If you’re looking for the biggest operational challenge in the NHS, running Barts Health Trust is surely it. The NHS’s largest trust in terms of staff and turnover, it has been judged inadequate on quality and finds itself in financial special measures, with a deficit of £135m last year. Turning this behemoth round is going to demand everything even an exceptional manager can throw at it.

It’s easy to imagine the job being taken by one of the NHS’s alpha male leaders: a big beast with a strong belief that they know what needs to be done – and the headstrong management style to push it through.

Instead, Barts has been led since June 2015 by Alwen Williams, a softly-spoken veteran of NHS management with a reputation for quiet efficiency and a background in running primary care trusts and as a senior executive at the NHS Trust Development Authority.

Staff morale rocked

She came into post – initially as an interim – after a highly critical Care Quality Commission report and the departure of the former chief executive. The task she faced can’t be overestimated. The trust was heavily dependent on interim executives and temporary clinical staff and was well on its way towards the NHS’s biggest ever deficit. Staff morale was rocked by the CQC report and the special measures which followed. The viability and future of Barts itself – formed from a merger of three trusts in 2012 – seemed questionable.

Fifteen months on, the picture is starting to change. Some clinical indicators are going in the right direction, its finances – although still horrendous by normal standards – have improved somewhat, and measures of staff engagement are encouraging. With the CQC already returning to some sites, Williams hopes to boost the trust’s standing to “requires improvement”, before aiming for a “good” rating.

She says “a real passion and commitment to the NHS” is what attracted her to the job. “They were looking for leadership. In a sense there was a vacuum there. A lot of people knew me as I had worked there before and I was known by local partners – everyone was very welcoming. But the staff were yearning for someone to come in.”

Local roots

Williams has spent around half of her 36-year NHS career in East London, and also lives in the area. Her children were born in the hospitals which now form part of the trust and she worked for nine years at the Royal London. All of this added up to a “connection” with what were effectively her local hospitals, she says. She also believes working across the NHS system gave her a “vantage point”, which has helped her to work more effectively with other organisations.

The challenge for Williams was how to make sustainable changes quickly while taking staff with her. The trust has strengthened leadership by introducing managing directors and local leadership teams at each of its main sites. A traditional NHS approach, involving exhaustive discussions of proposal documents, would have taken months, leading to implementation in the middle of winter. Instead, the system was designed – with staff input – within eight weeks. The changes came in last September, giving them time to bed in before winter – although the structure has been refined since.

“The way staff engaged with it and agreed to the changes we made was a real testament to them. We have not really had any challenges,’ Williams says.

Stable leadership

The trust board has also stabilised, with more permanent appointees replacing the board of interims Williams inherited. She is proud of the quality of people the trust has recruited. “At a time when we have been put into special measures, had huge challenges and have made significant organisational change, we were able to attract a high calibre team which is really important in terms of sustainability and long-term improvement,” she says. She acknowledges that working at Barts is hard for many people, but suggests it can be the challenge which attracts them: “These are tough jobs… you don’t come to work here for a quiet life!”

The same could be said for the chief executive’s role: it was never going to be an easy ride. “Barts is almost a microcosm of all these challenges,” she says. “The real leadership challenge is how to deliver sustainable improvement year in and year out – someone said to me it’s more a marathon than a sprint.”

Williams also thinks it’s vital to spread leadership widely across organisations in a way which keeps staff onside. “I’m not sure the NHS needs big charismatic leaders that everyone looks up to to take every decision. Because it then does not build the leadership culture we’re trying to build at Barts,” she says.

“There’s a much better understanding that unless you have your staff onside it’s almost impossible and you end up with lots of short-term measures. For me it is about how do you create an organisation where everyone sees themselves as part of that journey of improvement? Staff have to see they are engaged in being part of the solution rather than being told what to do.”

Williams says her career has taught her that high-performing organisations get the same things right: they focus on the patient through the engagement and empowerment of frontline staff, and they focus on strategy – that means on both performance (“delivering good quality services now”) and organisational development.

Her high points as a leader include being appointed as CEO of Barts and “leading NHS Tower Hamlets to be one of the best primary care trusts in the country – as confirmed by our position in the World Class Commissioning assessment,” she says. “My low point was definitely the decision to abolish PCTs, and the subsequent uncertainty and focus on transition to the new structures.”

Prototype chain

At a time when the idea of hospital chains is gaining traction in the NHS, Williams suggests Barts is a “prototype chain” with leaders at each of its sites. She is determined to be a visible presence in the trust, despite the devolved leadership model, joining roadshows at each site and aiming to give the global picture for the trust while local executives fill in what this means for each hospital.

“Staff have to see they are engaged in being part of the solution rather than being told what to do”

Among Barts’ multiple challenges, those involving the workforce are fundamental: it normally has around 2,000 vacant posts in its 16,000 headcount. There are some signs the trust is turning the tide on recruitment and retention, which would be a vital part of improving care and cutting its deficit. Retention rates are now the third best in London. The trust has ambitious targets on tackling staff shortages, but its increased use of bank rather than agency staff is making a difference.

The trust has its own quality improvement plan, called ‘safe and compassionate’. “We are now starting to develop it into a long term vision… that’s what we want to be renowned for, not just in East London, but nationally and internationally,” says Williams. “Our safe and compassionate plan is about speaking to what was important to our colleagues.”

Williams says the trust has “worked at pace” to make changes but a question mark must hang over how long the central authorities will allow it to continue racking up deficits. Williams says the challenge last year was to stabilise the finances and prevent the trust exceeding the £135m control total. It succeeded – which Williams sees as proof that the trust can get on top of its financial problems – but the position remains troubling, to say the least.

“The challenge we have in Barts is how do we use our resources effectively and efficiently to support the quality of patient care?” she says. “Clearly we’re not going to get to a surplus this year… it will take another three to four years. Our ambition for this year is to do for financial improvement what we have done for quality improvement.”

To that end, the trust has a plan for a 6% cost improvement this year. That’s ambitious, given that most NHS organisations struggle to make 2-3% in genuine, sustainable reductions. The target deficit this financial year is still a jaw-dropping £80m and already looks hard to reach. The trust recently found that it had a larger underlying deficit than it thought, creating a gap in its plans which will be difficult to fill.

Reaching for a cricketing analogy, Williams says: “Our run rate is going in the right direction but it is not as fast as we would like. We have brought the underlying deficit down from last year. We had already made a £10m reduction in agency spend but we need to make more. The reality this year is that the NHS as a whole is in a challenging position and the Barts numbers are a material part of that.

“The narrative for staff is very much around focusing both on money and quality,” she adds. “We ask if they are up for it, and they say ‘absolutely!’”

Encouraging feedback

On the quality side, the feedback so far from the CQC has been encouraging. “We’re optimistic that the CQC will have seen improvements,” she says. “From the organisation’s perspective it was a much more positive visit than it had been before, staff felt supported and were able to report to the CQC about improvements we have made.

Williams says Barts is “driving cultural change through a very different engagement with our staff” and this has resulted in some of the most encouraging signs of improvement. Barts is using a well-tested technique – Listening into Action, which has already been used at around 60 trusts. Part of the approach is to do regular staff ‘pulse checks’; at Barts, there has been a significant improvement between the pulse check last September and the one in May.

“I think we have some fantastic clinicians. Our job as leaders is to put some of the best systems and practices and governance in place,” she says.

Like all chief executives, she has to manage relationships with the centre as well as with staff. Conversations with regulators are “very respectful”, she insists. “I think fundamentally my job as chief executive is to build these really constructive relationships with the rest of the system and get to a place where they understand what we’re trying to do and have increasing confidence in us. We can’t be defensive as an organisation, we need to be open.”