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A day in the life of an NHS Chief Executive

Denise Raw, Principal of our Healthcare Practice, speaks to Karen James, who is currently the Chief Executive at Tameside NHS Foundation Trust.  Karen joined the Trust in 2013, after it was placed in special measures. 

Karen began her NHS career in the early 80’s – after qualifying as a Registered Nurse she developed her interest for improving capacity. Karen then went on to develop her career in general management roles before being appointed to her first board director post in 2002. Since then Karen operated as an Executive Director in both large District General Hospital and tertiary/teaching hospitals prior to moving to Tameside Hospital NHS Foundation Trust.

Can you talk me through the Trust, its turnover and how many people it employs, and any particular specialisms it offers?

Currently 160m, it’s a small district General hospital with 2500 staff, which is likely to increase as we have community services coming back to us in April. In terms of the provision of specialist services, we work in collaboration with other organisations that provide these clinical services.  As a consequence, we work with Wythenshawe, Central Manchester, Stockport and therefore we do provide in a “partnership way” some of those specialised services but generally it’s a District General hospital. 

In the future, services strategy will become an integrated care organisation, so we have a whole program to look at progressing this strategy. As this strategy develops, a number of other staff will be joining the organisation, which will include staff from the Local Authority and community. I will be working with a number of stakeholders to deliver something very different going forward.


Do we have a new name? Can we talk about that?

Monitor, our regulators agreed with our future strategy we are working with staff to come up with a new name – obviously it’s limited as it still has to have Tameside & Glossop in it and NHS FT.


Can you talk me through a typical day in the life of a CEO? 

I don’t think there is a typical day! Yesterday, because of all the A&E challenges I spent a lot of time in A&E with the staff in that department. I go from being operational in terms of supporting the staff and trying to understand their challenges – to being strategic. Yesterday I had meetings around the programme for moving us to an integrated care organisation and then I had another meeting with members of the Greater Manchester devolution team. From a day to day basis you can be working solely within the organisation, but very much outward facing in terms of trying to move future strategies forward. It does change quite significantly depending on the pressures at any point in time. I tend to enjoy – and get a lot from going out and working with clinical teams and supporting teams, talking to patients and their relatives about their experience; because you really do find out how you’re progressing against your internal improvement programme. So you have to be internally and externally focused. 


Since you joined the Trust, what would you say was your biggest achievement?

Changing the culture of the organisation and that it actually has a very positive impact on patient care and patient experience. We spent a lot of time with staff looking at what was important and what we are about – our “values and behaviours”. Hopefully they see us now as being very supportive and listening; we are much more open and transparent. I think that whole culture has enabled us to deliver huge improvements in quality and I can see that without having to look at any of our performance matrix – obviously the matrix illustrates that. It is important that you are visible and that you do connect with your staff and patients, as well as the wider community.


What are the biggest challenges you are currently facing?

There are many! We have got this great opportunity in terms of our future strategy to start delivering new models of care that will hopefully address some of the challenges, although delivering the future strategy is complex. It’s about system leadership.

This means we are having to provide that leadership across a whole system, across organisational boundaries and across professional boundaries. That is hugely challenging to me personally in terms of taking us forward because it is very different. I have the same challenges as most Chief Executives in terms of the day to day pressures we’ve got – managing A&E, financial challenges and workforce challenges - they are similar to most trusts, they are still there and they don’t go away. 


What is your plan for tackling these moving forward?

In terms of implementing the future strategy we have to accept that in some situations where we don’t have all the answers and there is not a lot of evidence out there so in some situations we are breaking new ground so we have to develop a “risk appetite“ that will allow to test new ways of working.  As such, we have to be less risk averse, and that’s very difficult under the current regulatory regime and that doesn’t allow us to take those risks. I think it is acknowledged nationally that the current frameworks are not helpful in supporting us in moving forward the NHS for a new future state. We have to manage this transitional period within the current regime. We are working through that with Monitor and the CQC, but it is a potential challenge. 


Christopher Smallwood – Chair of St Georges University Hospitals NHS FT, was recently quoted as saying: “The NHS is headed for financial ruin”. What are your thoughts on this?   

Well, yes if we don’t change! Everybody predicted the implications of an ageing population and subsequent workforce challenges. It’s going to be very difficult to address the financial challenges unless we absolutely, radically change our current model within the NHS.


Two years ago, around a quarter of hospitals recorded deficits – and last year this rose to half. Do you think care will be affected by a lack of adequate funding?  

I think difficult decisions have got to be made going forward. We are in a deficit position. Our future strategy over a 5 year period will enable us to achieve financial balance again. Our 5 year plan is very much aligned with Simon Stevens national 5 year plan. In terms of integration it is about horizontal and vertical integration so we are already working with our acute and primary care partners to deliver something very different. What I hope is the future will bring the NHS back to financial balance.  


Do you think the public should be more aware of the difficulties facing the NHS and do you think they should play a bigger part in supporting it (bearing in mind Sir David Nicholson’s comments some years ago that “The NHS is a “Burning Platform”)?

I think the public should be involved in future decisions and understand the pressures we have within the NHS. They should be part of those very difficult decisions around what the NHS looks like going forward, so absolutely they should be involved and certainly locally we have a significant engagement strategy .The public and our community need to be engaged with the process so that they can understand why and how to help us to make some of those service change decisions. I don’t think we have done enough of that, nationally or locally. 


How important are interims within a Trust and why have you used them in the past?

You use them obviously when you need additional capacity or you need specific skills that you haven’t got within your team to facilitate a programme or a project or you have a vacancy and you know that you still need that capacity whilst you are going through the recruitment process.


Do you agree with the Government’s recent capping on Agency pricing and do you think it will affect the future quality of interim support?

I think it depends on why you have made a decision to become an interim. I do think interims have a different mind-set, and some individuals’ skillsets lend themselves to being interims. As you will be aware, some interims just enjoy new challenges, they like going into different organisations. If you are an interim because you know you can earn more going through that process, then I suppose the capping on agency pricing will not be helpful. 

I generally agree with the principal on capping agency pricing; I think sometimes you are pushed into a corner and you have to agree certain pay rates because for that day you need a doctor or you need a specialist nurse and you have no alternative. Often people negotiate their own price and that’s difficult as it is just increasing the cost for the NHS. What do you do in those sorts of situations? It’s very different, if it’s clinical and it’s an agency – then it’s very hard. I think there should be some arrangements where you can’t play off one organisation against another. So I think some of the core principals supporting the reduction of agency spend are helpful but I don’t think they have all the agencies signed up so it’s a vicious circle. I think there has got to be a ceiling of some sort and I think we have to see agencies working together on this.


According to the recent Monitor Consultation, primary responsibility for monitoring the impact of price caps lies with Trusts’ boards, who will also need to ensure patient safety at all times. The rules include a “break-glass” provision for trusts to override the caps on exceptional safety grounds.  Are you prepared to employ an interim at this level should it be necessary? 

If there is good reason toAt the end of the day we are have to deliver services, we have to maintain patient safety and quality of our services so if there is a good rationale – I’m happy to have that conversation.  


If you were Minister for Health, what changes would you make to support Trust CEOs and enhance the patient experience?

First of all I’d look at the regulatory framework and I think they have to support what we are trying to do in the future. The regulatory frameworks are very organisation-led legal frameworks. Trying to work in the new system which Simon Stevens is advocating… it’s a place, system based model and the current arrangements, both financial and regulatory, do not support that. So I do think we have to make sure that operational policy and regulatory frameworks should be totally aligned. I also think that Chief Executives do need more support and “air cover” at times because it’s very challenging to try and drive new ways of working and to try and manage that transition whilst trying to keep everything on track in terms of the operational performance and the quality agenda - it’s very difficult to do. I think it’s providing the headroom somehow to allow us to make that transition. 


What’s the life span of a Chief Executive? On average it’s about 2 and half years, isn’t it? 

Nobody wants to apply for these positions anymore! It is about supporting that succession planning and it’s providing some “air cover“ for the current Chief Execs. They have very difficult jobs, making very difficult decisions. We are under so much scrutiny, and sometimes this can promote behaviours which are not helpful when you are required to manage a significant change agenda.  


What advice would you give to substantive and interim staff working to improve the NHS on a day-to-day basis?

You have to bear in mind it’s about patients at the end of the day, and I don’t say that flippantly because you do have to sometimes stand back in terms of decision making and make sure your decisions are based on improving outcomes for patients. We operate in a very political environment.


Do you find working in the NHS rewarding and what would you do to attract the right calibre of future leaders into the Health Service?

As it’s a people business, you have to enjoy working with others, as well as being passionate about making a difference for patients, their families and their carers.  I love it! I would never change my career pathway in any way. You have to really enjoy working in this type of environment; you have to have excellent leadership skills and people skills. You also have to demonstrate resilience, however. This career is quite diverse, challenging and rewarding.


How important is the role of the Interim Manager within the NHS and what advice would you give to those concerned about the new price caps?

My advice would depend on what motivated an individual in the first place to become an interim. I suppose it’s why they got into interim in the first place, my advice would change accordingly as to their incentive to do interim because they will be motivated in different ways won’t they. My advice would alter on what their motivation was to do interim work. 


Finally, how do you see the landscape of the NHS changing over the next 5 to 10 years?

I think it will radically change over the next few years. You won’t see hospitals as we know them. I think the smaller District General Hospitals will be part of a larger system. With respect to integration I think there will be greater centralisation in terms of specialist work in a smaller number of hospitals. Going forwards it will be less about hospital organisations and more about a Partnership approach.  We can see what is actually happening with hospital chains. There will be greater collaboration, networking, larger hospitals doing complex acute work. 

The smaller District General Hospitals will work much more in an integrated fashion with primary and community services to provide a very different service model for the local population. I’m seeing more collaboration with the private sector and that will enable us to deliver greater innovation. I think some of the things that are going on in medicine, e.g. genomics, will have a major impact on the way we deliver services going forward. We can be more predictive become more in that we will understand responses to treatment and therefore we can ensure patient treatment much more effective. I think science has a big role to play. I think innovation on the technology side, particularly in IT and  system managing patients in the community will work very differently which  will enable the community to manage their own health more effectively. I think the whole strategy is about the community taking greater ownership of their health.


If there was one wish that you could have to change the landscape of the NHS to have a positive impact on the health of the general population – what would it be? 

I think it’s all the other determinants to health. This really has become clear to me in terms of this Community. The other determinants of health are employment, housing and early years. I really do think we should align the other determinants to what we do in terms of our future healthcare strategy.  


Denise Raw is the Principal for Healthcare at Interim Partners.

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