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Thursday 04 October 2018

The power of persistence

By Matt Ross

Bournemouth and Christchurch trust has top staff survey results, & ambitious reform plans agreed with partners across Dorset. Chief exec Tony Spotswood recalls the lessons of the long and winding joruney to get here

“The most difficult time as a chief executive is the first three to four years, and then the job does become – not easier, but more containable, more manageable,” says Tony Spotswood, chief executive of the Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust. “You begin to feel more confident, and have a greater sense of where you need to apply your time.”

Indeed, there’s strong evidence that trust chief executives who’ve been in post for some years tend to be more effective. In July a King’s Fund report, Leadership in Today’s NHS, found that high leadership turnover creates “considerable negative impacts” including “strategic paralysis, a loss of organisational memory and diminished credibility of leaders,” and identified a link between rapid executive churn and poor organisational performance. The NHS Leadership Academy suggests leaders should remain in post for at least five years; yet according to the King’s Fund, the median tenure of an NHS provider chief executive is just three years.

Spotswood – who will celebrate 19 years in the job next April – has no doubt that high turnover damages the quality of leadership. “I think the longer you do this role, the more effectively you can do it,” he says. And this isn’t just about experience and expertise: success demands “an understanding that you’re here for the long term, and therefore your decisions are very much based on the medium- and long-term rather than fashioned around expediency.”

Second time lucky

Indeed, Spotswood is now at a key moment in one very long-term project: the merger of his trust with Poole Hospital NHS Foundation Trust, another district general hospital on the other side of the city, was first proposed in 2011. Two years later the Competition Commission (now the Competition and Markets Authority) rejected the plan, leaving a hole in Bournemouth’s finances that Spotswood expected to hit £200m by 2021. Facing fast-rising demand, the trust is a canary in the UK’s demographic mine: “We have the highest density of residents over the age of 85 in England,” he says. “And we are inundated with people on stag and hen do’s, so that brings its own challenges.”

Determined to reconfigure the area’s health and care provision, Dorset’s clinical commissioning group (CCG) brought  trust and local authority chief executives together to hammer out a strategy for centralising specialist services, with the goals of improving patient care, addressing staff shortages and reducing duplication. The result, encapsulated in the county’s Sustainability and Transformation Plan (STP), was a more ambitious, more detailed revival of the trust merger plans, envisaging Bournemouth as “the main emergency hospital for East Dorset, and Poole the major planned [care] site.”

What enabled the participants to make progress? Spotswood praises the talks’ facilitation by practitioners of the ‘Arbinger approach’: a way of “developing greater insight into the behaviours of others, and the impact that you have on other individuals.” Arbinger, he continues, encourages negotiators to “put yourself in other people’s shoes; to see them as individuals rather than as the chief executive of another organisation; to understand when you’re ‘in your own box’ and being defensive.”  

Moving to delivery

Under the plans, Spotswood explains, Bournemouth will provide many services including A&E, obstetrics, paediatrics and trauma – expanding capacity from 660 to 1150 beds – whilst Poole handles elective care. Concentrating emergency care in Bournemouth, he adds, enables the hospital to provide “hands-on consultant care 24 hours a day, seven days a week”; whilst dedicating Poole to planned work ensures that treatments won’t be displaced by emergency operations. Though efficiency will improve, he adds, “this isn’t driven by savings. It’s reflective of the workforce shortages that we’re increasingly going to see”.

Like every other A&E closure, this one has prompted opposition – with local activists launching a judicial review. But the court backed the reform plans on 5 September; and whilst the campaigners have asked for leave to appeal, Spotswood points out that “the judge found in favour of the CCG on every issue that the applicants raised, so it remains to be seen whether the appeal is allowed.” Meanwhile, the CMA – adjusting to the STP era – has given approval for the two trusts to appoint a single interim chair and chief executive, and to introduce joint leadership of four key services.

The CMA’s verdict mirrors votes of confidence from the Department for Health and Social Care (DHSC) and the Treasury. Dorset’s STP – which has already built a shared online health records system – has been rated ‘outstanding’ in the DHSC’s STP Progress Dashboard. And the merger plans have won £147m of capital investment – nearly half of the national £325m STP transformation funding announced in July 2017. Spotswood now expects the merger to go ahead during 2020-21, some nine years after it was first mooted.

Cheery in the face of change

Considering this long-standing uncertainty about the future, it is remarkable that Bournemouth was rated as the top-performing acute trust in the 2017 NHS National Staff Survey. As with negotiating the STP, Spotswood says, achieving these results has demanded both sustained effort and the use of smart management techniques – in this case, the “compassionate leadership” model championed by Professor Michael West, the King’s Fund’s head of leadership and organisational development.

“Organisations often want to retain influence over services, and are concerned that their control lessens if they become part of a bigger consortium or services are provided privately.” Photo: Sam Frost

The trust appointed 20 “change champions”, Spotswood explains, who themselves asked about 1200 staff “how it felt to work in the organisation, and what culture and behaviours they wanted to see.” Having identified the challenges, it consulted on how to address them – eventually introducing changes ranging “from customer care training, through resilience support, to specific support for clinicians in senior roles.” Meanwhile Spotswood promoted the ‘freedom to speak up’ campaign, and held events for the whole workforce at which people were encouraged to thank one another. “For many staff, the change has been quite profound and significant,” he adds – but it has not come quickly: “This work has taken three years.”

On shortages and sharing

So the trust has high morale, a top-rated STP and a Good CQC rating, with an Outstanding rating for leadership; yet it’s not immune to national recruitment and retention problems. The uncertainty created by Brexit “has been really unwelcome, and there’s no doubt that it’s had an impact in terms of recruiting from Europe,” Spotswood comments. “There’s another challenge in terms of trained nurses; some of the changes nationally to bursaries, I think, have had a direct influence on people wanting to go into nursing.”

By reducing duplication, the reform plans will help address some staff shortages. And Spotswood explains that “we’re planning to bring together pathology services across the whole of Dorset” – creating a shared service that should produce further efficiencies.

Shared services is something of a specialist subject for Spotswood, who in 2010 was commissioned by DHSC to review back office efficiency across the NHS. Nationally, progress since then has been slow; NHS Improvement is currently mounting a new push on the agenda. Why so little movement? “Organisations often want to retain influence over services, and are concerned that their control lessens if they become part of a bigger consortium or services are provided privately,” Spotswood replies. “And there’s a concern as to whether they’re going to get the quality of service they’ve previously enjoyed.”

“I do understand some of the hesitancy that organisations have,” he adds. Nonetheless, he believes there’s plenty of room to share more transactional services – such as payroll – and points out that Bournemouth and Poole have already merged their IT teams; estates staff are now coming together to manage redevelopment work on both sites.

And what’s required to get things moving? Many shared service schemes – including Dorset’s pathology project – demand shared data management systems and physical relocations, Spotswood replies, “and that can be quite expensive, so capital support is important.” Without government help to fund change programmes, he believes, “some health economies are going to prioritise their resources in other ways.”

It’s essential, he adds, to ensure that the teams affected by shared service projects are fully involved in the process. “How you go about this change is really important in terms of maintaining the right level of engagement,” he comments; people need to “believe they have some direct influence in shaping future arrangements.”

Working within the system

So Dorset’s STP reform plans have won the official stamp of approval. But as Spotswood acknowledges – and the merger’s troubled history illustrates – they’ve had to overcome serious regulatory headwinds. “The underlying tension is that organisations are held to account in terms of their own performance,” he points out, whilst “the intent of integrated care systems is that you do the right thing for the system, even if it isn’t necessarily the right thing for your organisation. That requires a level of maturity within the system, built around trust and an understanding from the regulators that it’s important to see the bigger picture.”

National bodies including NHS Improvement and NHS England have, he adds, “given a lot of support, encouraging us to think and work as a system.” Crucially, they’ve agreed to assess the STP members’ financial performance collectively rather than individually, creating a single ‘control total’ across Dorset. So where reform plans have looked set to reduce an organisation’s income, its funds can be topped up by its partners – addressing one of the key barriers to securing agreement. “My sense is that this is the right way forward,” comments Spotswood. “The regulatory system has to adapt.”

Ideally, he suggests, the system could benefit from some changes that “require regulatory change – but politically it’s a difficult time to put that new legislation in place.” And will the STP plan reduce waiting times to the level of a decade ago? That, he replies, would require both “some additional investment in capacity”, and “driving the transformation around both hospital and community services.”

This latter goal, he believes, would benefit from wider system change: “My personal view is that developing an accountable care approach – where an organisation takes responsibility for end-to-end care – has significant benefits,” he argues. “It aligns the incentives more appropriately, and allows you to manage the budget so that you prioritise the most important things. I think there are further gains that we could realise through grasping some of that change.”

In the meantime, though, with “some flexibility from the regulators, you can go quite far.”

The secrets of survival

“…never be frightened to appoint people who are more able than you!” Photo: Sam Frost

The fact that his trust has got this far, Spotswood believes, has much to do with the quality of his managers and staff: “As Professor Muir Gray told me, never be frightened to appoint people who are more able than you!” But it’s also down to his own understated, thoughtful, considerate style of leadership. In nearly two decades at the helm, what’s he learned about securing and succeeding in a chief exec’s role?

“Operational experience is really important, because it gives you credibility in working with clinicians – not just doctors, but nurses,” he replies. To secure the job, it’s valuable to have a track record of working on boards, with non-execs, and across organisational boundaries; and to succeed in it, leaders need “an appreciation of culture, and a style of management that genuinely promotes compassionate leadership.”

They also need an ability to delegate, outside interests, and plenty of support in the form of coaching or mentoring. “Everybody has a crisis of confidence at some point in their career,” he comments. “And you’ve got to have a safe environment in which you can play that out and understand how to address those issues.”

And after nearly 19 years in the role, has he had enough of trying to improve care and drive through reforms, in a system hemmed in by inappropriate regulatory structures and fast-rising demand? “I think it’s important that it’s seen through to the next stage,” he replies. “This isn’t the conclusion.”

It sounds like Tony Spotswood will stick around to see Dorset’s long-germinating reforms bear fruit. Getting here has taken a determined focus on good management and partnership working, plus flexibility on the part of regulators. And there’s something else; an asset denied to many trust chief executives across the NHS. The invaluable ingredient of time.

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