Press release: Stephen Thornton's speech to NHS Confederation Annual Conference, Manchester, July 2001
06 Jul 2001
I wonder, how do you respond when people ask you: "just what exactly is it that senior managers and leaders in the NHS actually do?
Often goaded by politicians, the tabloid media is always ready with its answer. Frankly, they think we're a waste of public money. In a cash limited service, money spent on management is money wasted that could otherwise be spent on patient care. We are all grey suited, male administrators who concern ourselves simply with financial bottom lines and care little about the quality of patient care. Frankly, it would be a lot better if we were replaced by matrons in starched uniforms and big hats.
We know the reality is very different. To start with, 46% of this representative audience of top NHS management, drawn from right across the UK, is female.
Much else has changed since the days when matron roamed the wards. Today, hospital care is a highly complex, multi-specialty, multi-disciplinary and often technologically driven enterprise. It functions at a furious pace. At the same time increasing volumes of health care take place outside traditional hospital settings, requiring much greater clinical autonomy as well as partnership working with a range of statutory and other agencies.
Meanwhile the potential for what health care interventions can do for people has increased expedientially, prompting constant appraisal of the appropriateness, the efficacy and the affordability of treatments by those of you with responsibility for commissioning and delivering services.
Society has changed too. The context within which we have to make these difficult decisions has become far more demanding.
Gone is deference to those in authority, including doctors. Often replaced by assertive, well-informed patients and carers, backed by vocal and demanding pressure groups. Gone too is the willingness of the public to trust institutions and professionals. Everything, quite rightly, is now subject to public accountability, to scrutiny and to potential exposure in the media.
Public expectations, too, are sky-high. So they should be. We are running a public service in the 4th largest economy in the world. But managing these expectations places yet another pressure on us. Who would have guessed from the recent headline in The Daily Mail, and I quote, "A betrayal of women", that Britain's cervical cancer screening programme is the most advanced and comprehensive of its kind in the world and that the initiative that prompted the headline was a genuine attempt to try and make it even better?
Neither are our politicians immune from these societal pressures. This is why they appear so much more demanding, so much more concerned with performance than ever before. This is why they seem to always demand delivery of impossibly difficult service targets.
The NHS has begun to respond to these health care complexities and the changing societal context, by embarking on the most comprehensive change management programme ever undertaken by a public service anywhere in the developed world. I don't have to tell you just what huge changes in the way services are delivered will be required if we are to successfully implement the radical ideas contained in English NHS Plan, the NHS Plan for Wales, the Scottish Health Plan and the expected outcomes of the various consultations presently taking place in Northern Ireland. In each part of the UK we face the task of radically redesigning care around patients not the system. As Secretary of State has just said, this means "overcoming old boundaries between services and traditional demarcations between staff. It means changing the relationship between NHS services and NHS patients."
All this requires leadership. Not using matron's regimented and authoritarian command and control style. No, modern management demands more subtle approaches. Developing networks of influence; motivating staff by involvement; developing external partnerships to replace competitive behaviour. Successful top management in particular needs to influence the environment, nurture innovation, enable and facilitate change, whilst simultaneously holding teams to account for continuous performance improvement. Top management also needs to identify and develop the real change agents, the front-line leaders, so often in the NHS the clinical leaders, who can make the biggest impact locally on quality. Liberating this talent and focusing it on what we need to achieve is our added value. So, this is my answer to the question I posed at the start of my presentation. Good management really does make a difference.
But without the backing to do the job, we will fail. Little will be achieved beyond the efforts of a super-human few. With this in mind, on your behalf over the last 12 months the Confederation has been urging those responsible for the NHS across the four home countries to acknowledge this fact, to recognise that NHS management really matters.
You will recall how the last Westminster government came in with a mandate to cut bureaucracy. They embarked on a series of measures to tighten the grip of central control of the service, positively motivated by a desire to end the practice of unacceptable local variation but which had the unintended consequence of disempowering many at the front-line. It reached its apotheosis with frantic financial earmarking, top slicing and hypothecation and the issuing of endless central dictats on everything from the employment of matrons to the cooking of mung beans in Matlock. An extraordinary example of this was a letter I have just seen from a regional office to a trust chief executive telling him that the font size of his headed notepaper was too small.
Despite this kind of nonsense, in the last 12 months I believe we have significantly shifted politicians' perceptions. In Scotland we became closely involved in the work of both the Modernisation Board and Forum. In Wales we continue to play a key role in the Task and Finish Groups charged with implementing the Plan for Wales.
Here in England, NHS management has also played its part since our influential involvement in last summer's modernisation action team process and our continuing membership of the Modernisation Board. As Alan Milburn began to engage with the detail and see the need for the kind of transformational leadership I referred to earlier, he turned to NHS management to play its part.
This was reflected in his last major speech before the general election when he called for a shift in the balance of power in the NHS in favour of the patient. "Many chief executives I speak to complain of too much day to day intrusion", he noted. "Too much of the NHS today still feels like a centrally run bureaucracy to those at the front line. This has to change".
Inevitably, there was some scepticism in the days immediately following his announcement. Welcoming it, the Guardian leader writer the following day questioned: "will Alan Milburn actually change his behaviour? Is it a true conversion?"
Meanwhile, a handful of rogue Department of Health announcements slipped through in the immediate aftermath. Perhaps the worst was the instruction that medical and nursing directors should control capital spending in NHS trusts. What self-respecting trust chief executive, I wonder, would think of committing such expenditure without seeking clinical advice?
We will continue to monitor these trends on your behalf. We will urge government to stick to its intentions. However, after today's speech from the Secretary of State I believe we have no reason to doubt his conversion to the cause of shifting the balance of power. He is right when he says, "I don't provide GP services. I don't manage NHS hospitals. You do".
I believe that as "shifting the balance of power" becomes a reality for the English NHS and as other parts of the UK adopt a similar approach, this will be remembered as a turning point in enabling NHS leadership to thrive. It will release the energy of so many to become what Secretary of State calls public sector entrepreneurs.
But what is needed to ensure this happens? What are the essential ingredients for success, the elements that make up what we are increasingly seeing as the emerging "compact for delivery" between the government and the management of the NHS? In return for a commitment from us to deliver the changes, to win hearts and minds for modernisation and to achieve real, practical improvements in the patient experience - to act as what Nigel Crisp yesterday called "ambassadors for the NHS" - what is it that we believe we need?
There is, as ever, one essential pre-requisite - the need for further sustained investment in the NHS over a longer time frame than the present settlement if all the home countries' targets are to be met.
We already know that this year's English SAFF round will result in some targets slipping. Next year will be even more challenging, as I am sure the local modernisation reviews will show. For many, the full year effect of this year's round will have to be a first call on next year's money. The costs of Agenda for Change and the Working Time Directive will be issues for next year, right across the UK. Neither is there scope for further traditional efficiency savings. In many places there will be a need to reinvest to build back quality lost as a result of simplistic cost-cutting exercises.
Just like on the railways, the extent of 30 years of under investment is only just becoming apparent. It will take much longer to repair than previously thought. Alan Milburn is right when he says the NHS is now the fastest growing health service in Europe, but this has barely been the case for 12 months. The Confederation will need to maintain its strong links with Treasury which we will use to work alongside the Department of Health in making the right arguments for additional resources in the next spending round.
What else do we need? There are eight essential elements that make up the "compact for delivery".
The first is for government to continue to set a positive climate within which NHS management can thrive. This "mood music" is vitally important. It sets the tone within which others' attitudes are set. It effects our ability to recruit and retain the right calibre of individuals, especially from amongst clinicians. This has been transformed in recent months. On Wednesday the Prime Minister told us "investment in management is investment in reform". Yesterday, Nigel Crisp applauded our success, and recognised that we held the future of the NHS in our hands. Today, Secretary of State spoke of the important role of boards - of executives and non-executives alike.
The second is about capacity. Parts of the NHS have been historically under-managed. This is a particular issue for English PCTs and Welsh local health groups. It is now time to revisit the question about whether they have the management resources to meet the expectations we now have of them. The Confederation has launched a project to examine this and will report our findings to government. In the meantime we believe it highly unlikely that the English department of health will achieve £100m in savings from the abolition of health authorities. This and more will be needed by the PCTs. The Secretary of State described PCTs this morning as the "engine of change in the NHS." They must not be set up to fail.
The third is about raising the profile of information and communications technology. The NHS does have a sound information strategy. But it must be given greater prominence. We must avoid diverting capital funds earmarked for this purpose to prop up current account spending. We need centrally determined data standards and procurement approaches; and, above all, much clearer, stronger national leadership for ICT.
The fourth is about performance improvement. On your behalf we continue to contribute to the work designing the new performance management system in England. Our starting point, to use the language of Paul Plsek earlier this morning, is to see the NHS as a complex adaptive system, not a machine machine bureaucracy. We need simple rules, and far fewer targets.
We have made strenuous representations about the emphasis being placed on "traffic lights" and crude, tick-box categorisation of NHS organisations. You don't make a pig fatter by weighing it!
This is why we were pleased to hear Nigel Crisp yesterday say that we could now expect a performance management system based on a more balanced scorecard, not what he called just the "big ticket items", but taking account of patient and staff views, and reflecting the quality of management effort.
The way our performance is judged must be open, coherent, understood, consistent and fair. We strongly believe that the advent of the new strategic health authorities provides a once and for all opportunity to get this right.
The fifth is about inculcating an ethos, a set of attitudes and behaviours that will enable clinical teams to enthusiastically engage in radical service redesign. That is why we were instrumental in the formation of the Leadership Centre in England and have been so supportive of the NHS Wales Centre for Leadership, the University of the NHS and the Modernisation Agency. From breakfast with Fillingham, through a whole series of fascinating workshops yesterday we heard what valuable work the agency is doing in partnership with the NHS. We believe it must remain developmental in focus, not become an agency of last resort, sent in by Ministers to pick up the pieces. It must continue to see itself as acting on behalf of its NHS clients.
The sixth relates to our most serious concern about the achievement of the plans in all four parts of the UK - our ability to recruit and retain the right staff, particularly in the most economically buoyant areas. We are not sure whether, corporately the NHS has access to a robust evidence base about what attracts people to the NHS and what would keep them. Such information is vital to us as we make decisions about planning the future workforce. Neither do we believe that the adversarial annual pay round creates a helpful environment. We urge a longer-term solution, linked more closely to the three-year financial settlement for the service.
Meanwhile, it is vital that government successfully concludes the consultant contract and Agenda for Change negotiations. The Confederation will continue to play an active role as core part of the management side of such negotiations. I certainly welcome Secretary of State's suggestion of a not dissimilar role for the Confederation in relation to the GP contract negotiations. We will of course, consult our membership on this proposal, but I believe there is real merit in the service being strongly represented in these settings.
The seventh is the need for continued backing from Ministers to enable greater risk taking. The local pressures on us to spend new money solely on meeting immediate service pressures are immense. We need support to ensure we can properly resource radical service redesign, acknowledging that modernisation is as much about doing things differently, in order to make a step change in the quality of care for patients.
The Confederation has a reputation for developing innovative, yet essentially practical solutions, which we have been pleased to see the Department take up. For example, we are just beginning to work with acute hospitals and PCTs who are involved in major capital developments to help think about how to ensure that we design truly 21st Century care systems and the buildings to match.
However, the more radical the modernisation, the more it will require politicians, clinicians and managers to promote the benefits of change and work together. The Kidderminster election result provides lessons for us all. "Reform is difficult", Secretary of State has just told us, "there may be a rocky ride". The scale of service redesign and reconfiguration required to modernise is such that we must develop more effective local strategies for public involvement and communication. The role of government is not only to ensure we have a coherent strategy for hospital development but to back local management decisions that have been arrived at by due process.
Radical modernisation requires top quality leadership to ensure effective implementation. We believe that, given the proper resources to do the job, NHS management can provide this. We were pleased to receive clarification from the Department yesterday that where there is a need to support poorly performing trusts this will be done under NHS management leadership. However, we will not stand in the way of more radical solutions, including possible use of private sector expertise, via franchising or other methods. All we ask is for there to be a clear statement of policy and a level playing field. Personally I remain convinced that NHS management can match the best that any private sector management solution might offer.
My eighth and final point concerns reorganisation. We ask the Westminster government, the Scottish Executive and the Assemblies in Wales and Northern Ireland to recognise that the proposed structural changes - in England, creating strategic health authorities and care trusts and achieving comprehensive PCT coverage; in Scotland creating unified health boards; in Wales abolishing health authorities and empowering local health groups; and in Northern Ireland achieving structural changes yet to be announced, will create a huge organisational change agenda for NHS management, particularly given the foreshortened timescales just announced. Whilst this will secure early clarity for the new organisations, NHS management will need political support and understanding over what will be an extremely challenging next two years.
An important test for any major change process is the extent to which those of us directly affected by it are supported as we help redefine our own futures in the wider interests of people we serve.
The tone for this conference was set so spectacularly on Wednesday afternoon by Benjamin Zander. I have never experienced such a positive event. Powerfully and evocatively he showed us how to envisage a world of endless possibilities, not world of insoluble problems. He warned us graphically of the dangers of a downward spiral mindset. He helped describe what most of us really knew already but found hard to express - that the essence of our job is to awaken the possibilities in other people. What a simple yet profound definition of leadership.
But will that remain our view on Monday morning, in the office, the clinic or the surgery? Will we continue to believe that we have it within ourselves to transform the experience of those we seek to serve? You know, with the right backing from government, the tools and resources to do the job combined with your energy and commitment, I believe we might just.
Notes for editors
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