicts arose, the protocol established has been that the two vice chairs lead those discussions. They have been relatively few. In other cases where NELFT and BHRUT have been in direct competition, Joe would step out of that item during both board meetings.
With the benefit of hindsight would you do it again and why?
We would do it again as there is a need for improving patient outcomes and encouraging more joined-up care, and the need is becoming more apparent as time goes on. The vision is that we need to 'look after the whole person, for the whole of their health requirement for the whole of their life'. Having a joint chair also means the two trusts can make better use of vital resources like our staff, estates and IT and have a 'helicopter view' over two trusts allows for better visibility for patient care.
However, there is a need for more clarity from the regulators around system working, and for space, time and support to make improvements, rather than to encounter the real risk of continual further regulatory actions.
KATHY McLEAN
Chair, University Hospitals of Derby and Burton NHS Foundation Trust
(formerly Derby Teaching Hospitals NHS Foundation Trust and Burton Hospitals NHS Foundation Trust)
What was the original rationale for the arrangement and what were your reasons for agreeing to the approach?
We appointed a joint chair due to a merger - where the larger trust merged with the smaller trust.
What were the expected benefits of adopting this approach?
Two of the main benefits of the transaction were the improvement of patient care and recruitment, and a great deal of progress has been made, although there is still more to do in that area. Importantly, the larger organisation made working closely with partners and building relationships with them simpler.
Prior to the transaction, there were many unfilled vacancies at the one site, for example in radiology, but post-transaction the vacancies were filled. It has become easier to attract people with the right skillsets following the merger and increased the ability to recruit diverse NED and executive board members.
The transaction also made the new organisation more able to deal with the challenges it faced and made it more sustainable in the long term. There have been clinical service changes which have improved quality for patients which were not possible before the merger.
What unanticipated risks/issues have you experienced and how have you managed them?
The availability and use of capital at both sites was different, where Derby had a PFI building and Burton didn't. Different IT systems in both sites have also been challenging as integrated IT systems underpin easier communications. There were also, and still are, challenges in working across two STPs, not least the time commitment required.
MARIE GABRIEL
Chair, Norfolk and Suffolk NHS Foundation Trust (NSFT)
East London NHS Foundation Trust (ELFT)
What was the original rationale for the arrangement and what were your reasons for agreeing to the approach?
This approach was originally agreed to support NSFT out of special measures. ELFT were already acting as a buddy helping NSFT improve. This wasn't a joint chair appointment with a future merger in mind but as a buddy arrangement to another trust.
What were the expected benefits of adopting this approach?
We anticipated this approach would provide the opportunity to improve and support the NSFT, as well as the opportunity to improve quality of care and to support others and help develop others in the trust. Being a joint chair also importantly means you can bring good things back to your old trust that you've learnt from the buddy trust.
What unanticipated risks/issues have you experienced and how have you managed them?
Managing time between the two trusts is difficult, and can be unusual – particularly where you have to adapt to two different cultures and styles of leadership. As well as the issue of culture, maintaining an equal focus on both trusts can be demanding, especially as you have responsibility and accountability for both trusts which have contrasting geographies and challenges.
A joint chair can also stretch the other NEDS, which, if handled well, provide opportunities for them to develop their non-executive experience and insight into being a chair.
For those that chair two foundation trusts, extra focus must be invested in working with the council of governors who appoint the chair and inform the chair's appraisals. They must understand the benefit/impact for their particular trust, be kept informed and assured that patient and organisation benefits are secured.
Regulators need to think quite carefully about what having a joint chair for more than one trust means for the trusts, there needs to be a negotiation with the regulators on how much support can be provided by the chair and how much support they as regulators provide. Being a chair is about reflection, being seen in the trust and speaking to the front line which is difficult at two trusts that are not in proximity.
Have conflicts of interest arisen and if so, how have they been managed?
There were conflicts of interests which were declared, for example ELFT had a role in supporting negotiations of buddy arrangements so we declared a conflict in setting those terms.
With the benefit of hindsight would you do it again and why?
We would do this again, but Marie would advise those looking to become a joint chair that they do their due diligence before they go in to the other trust to find out what needs to be done and what the purpose for having a joint chair is given this can vary considerably. The individual needs to gain a clear understanding of the local geography - the distance between the two trusts has often been a challenge. Being an experienced chair is helpful but you also need to be clear about why you want to take the role of a joint chair.
Tackling chairing roles at trusts with difficulties will always be challenging and create work for the chair, but it also means you can make more impact. It is good for one part of the NHS to be helping another part, and for colleagues in different trusts to learn from each other.
ROBIN TALBOT
Chair, North Cumbria Integrated Care NHS Foundation Trust
(formerly Cumbria Partnership NHS Foundation Trust and North Cumbria University Hospitals NHS Trust)
What was the original rationale for the arrangement and what were your reasons for agreeing to the approach?
As planned, these two trusts merged in October 2019. Before this point the board had already merged with joint executives and joint NEDs working across both trusts.
What were the expected benefits of adopting this approach?
We expected this approach to aid with the move towards an integrated healthcare system, particularly by creating a common agenda which aligned our objectives. Practically, we also expected there to be benefits with streamlining paperwork and the number of meetings, as well as economies of scale.
What unanticipated risks/issues have you experienced and how have you managed them?
Managing joint control totals was a challenge. In terms of the existing workforce, as the trusts work closer together, some staff might feel further away from what is actually happening in the trust. Similarly, it created visibility issues for senior staff, as the trusts merge and get bigger, staff such as senior managers cannot be everywhere all the time. The trusts are geographically isolated so there aren't many opportunities that exist to work outside.
The merger also highlighted workload issues. Workloads were already enormous within each trust – for example, agendas and meeting papers are incredibly long and it's hard to reduce these.
NEDs also understandably needed support to understand their roles in the run up and within a newly merged trust. There is also a need to bring governors on the journey such that they understand the objectives of the merger, and the challenge in improving committees and how they work.
Finally, there was a risk to parity of esteem with the community and mental health trust in particular and a sense it was losing its individual identity.
Have conflicts of interest arisen and if so, how have they been managed?
As this was a merger rather than a chair in common, we didn't face this issue.
With the benefit of hindsight would you do it again and why?
Yes - there are many benefits in terms of shared learning and cross-fertilisation of ideas and practice and these outweigh the challenges posed by time constraints and managing conflicts of interest.
PAUL DEVLIN
Chair, Lincolnshire Partnership NHS Foundation Trust
Nottinghamshire Healthcare NHS Foundation Trust
What was the original rationale for the arrangement?
Paul has extensive experience as a chair, a NED and Care Quality Commission inspector and wished to use his experience to build on work to develop a positive culture at a new trust as his term in Lincolnshire began to draw to an end.
What were the expected benefits of adopting this approach?
We hoped Paul's experience in Lincolnshire would help bring about improvements in Nottinghamshire, but also bring back what is good in Nottinghamshire to Lincolnshire leading to a cross-fertilisation of good practice.
What unanticipated risks/issues have you experienced and how have you managed them?
The two systems that the trusts are part of are very different, so there was a considerable amount of learning. Time commitment is also an issue and it has been necessary to look carefully at what the chair needs to do at each trust and what can be delegated. The governance teams at the trusts are in contact with each other to co-ordinate work, ensure that there is no overlap and to ensure that Paul is available for key meetings at each trust. This has also had the benefit of shared learning across the two trusts.
Have conflicts of interest arisen and if so, how have they been managed?
Paul anticipated that conflicts of interest might arise from the outset and put in place open and transparent processes so that conflicts can be identified, declared and managed. The governance teams are in touch with each other and this facilitates the avoidance or management of conflicts.
With the benefit of hindsight would you do it again and why?
There are many benefits in terms of shared learning and cross-fertilisation of ideas and practice and these outweigh the challenges posed by time constraints and managing conflicts of interest.