System leadership viewpoints: Ruth Carnall

Ruth Carnall is a managing partner at Carnall Farrar. Ruth has extensive experience as a chief executive in NHS London. In this capacity, she oversaw an extensive programme of performance improvement and strategic change.

This interview is taken from our report on the practice of system leadership.

Did you see yourself as a system leader?

When I was chief executive of the London SHA, I saw my job as two things. One, as a system leader, somebody whose job was to bring people and organisations together and try to get more than the sum of the parts. But I also saw myself as responsible, accountable for performance.

So, however silly it might seem, I did feel very accountable for performance in London – operational performance, financial, strategic change, public opinion, complaints, whatever. If it happened in London, I felt accountable for it and, weirdly, even if it was in a foundation trust. I could have pointed to a rulebook that said it wasn’t my job to manage that. But David Nicholson’s attitude [when he was chief executive of the NHS] would have been ‘it is on your patch, sort it’. And indeed many foundation trusts, not all, looked to me for leadership on some issues even if the rulebook said they weren’t accountable to me.

What were some of the things you learned?

We had some tools for accountability. Some were direct. PCT chief executives were accountable both to their chairs and to the strategic health authority. Chairs of PCTs were accountable to the chair of the health authority, so there were some direct lines. Chief executives of NHS trusts were accountable to the chief executive of the health authority as well as to their board. And the health authority had oversight responsibilities for signing off plans. So it wasn’t possible for a PCT, for example, to plough ahead with the change programme that it fancied doing without the support and approval of the health authority. So there was some direct power – quite a lot actually. And for foundation trusts, the provisional withholding of support for major projects was a powerful if indirect lever.

Take the stroke changes, which involved quite a lot of foundation trusts. We said there were going to be eight hyperacute stroke units and one of them could have said ‘we don’t care, we are going to do a ninth.’ But they didn’t.

And that was because we achieved the change by producing a powerful case for it. ‘Why are we doing this, what is the evidence at the back of it, does everybody agree? Yes they do. And here is the evidence that effectively eight networks is the right number. Here is the evidence for that. Here is the clinical backing for that. Does everybody agree? Yes. Okay, we need a process then to select which are the eight. It is a balance of quality and access. Do you agree? Yes. Okay, here is the process. Do you think it is fair? Yes. Okay, we have applied it, and it means this teaching hospital doesn’t get one.’ And if they argued, you could point to all these steps which demonstrated that if they took that position, it was being taken out of self-interest.

So it was possible to corral commissioner power (the PCTs across London), political power (the joint committee for London), and clinical power, with David Fish and others saying ‘this is about the greater good, and you are going out on a limb if you say it is unacceptable’.

The clinical leadership is vital. You need the best, most diverse group of clinical leaders that you can possibly muster.

One of the biggest sources of influence was your ability to get powerful clinical leaders on side and then to take responsibility for leading it on your behalf. And I think, to be fair, it is a lot easier to do that in London. There are a lot more clinical leaders, and some incredibly capable ones.

And there is a sense of place – ‘we are going to improve services for the population of London’ – even if that may well involve moving services, changing where they are delivered. There isn’t really something called the south-west, or the East Midlands, where if you talk to a clinician their affiliation will be to Exeter, to Plymouth, to Nottingham, or wherever. So you can get a coherence in London, and I think it is easier in the big cities like Manchester and Birmingham and Newcastle, because of the sense of place and of a whole population. The downside is that if you drop a pin in London you have Number 10 on your case before you can turn around. But the upside is that if you get that right, the balance of political power right, it can just take a change forward in a way that in other places it can’t. And the stroke case is interesting because what that demonstrated, in the end, was that the power of that clinical collaboration overcame the personal position of the Secretary of State at the time.

I think it is essentially the same, whatever you are trying to do.

If you want to make changes to hospital services, then unless you take into account the social care dimension, the community care, the primary care, it isn’t going to happen.

So if you take the big integrated care plan for North West London, that all started with the case for change… ‘What is it that is wrong with what we are doing at the moment? Who is prepared to stand up and say that?’ Both on the basis of the evidence and with an emotional component as well. It needed some aspects of local government to be saying ‘this is not the way to care for elderly people with multiple long-term conditions’ and some evidence for that, and for the GPs to be saying ‘some 200 people in North West London have lost their limbs unnecessarily because of our crap diabetic care’. So that involved a wider coalition than the stroke case, but in a narrower geography.

And, of course, you get people who are opposed. Take Barnet and Chase Farm, where one of the local councils was opposed for 25 years. But there does come a tipping point, where people will go from saying ‘we don’t want this done, we are going to combat it’ to them saying, ‘well, this has dragged on so long, why don’t you get on and implement’. It took 20-odd years, but it is now happening, and there are some very positive noises about the gains from that change.

It doesn’t always work. I’ve talked before about Lewisham and South London, and the original compromise we made there, which I bitterly regret. I didn’t recognise that I was trying to push a boulder up a hill that wasn’t going to make it – that it wasn’t going to work because of the dynamics. So that leadership judgement is a very inexact science. I had 30 years’ experience at that point and I got it wrong. I have 38 years’ experience now and would probably get that one right. But I would probably still get others wrong.

Where are we now?

But that’s the past. The question is where are we now? I should preface all of this by saying I lost a job I really loved, and didn’t want to lose it, and I would have done it until I retired. So people may say I am jaundiced and prejudiced. But I go round now trying to help people deliver changes in the current NHS – and it is so much more difficult.

Making change in the NHS is controversial. It involves judgement – difficult choices between investment in one thing and investment in another. Quality against access… A whole series of complex trade-offs, where many, many parties have a perfectly legitimate interest in aspects of it, and a degree of authority over that.

It is an exposed business politically in the media, it is a pressured business financially, and the business of leading change is a controversial and complex one. So you do need authority, because otherwise how do you decide? You need authority that matches the scale of the change. And what I see are a lot of small commissioning organisations who lack that authority, that scale; and an accountability structure for the NHS as a whole that is hugely divisive. So there is Public Health England, the Department of Health, the TDA [NHS Trust Development Authority], Monitor, the CQC, NHS England and its regional structure. It isn’t clear to people in the system how all of that works together – to support, or at least to legitimise, a process of change. So people don’t know how you get stuff decided.

So you can see individual CCGs doing some fantastic things locally and they are doing things that health authorities could never have done – because they have a connection and an ownership of a place that health authorities could never have had… Local relationships that are delivering important things on the ground. Where they are genuinely GP led, they live there, they work there, their kids go to school there, they stay in the same practice forever. They have a far better understanding of the population, its needs, and the community than any health authority ever could have done… And often good relations with the leadership of local government and with religious communities, which, in some places, is very important.

The problem is the scale of the transformation needed requires change at scale and at pace and they are clearly unequipped to deliver. There is a lack of a clear structure for them to come together, no structures for them to be brought together, nowhere where it is clear that there is decision-making power. Some of the academic health science networks are doing really good things, making change on the basis of clinical evidence. But they are not doing it at pace, that’s for sure. If you were to say the health science network should sort out the configuration of all services in central London, they wouldn’t be able to do it. They lack the authority to do it – it is not their role, it is not within their remit.

So how do CCGs work together where there is nobody to provide any structure for them to work with? So they are left to develop their own networks, supported sometimes by NHS England, but those networks are really weak in the face of the scale of change that is needed and the financial pressure. So that’s one problem.

The second problem – which people don’t talk about, and which we should – is that every time (although that is probably an exaggeration), but every time the NHS gets restructured, the old set of rules about how things get approved do not get swept away, they just get built on.

So Andrew Lansley purported to strip away bureaucracy and replace it with four simple tests for change. And that is absolute rubbish. I have just been helping with a piece of work about changing services across Manchester and there are over 200 elements of assurance applied to that. It all purports to be helpful. But it is actually a set of hurdles, a set of barriers to change. So there is the statutory consultation process, the inequalities impact assessment, NHS England’s assurance process, the Finance and Investment Group process, the Independent Reconfiguration Panel, judicial review, the TDA [NHS Trust Development Authority] process, the Monitor process, and it just goes on and on.

So you have a group of inexperienced organisations without a clear structure to work within, required to do something beyond heroic, and then what you apply to help them is a set of bureaucratic constraints. You can find a way through, it is possible to do that. But that’s not the way to deliver transformation – making people jump through all these hoops so that they don’t want to do it a second time.

We are losing clinical leadership, including in CCGs, because they are just having barrier after barrier put in their way and they don’t want to go through it again.

A new government should have a genuine review of all the red tape. What is it? What are the different steps in the process that have to be gone through? Why are they needed? We once added up how long it would take as a minimum, with all the consultation and hoops, to get a significant change through, assuming you were not subject to judicial review. It was two and a half years. It would be worse now.

I am not in the ‘let’s have another reorganisation’ camp. That would be dreadful after all the upheaval that has happened. So I think it is about finding a way to provide the right sort of support to CCGs, incentivising providers to participate, and making sure that the regulatory framework reinforces that.

I think the Forward View has done a great job, but I wonder what the means of following it through will be. So there needs to be some transitional funding, and NHS England, the TDA [NHS Trust Development Authority] and Monitor in particular need to figure out how they are going to provide coherent national system leadership.

I think they need to intervene at an early stage, not intervene at a late stage, which is what happens at the moment. So… ‘What is your case for change? Tell us. Show us the evidence.’ And then instead of saying yes and meaning no, throw everything you have got at supporting those local systems to work through the barriers, and then use the learning from that.

So, create a local steering group that has a very senior person from Monitor, a very senior person from NHS England, and from the TDA [NHS Trust Development Authority], helping them to do it. That then becomes a model for how stuff is done, and you replicate it elsewhere. And then you don’t need the most senior people. So do it with a limited number of places to start with.

The right thing would be for Monitor, the TDA and NHS England to decide on five or six systems in the country where big change is needed, where there is a compelling case for change, and then commit their leadership to achieving it.

People will say ‘she can’t see beyond the end of the job that she used to have, and she is just recreating a strategic health authority’. But I do think those three organisations are going to have to find a way of providing coherence.

An alternative model may lie in some of what is in the Dalton review. So the big teaching hospitals will survive, and if nothing is done will just suck in more resource and people and activity. So you could say to one of them ‘you’ve got the budget for the whole of this chunk of London, and here is what we expect to see you deliver in terms of outcomes for that’. But that would require an awful lot of legislative and policy change. They would have to be able to employ GPs, and public health would be less with local government. It would be difficult to make it a great solution for integrating care for the frail, the elderly, where what you need in Barnet, say, or Redbridge is something that is sensitive to Barnet or Redbridge. You could lose a lot of diversity and access. You would have to guard against that. But it is a potential leadership model, and I do think it is worth piloting in one place.

What can be done to develop system leaders?

It is difficult. There are two ends to it. One is that there are still some highly experienced people in the NHS who have got their gong and got the wisdom. We should persuade them to go to places that need significant change and tell them they are not going to be sacked and their pension is safe, and help these places do it. At the other end, we have to find ways of protecting some very bright, very enthusiastic, young managers and chief executives who are struggling with the system as it is. And an important part of that is making the system easier for them to operate.

Watch Nick Timmins' interview with Ruth

Read the next interview: Professor Dame Sally Davies >

More on system leadership