Ifti Majid: To be more representative means doing things differently

Episode 2: Ifti Majid on leadership, organisational culture, effective boards and thinking differently.

8 September 2021


Does culture eat strategy for breakfast? In this episode, Matthew Taylor sits down with Ifti Majid, chief executive of Derbyshire Healthcare NHS Foundation Trust and co-chair of the NHS Confederation’s BME Leadership Network, to discuss organisational culture in times of crisis, the characteristics of effective boards, supporting staff through the pandemic and why 4,000 handwritten notes have made a massive impact.

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  • Matthew Taylor

    Hello. Welcome to Health on the Line. Thank you for the great response we had to our first episode with Rob Webster. Please do give us feedback or even better, leave a review in your podcast app.

    Now, how would you feel as an employee of a big organisation, say, 4,000 people if you've got a personal, handwritten thank you note from the chief executive. Imagine if you told your friend at work about it and they said, “Well, that's amazing because I got one too.” And then another workmate said, “Me too.” Eventually, you work out that the chief executive had written those notes individually to all 4,000 of your colleagues. What would that say to you about that chief executive and about the organisation you work for? Let's find out.

    I’m delighted to be joined by Ifti Majid. Ifti has been the chief executive of Derbyshire Healthcare NHS Foundation Trust for almost four years. And in addition to many other roles, is also co-chair of the NHS Confederation's BME Leadership Network. Hi, how are you?

    Ifti Majid

    Yes, I'm very well. Hello, Matthew.


    Before we talk about that letter and what it says about you and leadership in general, how are things in Derbyshire right now? How's it going?


    Well, I think probably in common with lots of other organisations up and up and down the country, it's really busy in terms of the ongoing managing of the Covid pandemic and the extra requirements that that puts on all of us, all colleagues in the organisation. And actually probably as much the worry, the anxiety, the tiredness that goes with that rather than, actually, we have relatively few colleagues away with COVID and few patients.

    But I think it's the emotional length of time we've been doing this. And then secondly, of course, we're dealing with really increased demand in the sector that we work in. So it's a tough time for everybody, Matthew.


    So on the day that we're having this conversation Ifti, the Confederation and NHS Providers have jointly identified the need for £10 billion extra to deal with those ongoing COVID costs that you described, but also to deal with the backlog. There is a gap isn't there? There is a resourcing gap. And if the government doesn't put more money in to help us deal with the ongoing effects of COVID and to deal with that backlog, the pressure you describe is simply going to grow, isn't it?


    I would start with saying we’re a people business aren’t we and before we start to talk about recovering services, before we start to talk about dealing with the backlog, we have to deal with how our colleagues are feeling, how we have to deal with, you know, the emotional response to what has been a trauma and that in itself will take resources.

    You know, it is great, isn't it, that we have hubs looking after colleagues or working with colleagues and supporting their mental health and wellbeing throughout the country? And that's a great start. But, we have colleagues who taken have not had restorative rest, who've not taken as much annual leave as they should have taken. We've had colleagues who have kept going and kept delivering services throughout this whole period of time. So we need to think about them first.

    And then you're absolutely right. We need to then think about the population we serve. How do we work together to sort of restore services, deal with waiting lists? It is about resources, but I think it's also about learning the lessons, Matthew. I think it's also about how do we work differently, how do we use the things that have grown positively out of the last 18 months?


    I want to explore that, but I want to ask a question, you a question Ifti, I asked Rob Webster, which was the growth in demand. Now, obviously, a lot of this is to do with COVID, to do with the fact that people didn't go to the doctor, didn't get treatment during COVID, weren't able to get this hospital. But do you think there's something else going on? Do you think there's some other reason why we're seeing growing demand in almost all parts of the health service?


    Well, I think it's a really interesting question, and I think this is linked to a societal response to an enormous event that has happened in people's lives. You know, if we think about traumas, traumas often impact on a part of your life, don't they? But actually, for nearly everybody in the country, everybody globally, actually this pandemic is something that has hit, it's hit our employment lives. It’s hit the things that we do to rest and recuperate. It's impacted on our family lives and our family relationships. Nearly everybody has suffered loss of some description or another. That has to have an impact on our health and wellbeing, doesn't it? And I think that's why we're seeing this, this increase in demand. There is a huge link isn't there between emotions and emotional response to something and our physical health response to it.


    It suggests to me that part of what we need to be doing is having a wider conversation about the foundations for health and wellbeing, and maybe we can come on to that in a second Ifti. Let's go back to those 4,000 letters that you wrote. Tell me why you did that?


    For me, it's a wider concept about what makes our services work well. And what makes our services work well are the colleagues that come together every day to deliver those services. And it struck me, I mean, throughout the pandemic, as an organisation, we have really worked hard to engage colleagues in the organisation to hear what it felt like. And it struck us, it struck me that there are, you know, appreciation was something, is something, that through a time of pressure and stress, is something that's really, really important. And we did lots of engagement. We call them live engagement events where I would meet either the whole organisation or, well, it would be open to the whole organisation or to our different divisions. And I found myself saying thank you an awful lot during those sessions.

    And as we were heading towards Christmas, I thought what, I need, what I really want to do is to be able to say thank you individually to people. And I was obviously being quite careful about going out and about. And so jotting a personal note to colleagues seemed a logical thing to do. You know, I think one of the things that made it easier is that we're a small to medium organisation. I've worked here for a long time. So I knew a lot, and know, a lot of people. So actually, as I started writing these notes out to people, it became just like when you're writing a letter, you put some personal touches and because you know people. And it was a great pleasure.

    I have to say it made the end of my year; had been a difficult year. It was just having that sense of connection with colleagues. And I suppose one of the biggest lessons I learnt was that what COVID does is it amplifies the culture that you've got in place. Or that was in place prior to COVID. I think if you had a culture that was sort of top-down, closed, fear of speaking up, then during a period of stress, then that gets amplified, doesn't it? And prior to COVID, we were starting to do these things. You know, we had an open organisation, we had lots of conversations within the organisation. We tended to think out loud as an organisation. It felt like we were well connected. And so that was the culture that we carried with us, that sort of people-first focus. So it felt a natural thing to do to want to connect with people.


    When I heard what you'd done Ifti I liked it on so many levels, it says a lot about you and your leadership style. But also I think you put vouchers with your letters. But actually, it was the letter that people cared more about than the voucher.

    I guess if you’re a kind of cold rationalist approach, you might say, well, a chief executive like you spending your weekends writing these notes where you could have been poring over a spreadsheet, you could have been thinking about your medium-term strategy. And actually, it reminds me, because I've been a leader in various ways throughout my career, of the symbolism of leadership. That leadership is an art, it's not a science. And there are these moments when symbols, as long as they're authentic, they're saying something real, they're not just artefact. They're not just kind, artificial ways of trying to pretend you care, but they really symbolise something. Symbolism is a really important part of leadership, isn't it Ifti?


    You use the word authentic Matthew, and I think that symbolism falls down, if it isn't part of an even authentic response to it, to a situation or to a way of leading or managing an organisation. And there is no doubt that the things that I was doing, the way that I was engaging with colleagues in the run up to sending the letter to everybody or the note to everybody, had I not done that, then sending a note would have looked like, it would have stood out like a sore thumb.

    So it has to sit within an authentic approach, it has to sit in an approach where people get it, they think, ‘Well, I can, I can keep doing that. I can understand why, why he did it’, and you are why you are quite right, it was something that was talked a lot about in the organisation, not for the fact that we'd given everybody a voucher to treat themselves before Christmas, to say thank you, but because of the personal contact, you know.

    But we do that in different ways as well don’t we as chief execs and authentic leaders? So, I know myself like many other chief execs I do a video sort of blog every Friday and I do a written blog on a Monday. And every week I get people coming back and commenting on what I've said. And it creates a bond, doesn't it, between you as a leader and colleagues within the organisation that you're leading? And I think that bond is really important and you have to give something, give yourself because if you make a connection, then the messages to do with the strategy that you referenced earlier, the messages to do with how you want to support risks to be managed in the organisation, those things then get picked up because you have that personal connections.


    Ifti you said earlier that you felt in various ways the way in which we had to respond to COVID had led us to do things differently. I think that, I don’t know if you agree Ifti, but I think it's important at this point that organisations systematically think about the ways in which they responded to COVID and go through a process of kind of working out, what are the things that we don't need to do anymore because they're no longer relevant? But what are the things we want to retain? Because the danger is we will move into a new normal and we won't reflect on the learning that has taken place and we won't reflect on what we do and what we don't want to retain. So it's important to be having this conversation.


    Well I think, it is important to be having this conversation. You're quite right. There are things that we need to do differently. And I think that there have been things that have worked less well and I'll come onto those in a minute or certainly come on to one of those that I've noticed in a minute. So use of digital both for colleagues, but also, you know, we have had some really positive feedback from people who use our services from patients about attend anywhere and sort of at non face-to-face contact. So there is a piece of work to do clinically to understand how do we how do we engage with people who use our services? And I think that's something that we certainly need to think more about.


    And you mentioned Ifti something that hasn't worked so well. When you say that, I'm delighted that you say it in the sense that one of the things that I found interesting coming into the NHS from outside is that there's a reticence about being open about things that don't work, things that aren't quite right. I think people fear that to admit that will get you being criticised from the centre or being, I don't know, lambasted in the local press or whatever it might be. So it's great to share things that don't quite work. So what were you going to talk about there?


    Well, we've been, for 18 months we've been in, you might call it an elongated incident management approach. And with that goes some level of centralisation. And we now need to think about, how do we get back to a position of devolved responsibility and accountability? How do we get back to using governance mechanisms and that we make decisions at a level that's much closer to the front line?


    So you mentioned governance, and I want to come back to that in a moment. But just before I do, I just want to talk a little bit about you and your career. I think you started out in the health service just down the road from where I'm speaking to you in South London, at St George's. And another thing that's kind of hit me about coming into the health service from outside is so many managers, so many leaders, the vast majority are kind of NHS lifers. And they started at the front line of patient care. Now, in one way, that's an immense strength because it means that when you speak to colleagues, you know the job that they've done, they know that you understand that. Do you think there are any downsides as well about the fact that the overwhelmingly NHS leaders are people who've spent most of, if not their whole life within the NHS?


    Without doubt. And one of the main things is for people like me is to surround myself with people who have different ideas that have got experience from different sectors. You know, one of the downsides is that through the NHS, we can get caught up in thinking in the same way, you know, it takes a style of leadership and a confidence of leadership to look for difference. And I think that's something that I've learnt that I work better in a, you know, in an exec team where people have different and have had different experiences. And I think I've also learnt as an executive and as a chief executive of the power of our non-execs. Because whilst you say many executives are NHS lifers that is certainly not the case for half of our boards, for our non-execs. And we need to listen, we need to learn from our non-exec colleagues.


    Well, that takes us back to this issue of governance and you've written and said quite a lot about boards. What kind of conclusions have you drawn through your career about what are the characteristics of effective boards? And also, is this part of this kind of challenge of COVID, that during COVID boards, I think have been really involved in the kind of day-to-day making sure that things are holding together, and in a way, maybe boards are going to have to step back a little bit and slightly more strategic.


    Well, I think that you've hit the nail on the head. I think that a successful board is about understanding the environments that we're operating in, defining the strategy, understanding the risks to the delivery of that strategy, and really importantly, setting the tone, setting the culture of the organisation to deliver that strategy. And actually, over the last 18 months you could argue that the strategy has been set by the government, by the department and NHS England. And what boards have been doing is monitoring whether that strategy has been delivered as opposed to setting it themselves.

    But one of the things I would say is that I think throughout that process, the responsibility of boards is to set the culture, be really clear about the how of the organisation, how the organisation operates, is something that has to have still been there. Something that we as a board, I've talked an awful lot about. So there are the things that are often discussed, which are around the strategy, around risk management and the role of boards there, the role of boards in the developing ICS structures and some interesting and challenging conversations that we're all going to have there, but for me, the bit that you know we need to be focusing on as boards is the culture. And the culture, of course, is all set, set and driven by relationships.

    That is the important thing for me in terms of thinking about, well, how is that culture cascaded down through an organisation? Because if a board is not doing it, how, you know, how can we expect teams to do it? How can we expect services to do it?


    And how important is the diversity of the board, which is another issue that you've been involved in and that we've been working on, you know, through the NHS Confederation, is trying to have more diverse, more broadly representative boards. How important is that as part of the story of effective boards?


    Well, it's massive, isn't it? And you have to go back to, you know, one of the core responsibilities that we have as leaders sitting around the board table is to give our local communities confidence in us as the most senior leadership team, that we can create and deliver services that are culturally accessible, culturally relevant to them. How are we going to do that if we're not representative of our local communities?

    For me, I started to think about the approach to diversity as being like a pyramid, really. There were a range of core tactical strategies that we need to deploy. That's the base of the pyramid. Do we have clear processes and procedures in place that support diversity? And you know, there's then that middle of that pyramid, which is about how you cascade that ownership throughout the organisation. And you know, there is something here about visibility, about representation, but there's also there's also something here about cultural awareness or cultural understanding.

    And I think those two levels. If you look at the Fenton report, if you look at the report from King's Fund and Health Observatory recently, I think that those reports talk to those levels. The bit at the very top of the pyramid, if you like the bit that holds the sides together, that gives the structure, is the culture and that is set by the board. So it's part of an overarching strategy to deliver difference within the organisation.

    And if we recognise that if we want to look for difference in our senior leadership, if we want to be more representative, that means doing things differently. That means starting... when we think about recruitment, it's not just about who sits on the final panel, it's right back to seeking advice. We seek advice and guidance from, for example, our BME network about the chair's job description that we've put out. To test out whether or not we're accidentally excluding people, by the way that we describe the requirements. You have to think, so you have to think differently right from the very start, you know about how you describe the job, how you advertise the job and then really importantly, what your interview process is, how you engage the members of the local community in that in that interview process.

    And you know, out of our last four board appointments, three of those have been members of our BME community. And I understand that we are now the only organisation in the country with a BME chief executive and chair.


    Well, that takes me to ask you to reflect on the change that’s happened throughout your career. So I'm assuming that when you started, you had to confront racism, that you went then through a period when people felt that, as it were, merely not being racist would be enough to solve the problem. To a growing recognition of the need to be much more proactive. Do you feel you that the corner has been turned in a sense, that we do now, the NHS as a whole, does understand, does get what is involved to be truly diverse and to see diversity as a strength? Or do you still think there's further to go on the journey?


    There is no doubt that, you know, COVID, the last 18 months, have shone a light on the health inequalities and the role that discrimination plays in health inequalities. I think that is clear and certain. We have more information than we've ever had before, and in particular, you know, I'm drawn again to Kevin Fenton's report sort of fairly early on in the pandemic that was quite clear about responsibilities. And later the Observatory King's Fund report, which I think talks to the practicalities, the tactical things that we should be doing.

    I think what's less talked about is the cultural responsibility, the responsibility of boards to bring about cultural change. I think I think that is something that is less talked about. And my worry is that without boards taking that personal accountability and personal responsibility, that actually the sustainability of the impacts described in the reports I've mentioned won't be realised.


    And we have this opportunity now as we construct ICS boards. Tell me, Ifti, particularly from a kind of Derbyshire perspective, what are your hopes and what are your fears around the ICS agenda?


    The hopes for me are all about, you know, remembering what we're in this for, we’re in this to keep our populations well and to support them when they are unwell and to improve their sort of overall health. So I think the way that we are thinking ICSs up with a focus on local populations is really good. It's definitely something that we should be applauding.

    I talked earlier about the need to recognise that, you know, our role is as leaders in a system is about understanding and connecting with our local populations, in particular our local diverse populations. And again, I think that the way that we're setting up our new systems gives us the opportunity to do that.

    There are risks. One of the things that I worry most about is that whenever you go through a reorganisation you know, the evidence is that the level of diversity in your leadership drops, and that is something that we have to be really, really mindful of and really careful of, and be specifically set out to ensure that doesn't happen.


    And one of the really big issues is going to be about the relationship between the health service and local authorities and getting that right. And as I talk to people around the country, that seems to be one of the really big variables. How strong are the relationships that exist in Derbyshire and how important to the future of the ICS agenda is going to be getting those relationships between health leaders and local authority leaders right?


    Well, I think we're very lucky in Derbyshire because we have good relationships between a set of health leaders and leaders in the local authority. And those relationships tend to be around social care, because I think those are the pathways that we inevitably gravitate towards. And I think that some of the policy can and has in the past driven a potential wedge between health and the local authority. And particularly, I think where we're driving a sort of NHS performance structure, maybe through regions and nationally that tends to tends to naturally focus on the health and the accountability of health leaders and sets the local authority leaders to the side.

    So I think the key going forward is how we make those accountability conversations relevant to our colleagues in the local authority so that they engage in them. I think I think there is a real benefit for us in doing that.


    So final question after we started talking about your style as an organisational leader, we're ending up talking more about system leadership. What do you see as the difference between organisational and system leadership and in a sense, thinking of your own kind of leadership journey as you start to think of yourself more as a system leader potentially, what is the learning that you've been able to use when you start to think about that different kind of challenge?


    It’s really interesting, isn't it? Because there is there is, something about when you're when you're working cross organisational, you're working in the system, you know, the positional power that you have is as the chief executive or as a senior leader in your own organisation isn't there or is diminished. So, so actually, this relies on, you know, how well we build relationships across the system as leaders. About how well we're able to influence and how we develop and use our influencing skills. And I think it also relies on our willingness to engage in areas that maybe aren't within our, you know, sort of statutory sphere of responsibility.

    So collaboration is a word that is featuring such a lot in the development of ICSs and I think it's something that we say really quickly without realising what a skill it is, actually, and that it's something that we need to work really hard on as leaders because we know we are, we have all been brought up currently as leaders in the NHS to have a level of, almost to be combative.

    As providers, something that we have done for years is to throw bricks at commissioners and talk about services not being funded, and ‘this responsibility is not mine’, we do it, but we have not been given the resources to do it. And you know, those sorts of conversations are how we've been schooled. And actually the whole concept of collaboration is that we're taking that responsibility and accountability ourselves for things that maybe don't sit within our portfolios. That's a very different approach that we need to be taking.


    I think that's such a powerful point Ifti and if we're going to make this ICS agenda work it is going to require us to understand the very different leadership skills required. My own thought in this area is that, is the thing that system leadership requires is the definition very concretely of the value added that system working will provide. When you are an organisational leader, of course, you work very hard to do everything you can, but in a way you don't need a proposition. You just need to run the organisation really well. But system leadership means identifying the thing that working as a system is going to bring that isn't there, and that needs to be very specific to every circumstance. Ifti it's been great talking to you, I look forward to seeing you again soon and good luck.


    Thank you very much.


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