In the first episode of Health on the Line, Matthew Taylor talks to ICS lead for West Yorkshire and Harrogate, and HSJ Chief Executive of the Year, Rob Webster CBE, about his view on system working, on the NHS workforce being its best asset, and how experiences within his own family have taught him important lessons about leadership and being open about our experiences.
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Health on the Line
Our new podcast series offers fresh perspectives on the healthcare challenges of our time and ways to confront them. Tune in for interviews with the movers and shakers making waves across health and care.
Hello. One of the reasons I grabbed the opportunity to lead the NHS Confederation is the strong degree of consensus that exists at all levels of the NHS, behind the principles of system working, service integration, a focus on population health and tackling health inequalities. And when I've asked people where system working is going well, delivering results, one place and the name of one leader have come up over and again. On the first edition of the Confed’s new podcast, Health on the Line, I'll be talking to that leader.
I'm delighted to be joined by Rob Webster, ICS lead for the West Yorkshire and Harrogate system. Hi, Rob. How are you?
Very good thanks, Matthew.
Thanks so much for joining us. Just to start off. Tell us how things are feeling right now for you in West Yorkshire and Harrogate. What's the kind of current state of play?
Interesting and tough I would say, as always, I think we're pretty much in our fourth wave of Covid. Some parts of West Yorkshire, it's never really gone away in terms of restrictions and pressure and in the middle of all of that we're trying to address, you know, significant health inequalities and deal with the issue that's come back to haunt us that is waiting times. So I think pretty tough, but also pretty hopeful.
So one of the ways we've described this at the Confed, Rob, is that is that it feels like we're in the middle of a kind of winter crisis, even though it's August, which is normally a time when there's a little bit of kind of a little bit of of of give in the system. Is that how it feels to you?
It feel it feels in many ways more challenging than the winter, and it's certainly the case that all parts of the system are under pressure. Whether that's social care, primary care, our hospitals, mental health services. And I think part of that's to do with staffing and staff well-being. And the opening up of society means that staff who this time last year who would’ve been working with us because, frankly there wasn't much else to do, are taking a well-deserved break.
And do you think, Rob, that we fully understand why demand is so great across the system? So obviously we've got the overhang of Covid, the people who didn't come forward during Covid with the issues that they had. We've got Covid itself and long Covid. So, do you think that the if you put all that together, that explains this unprecedented level of demand, or do you think there might be other things going on that we don't fully understand?
I think it's a great question. We certainly knew, didn't we, as we came into the pandemic, that there'd be four sets of needs that we would have to address over a period, and they'd come at different times. So, the immediate pressures of Covid and the pressures for people who were not getting services because of Covid pressures in the system, then the exacerbation of long-term conditions for people living with multi morbidity and then a tsunami of mental health pressure. And that certainly seems to be the case. So those things are coming true.
At the same time, I think there are process problems that we have around communicating with people so they know where they are in the system. I think there are, you know, things that were issues beforehand about the clunky nature of the system and how it works. Often, you know, often in really poor ways for coordination for people that are now being seen very visibly because they're causing bottlenecks or problems. So, I think a it's a combination of factors. And that's why we need systems and system leadership to make sure they got the right kind of response. And systems that engage with communities in ways which allow us to work together on those responses should be.
I've often thought as a leader, never working under the kind of pressure I'm sure you're under now, but I've often thought that, you know, when things are really difficult, the tendency is simply to put our heads down and try to manage. But actually, those are moments of real learning. And so you have somehow, don't you as a leader, to deal with this crisis, but also to see that these moments can often reveal quite powerful things about what is and what is not working in our system.
That’s exactly right and I think that that there are elements of the system that can really help us here. After the first wave of the pandemic, we did some real rapid evaluation with the Academic Health Science Network about what we learnt here. You know, we could of, for example, just decided that there were some interventions that we now had which we wanted to continue delivering, like remote based, you know, improving access to psychological therapies. That would have been good. But the bigger question was, how did we manage to transform services, on IAPT very quickly? And what were the conditions for success? How do we recreate those conditions so we can keep improving?
So, Rob, before we turn to these kind of issues around system working, what that means, system leadership. Tell us a bit more about your own career because that's a fascinating story for me personally, because I think we might have overlapped in the centre of government during the delivery unit and, of course, you’ve done my job. So tell us a bit about the career that's led to you being now the ICS lead in West Yorkshire and Harrogate.
Yeah. So the first thing to say is that I've worked at all levels in the system, and that's genuinely helpful because it gives me perspective, which really helps with system working. So I started out my career in Department of Health, and I was a professional statistician to begin with then, and moved into policy, became a senior civil servant. Was fortunate enough to work closely with ministers and special advisers on the NHS plan in 2000, which was a big transformation in health and care at the time. And in the mid-2000s, worked in the Cabinet Office on capability of Whitehall departments before becoming a chief executive in the NHS. And I subsequently ran commissioning organisations, provider organisations.
As you say, the NHS Confederation, and now I’m running a system and a trust. So lots of experience. And within that, things like being an exec director of a public private partnership, being a charity trustee. And I genuinely think those things have helped me get perspective. And I've actually loved every job that I've done because it's been fascinating, challenging, and it's resulted in delivery, usually.
Going from being a kind of policy wonk, which is, of course, my background, to actually running real things on the ground. What did that tell you about what people at the centre, what policy analysts often get right and wrong about what's actually happening out in the field? I remember when I would advise the Secretary of State, they would have a sense that when they made a speech, everyone in the NHS was listening to the speech, and you'd kind of say, look, this is a big, complex system. You can probably manage one or two messages at any given time. And at the moment, you're trying to communicate 25. So, what did the shift from policy to real operational delivery, what did that teach you about the difference between those worlds?
There was there was a really great moment, actually, when I started my first job as a PCT chief executive, having moved from the delivery unit. And I think the day I started, I got a letter from one of the GP's that said something like 'Dear Mr Webster, I understand that you've come from Number 10 to come and be the chief executive here, where you will make a complete mess of everything as you are one of those policy wonks who doesn't know anything about the real world. And then leave, having got the badge to say that you've done it.'
And what that reinforced to me was all the things that I was given credit for in Whitehall, would actually be held against me by many people in the service or in the system, because it sometimes feels so detached. When, actually, at the root my experience at the root of what ministers want, what politicians want, what senior officials want, what frontline staff want, what people want, at the root of that is the same thing. And sometimes our expectations are misunderstandings around communication, the language we use, mean that we we have this othering, you know, the targets or the people's targets, that other people's issues, they’re not ours, so that that was it. That was a kind of seminal moment for me about perspective.
And I've read interviews with you, Rob, and you often speak powerfully and in very personal terms about your approach to work, about bringing your whole self to work. Tell us more about that and why you've chosen as a leader to to talk about yourself and your family quite often in terms of explaining the way in which you approach your work.
There's a couple of things, really. So, the first one is that coming from a civil service background, originally, it's very easy to disassociate yourself from, you know, the visceral and emotional impact of work on others because you are creating, you know, intellectual constructs and providing advice around impact of issues. And often when we're talking about developing policy, we must engage with some people with lived experience as if the 1300 people who are going to work in my ICS don’t have lived experience, for example.
I remember an NHS Employees conference where guy stood up and said I'm the only patient here, and there was about 400 people in the room, I said, you’re not mate you’re really not. And I asked people, anyone who had a long-term condition like asthma, diabetes, COPD to stand up, and then anyone with a mental health condition, if they were brave enough to or anyone with caring responsibilities and everyone in the room was stood up, but we just don't see it. So I guess there's a kind of intellectual thing about what we’re doing here, which allows us to disassociate our lived experience from our intellectual processes for thinking about the actions that we take.
And then the second and probably more personally powerful one was, you know, I said very openly, my brother died by suicide in 2003, and I didn't really talk about it for a good decade because the stigma attached to suicide, the stigma attached to mental illness. And I chose because of, I think, a Time to Talk, a Time to Talk pledge I chose talk about it. And I was deluged with comments from people saying that's happened to me, that happened to my family, that happened to my friend, we don't talk about it, there's not enough dialogue about this, from people I knew quite well, actually, and I didn't know that about them.
So that taught me that actually there's something here that needs to be said sometimes if we're going to change and if we're going to change people's minds, you know, really change people's behaviour to change their minds. So, I guess it's for me, part of connecting with folk. And if you're going to be a leader, you have to be able to connect with people intellectually and emotionally, I think.
And of course, there's two groups of people that you must think about all the time. One is the people who work with you and the other is the community you serve. Tell us about how you think about them. And I guess also that they're not separate groups, are they?
I love that last part, Matthew, they're not separate groups. And again, that's that's the part of that whole bringing your whole self to work piece. I think hidden in plain sight for too long has been the fact that the NHS is made of people. You know, we're too often stuck in this, you know, construct of policy and bureaucracy and creating elegant systems, but without recognising that actually we spend most of our money on people that we can't deliver care without people. And we have a set of individuals who consistently work longer than they're paid for and generally tend to be vocational and values based in their outlook. What a fantastic resource that is.
So, in every conversation that I have I recognise it's a people conversation. And that shift in perspective, that reframing helps me think about delivery. How is this going to be delivered and how are we going to achieve this and how are we going to change people's minds so that they work differently in the future, are questions I always ask myself. So I think it's essential that we all start to think that way I would say.
In terms of communities, I've always felt that, you know, people make rational choices, and we don't like those rational choices that they make. A&E’s a great example. Why do people keep turning up at A&E? Because they believe it's the best thing to do at that point. Having assessed the options. What we're seeing in the pandemic, I think, is more evidence of what I believe fundamentally. The communities and people themselves have a huge amount of capacity to make a fundamental difference. Whenever you see a Hollywood potboiler about about a pandemic, society breaks down and people start looting and killing each other. What have we seen in the UK? We've seen an outbreak of altruism and people being kind and caring and supportive.
So, I think that as we enter into a new phase of the health care system, I'd love to see two things happen. I'd love to see us recognise that people are our biggest asset in terms of our staff right across health and care. And I'd love us to understand that we need to get much more done by communities themselves, and they themselves have assets.
I absolutely agree. And I think that's something we have to work on in the NHS. Now, let's talk about system working. It's a phrase that is used an enormous amount. What do you see as being the essence of system working, system leadership?
Well, usually doing something in the service of a greater good or a common ideal or common purpose, that requires collective leadership and collective ambition. And, you know, what I find is that it's not too difficult. It doesn't take much effort, really, to engage with others in a system and come up with something that you all care about and want to make better. And system leadership, I think, is really about creating that space where you will die in a ditch together for something and you will do things outside of your own interest or outside the interest of your own organisation in pursuit of that thing. And for us in West Yorkshire and Harrogate, it's improving outcomes for local people. And in doing that, addressing some of the hideous inequalities that we see, that we are not surprised by and not shocked by anymore. When we should be shocked.
Because if you're a person with a learning disability and you die 15 or 20 years sooner than other people. That's not right. If you're black or Asian and your experience of care is poorer than for white citizens, that's not right. You know, if you're if you've got a serious mental illness and you're going to die eighteen point six years sooner because you're a man, that's not right. And so I think we've we found a space where we can cohere around a common set of aims and objectives, and work in a common set of ways with common behaviours, which will really drive improvement. And I think that's what it's all about me.
Yes, someone asked me the other day how I define system leadership. And I thought the difference in system leadership and organisational leadership is that organisational leadership, your span of authority is defined in the role. Whereas system leadership means you have to identify and act on a very concrete and specific account of how you and the system adds value. So, there's a proposition at the heart of system leadership, and that proposition is by working as a system, we can achieve X or Y. So, do you agree that's at the essence of it? Is that account of value added?
Definitely. There's certainly there's certainly more of a sense that people hold you to account for the value added. Because what they want to see is value from their investment in the system. Or their lack of objection, you know, at the worst. You know, they're not going to object to the system working in a certain way. But but what people often want is proof, you know, how is this making things better? So I do I do believe that that's true. And actually, I think my career history’s helped with my perspective on this.
So as a senior civil servant with three billion pounds to spend and the power to direct people to do stuff on behalf of the Secretary of State. You know, I understood, you know, the power and authority that I had as a as a trust chief executive. Now I have the authority of the board, hundreds of millions of pounds to spend and the ability to direct people to do things. But as chief executive Confederation, I had to know no real money, no real staff. And the only authority that I had came from the membership. A fundamentally different approach. And that's an ICS lead, you know, the authority I have with others in the system comes from my contribution around that shared purpose. And understanding those different dynamics, I think is really important for leaders, you know, what am I in control of? What can I influence? What can I neither control nor influence? And let me spend all my time on the first two and ignore the last one. So, so very strongly agree with what yes, what you're saying, and I see it play out in practice.
So tell us, Rob, how is partnership working, system working, making a difference concretely in West Yorkshire and Harrogate?
We're a true partnership of the NHS, local government, third sector communities, and it doesn't matter if you're a commissioner or a provider, but everybody's in the system and it's a partnership that also supports the partners. And having that strong partnership genuinely helps us tackle real problems. So, if you look at things like the vaccination programme for Covid, it became clear quite quickly that people in cohorts four and six would have carers and those carers needed to be vaccinated.
But what also became clear quite quickly was that there's no definition of carers. So, we quickly correct, because we’ve got a carers programme, we said to the carers programme, can you come up with a definition of all carers? They came up with the definition, we shared that, we agreed it, we sent it to all GPs. We said anyone who fits this definition needs to be vaccinated, should be vaccinated at the same time as the person the caring for. And we knew we had to get the message out about that, so because we’ve got a third sector membership. We said to them can we work with you to get the message out? What's the best way to do that? Let's do it through parents groups, because they’re the ones chatting about how do you get this vaccine.
As a result of that, 51,000 more people are now registered with their GP as a carer than previously, which means that those 51000 people have more rights, get better support in general from their primary care practice. So that's an example of how you kind of bring together a shared ambition. And when there's a problem nationally, you just solve it, which is part of, part of our ethos, really, you know, we have a saying that we should stop admiring the problem and address it.
And listening to you, Rob, it confirms to me that there's a there'/s a soft and a hard side to this, isn't there? The soft side about relationships, about a shared mission and purpose. And then there's the other side, which is, you know, even in the examples you gave, data is an important part of this, that if system working is going to be powerful, then creating and sharing the data that you need to identify need in the community, for example, to be clear about outcomes and variations in outcomes. You know, that's as important, isn't it? You've got to be tough as well in terms of the tools that you're going to need in the toolkit to make a difference.
Oh, definitely. I mean, there’s some seminal learning over the years that had I when I worked with someone called Maria van Böeschöten and she used to help negotiate difficult issues in conflict. And the thing she taught me was, you have to be tough on the issues, but not on the people. And too often we're kind of tough on the people and soft on the issues. So, we always focus on that.
A decade or so ago, I was fortunate enough to go to Jönköping and to work with them there and the really fantastic work they do around improvement and putting the person first, seeing things from different people's perspectives is mirroed by a really tough focus on numbers and data and improvement. And that's that's definitely what we're trying to do here. And the other seminal piece of work I’d pull out is the work of Julia Unwin on kindness in public policy, which really reinforces this point about relationships sitting alongside the rules. So, what that’s taught me is that you need good rules and good relationships.
Often, you'll have heard this, you know, people say it's all about the relationships. Yes, that's necessary, but it's not sufficient. You need good rules, you need good data, you need good governance, you need to be able to make decisions. So, we focused on both really in the partnership here. Spending time being supported to get the relationships right and spending time on getting the rules right, the Covid governance right, the data right.
Yeah, and I think that's so true, Rob. You know, I'm a great fan of the Buurtzorg model that's used in the Netherlands for social care. People often talk about that as a model without any kind of hierarchy. And it's true that there isn't, it's a non-bureaucratic model. But in that system of self-organising teams, they rely on really powerful data to tell those teams how they're doing. And whilst the teams may not suffer loads of layers of middle management, if your team is underperforming, you must bring a coach in, and that coach must work with your team to get it right.
So, it's a misunderstanding of a system like that, say, oh, this is just a kind of entirely based upon people's goodwill. There's some real tough stuff at the middle of it. And I think exactly your point, which is getting the rules right, getting the expectations right, getting the systems right, you can do all that without an organisation become a bureaucratic nightmare. And that's, of course, one of the challenges of leadership.
I think there's a really important point there, Matthew, about where we are right now, which is that we've we spent a lot of time in West Yorkshire and in other parts of the country really creating partnerships which are true partnerships. And they reflect a system, and a system way of working. And throughout that period, we said, look, this isn't an organisation, it's a system. And you are the system. I always say that it's like the old adage, where you have a moment where you realise, you're not stuck in traffic, you are traffic. And it makes you think differently and act differently.
So in the same way we keep reinforcing, it's not the system, you are the system. You're just a different manifestation of the system at different parts of it. What we're now about to do is to parachute an organisation in the middle of that and call it a system, which could cause problems because people will default to hierarchy, bureaucracy, when what they need to do is what we're trying to do here, which is an act of leadership, is to maintain and retain all of that work that we've had around working together in a system. Despite the fact of an organisation in the middle of that.
So, I, Rob, had my first meeting with the Secretary of State yesterday. It was a few of us and it was Chatham House. But I can talk about what I said at least, and what I said to the Secretary of State was that I had seen this consensus behind system working, service integration, population health, and I welcomed it. And I said to him, it felt to me at this stage, there are three things that could stop this working, which could mean that in a few years we look back and say we wasted that opportunity of that consensus.
The first is, is clarity. And by clarity, there's lots and lots of instructions and the bills are very complex, and guidance about how this is supposed to work. But I think we somehow lack a kind of core narrative about how, we're talking, you and I, about, for example, the idea that at the core of systems is the value added, what is the value-added proposition? And that may be very different from one place to another in places that have a long history of integration it may be different from places that have been thrust together. And that's fine. But you've got to be clear about the value added, what really does place-based integration mean and how would you know you were getting it right? What do we want to achieve at the neighbourhood level in terms of engaging the public? So, I think what we're kind of slightly missing a narrative. And if you don't have that strong narrative, that's where bureaucracy kind of fills the vacuum because people aren't clear about what they should do and they become risk averse. So first, I think there's a need for greater clarity about the fundamental principles of the system.
Secondly, devolution, because as you and I both know, the centre is forever saying, we want to devolve to local level and they mean it. But then every time something goes wrong, where every time a minister wants to make an announcement, then a new central indication, central prescription comes in. There's the regulatory context. We still don't really know how to regulate systems. So, I said to him, you know, it's really important if you believe in devolution that you resist those constant temptations to lay down things from the centre or to overregulate.
And then thirdly, of course, funding that we need proper sustainable funding. We need to fund those areas of the system that haven't been funded even in the last few years, social care, public health, workforce, capital. Would you agree, Rob, that clarity, that that genuinely devolving and that getting the funding right, do you think those are the critical things to enabling this this new model to work?
Certainly, the narrative point is so, so important. You know, you can say integration and people thinking about joining up organisations. I always say I'm a black belt in restructuring because I've been made to do it so many times. But that's not the job. The job is integrating services and support around the needs of people and including them in the team. And, you know, if you ask somebody, you know, people think they don't work in a system. I just ask them to speak to a carer. Or to somebody living with a condition, and say, what's it like for you? I know what they'll say is, you know, I get good care here. I get poor care here, you know, it's not joined up.
I'm sick of telling people the same story over and over again. And all that brings is a burden of treatment as well as the burden of disease. You've made it hard for me. So, so we need a narrative that says, you know, we're doing this because we will improve outcomes for people, we’ll address the inequalities that bedevil the system, we'll address unwarranted variations in care where some people get great care and some people don't. And we'll use our money and resources wisely. And in doing that, we will recognise that investment in health and care is an investment. It's not a cost. It's jobs, it's the economy. It's people. It's productivity, it's improvement. It's always been a global leader in MedTech, you know, however you want to play it. So that narrative does need to be incredibly strong.
I think over and above your three areas, the thing that I would add later on would be joined up government. And, in a strange way, I think the pandemic with the emergency preparedness and resilience arrangements has been liberating. For joining up more of the issues that government expect of us here in the system, because ICSs as a true partnership of local government, the NHS, third sector and others is a place where I can join things up. So, in peacetime, I would really like there to be much more joined up government about the role of education, criminal justice system, the role of housing policy and economic development in the health of people and health in all policies would be a really smart move. Because you know as well as I do, 80 per cent of things that affect your health have nothing to do with the NHS.
Yeah, and I completely agree. And I think that we need to see that at the centre as well. So, we have to see Health policy as central to levelling up. And we need to see our Secretary of State working with education, with local government, of course, with other departments to make sure that there's a joining up at the national level as well.
Drawing to a close the two or three quick last questions. What's difficult, Rob? What are the kind of wicked issues, do you think? I mean, I'll give you an example of one that I hear a bit, which is still a resistance to being open about differences in health outcomes and in performance. But what do you see as the kind of nettles that you're going to have to grasp? And that will be, in a sense, a measure of that system working, making a difference?
I think we’re much better understanding differences in outcomes and performance and outing them as issues. I think all of the work around race and race equality that we've been doing is a is a profoundly important example of that, where I think unlike a decade ago, we will say, won’t we, that this, the NHS is institutionally racist. You know, we are unfortunately seeing people who work for us from black and Asian backgrounds having poorer experiences and poorer careers. And we've got to address that, and I think the fact that people will say that, will do something about it is a positive. I think we're conditioned, aren’t we, to behave in a way which engenders a particular response. And I think prior to the pandemic, things were improving in terms of the kind of response that we had to the pressures that we faced from, the regulator and others.
And I guess if people are going to be open and we're grasping nettles around deep inequality and performance pressures and staffing, then the response that you get from the regulator, from government, from the departments, needs to be one of curiosity about what's really going on here? How do we improve the position? What about this is about spreading good practice, what is about investment? What is about innovation? What's a fundamental problem of management? For too long, I think they’ve started with the question being it's a fundamental problem of management. What I've seen around me some of the finest leaders in the country working incredibly hard to deliver significant improvements to health and care during a pandemic. So, I guess that's one of the big ones, is one of culture.
Yeah. No, I completely agree. And unless you have that, it's very hard for a system to be a learning system. If you don't have a culture of openness and trust rather than one of kind of blame and fear. Final question, Rob. We work at the Confed with new NHS leaders. Give us one bit of advice for somebody listening to this who has just started out on their leadership journey in the NHS.
Be yourself. It's much easier than trying to be somebody else. And people are incredibly generous with their time. And if you ask for advice now, you'll get it.
Rob, it's been great talking to you. Good luck in the challenging months and years ahead. Thank you.
Outro voice over
You've been listening to Health on the Line from the NHS Confederation. Visit nhsconfed.org for more information about us and to register for events and webinars that delve deeper into the issues explored in this podcast. Save the date for NHS ConfedExpo, the premier event in the health and care calendar taking place on 15 and 16 June 2022, in Liverpool.