The obligation to dissent: Richard Murray on making an impact on health and care

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  • Posted:Thursday 23 January 2020

A podcast about big ideas in health and care. We talk with experts from The King’s Fund and beyond about the NHS, social care, and all things health policy and leadership. New episodes monthly.

What is it like being the Chief Executive of The King’s Fund? Helen McKenna spoke with Richard Murray about his first year in the job, the role of think tanks, the new strategy for The King's Fund and his vision for the health and care system. 

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HM: Helen McKenna
RM: Richard Murray

HM: Hello and welcome to The King's Fund podcast where we talk about the big issues and ideas in health and care. I'm Helen McKenna, I'm a senior fellow here at the Fund and I'm going to be your host for this episode. Today I'm pleased to be joined by a very special guest who is making his debut appearance on the podcast and that guest is our very own Chief Executive, Richard Murray. Richard, welcome to the podcast.

RM: Thank you Helen.

HM: So later in this episode we'll be talking more about your career journey and your leadership style as well as getting your reflections on the role that organisations such as The King's Fund can play in the wider health and care system, but first when you were a child, what job did you see yourself doing?

RM: When I was really a child it was definitely a zookeeper but there aren't many jobs in zookeeping and then I found out I'm allergic to fur so that quickly -

HM: Which would be a definite problem, yes.

RM: - that killed that particular job. As a teenager I had a very brief desire to be a pop singer and indeed formed a very short lived duo pop group with one of my friends who happened to own a synthesiser and you kind of think would this be a Pet Shop Boys/Erasure/Soft Cell, but we were somewhat held back by the fact that neither of us could write music and neither of us could sing and in fact neither of us could play the synthesiser either. So instead I decided to go to university. Oh well, music's loss.

HM: Yes, absolutely and I'm pretty convinced that actually not everyone who is successful in music can sing or write music. So…

RM: (Laughter) If only I'd known that at the time.

HM: So I wanted to start by spending a bit of time exploring your career journey to date. You trained as an economist and from there you specialised in health economics. What was it that drew you to health specifically?

RM: Well, I'll be absolutely frank, it was a mistake. So I was an academic, took a lecturing job in London and I came down from York and York University is the centre of health economics in England and indeed still is and we work very closely with colleagues at York, but the people in London that I went to work for mistakenly assumed that I'd come from the health economics community in York which I hadn't, I had nothing to do with them whatsoever and they put me down to teach a health economics course. So I quickly had to learn it and become a health economist slightly by mistake. It's absolutely fascinating, it's really interesting, touches every part of people's lives and then roles came up in the Department of Health and I moved across into that as a true health economist, but it was something of a mistake at the very beginning but one I've not regretted ever since.

HM: And once you settled on health as a sector, you spent time in a number of roles and different organisations including obviously you've mentioned the Department of Health, you were at McKinsey, you were at NHS England, can you tell me a bit about the thinking behind that journey? Were they part of a career plan for example?

RM: They were not part of a long-term career plan, no. So I did commit to health, so all of those moves were within the world of health and when I was at McKinsey that's almost all I worked on while I was there. There were a couple of things that did guide the moves that I made partly the culture of the organisations that I was going to be working in and I stayed longer in ones that were good and less long in some that weren't so good, and I think for a lot of them, particularly if you work in health, you're often surrounded by very, very dedicated people. The kind of moral force of the NHS means most people are hugely motivated, but that also means you need to know that you're having an impact, you're doing some good.

HM: You mentioned culture there, what are your reflections on how the culture varies across those different settings?

RM: Culture does vary enormously and even within organisations over time. One of the ones I've taken away with me over the years is what they call the obligation to dissent. If you think it's wrong then say so and if you don’t speak up and say, "I think this is wrong," then you're part of the problem and I think that's got real power. Also in the other places that I've worked in I've seen leaders the point at which they get surrounded by people that are either too afraid to speak out or are not motivated to speak out is the point at which you can start dating the end of their career. You need people around you often people that you trust but also that value their dedication and value their sense of responsibility that they don't want things to go wrong, and I do fear sometimes in the NHS that, whether if you think about things that happened at Mid Staffs or other places, that willingness to say, "I don't think this is right, something has gone wrong, I don't think we're working best for patients," is often at the root cause of many things that then end up unfortunately on the front pages of the newspapers.

HM: And so you've been at the Fund since 2014 previously as the Director of Policy and then you became Chief Executive I think around this time last year, so you've been in post for twelve months, what are your reflections on the role so far? Has it been just as you expected or is there anything that's surprised you about it?

RM: I think one of the things, and I think probably particularly in an organisation like The King's Fund, we are small, we're not very big, but we're very, very diverse in the businesses that we work in. So we are a classic thinktank but we also do a lot of organisational development, we've also got a building, we've got a venue, we're running events outside of them and so there's an element of the logistical work that you need to get your hands around very much reliant on other experts obviously and relying on people that are both very talented but also willing to tell you if they think you're going down the wrong route. I think the other thing that does… where I think does rest quite heavily on my shoulders but also I think on other senior people at the Fund and of course everybody at the Fund and I'm sure was the same with Chris Ham, is we are in a very privileged position of independence and there are many problems across health, health care, social care, voluntary sector and you do feel a real sense of responsibility to make the most of all the assets and all the advantages that we've got so that somebody notices, so that you actually make a difference and that you don’t end up in three years' time looking at a system that's still really, really struggling and think, well I could have done something about that and didn't. So that I think, that sense of responsibility of really marshalling all the skills and talents that are here for the maximum benefit is something that you… is kind of the thing that sometimes you're sitting on a Sunday thinking, have we got that right? Are we still doing the right thing?

HM: I also wanted to get your views on the responsibilities of organisations like ours and the role we play in the wider health and care system, I think particularly given your experience of working across the sector, how do you see the purpose of The King's Fund and how that fits?

RM: Well we undertake a number of different roles. I'd start by really emphasising the advantages, the huge advantages and the responsibility that goes with being independent. We are responsible to our trustees of course for the enduring sustainability of The King's Fund, we're over 100 years old and we want to know that we're going to be here in the next 100 years as well, but that independence means that we can step outside both some of the political and operational challenges and try to be as far as possible a neutral independent body but that really wants to help. I mean so I know it's a cheesy phrase, we're here to help you, but in our case there isn't much point of us unless we can do that. We still have a very important role speaking truth to power. We can speak out. We need to use that well. So it's not just chucking sticks and stones either at NHS leaders or politicians, you also need to be ready to say, "Well done, that was fantastic, really," so that you're trying to provide a genuine picture. So we really need to make sure that balance is there. Like others, we're trying to help find best practice, help people work their way through. We can do it by working across the country by drawing on international evidence to try and help point the way that may be the way forward, but also I think we do things around providing a space, a safe space for people to come together. We don't always need to know the answer but by putting the right people in the room they can talk to each other and I think again even though we don't always know the answer through bringing together the right people in the public domain in events and things like that, again we can find a safer space for people to think through the problems that they're finding and find their own solutions.

HM: And we've talked about the role of thinktanks, being evidence-based is clearly something that we prize a lot at The King's Fund, but there's also a challenge for thinktanks and I think for us to come up with and promote new ways of doing things that sometimes goes beyond the evidence. How do we make sure… from your perspective how do we make sure that we do both?

RM: Well you're absolutely right Helen and for us, and I think for others, when you want to move beyond that into, “well I can't prove it but I think this is the right thing to do”, it's just to be really clear when you're doing that, when you're moving beyond saying, "Look, I can give you references for this or I can put up the research that's done it," and you're not in the zone anymore, but particularly in an emergency sometimes waiting for the peer-reviewed publication well, to be honest, you don't bother waiting because it will be too late. You need to be timely and if you're not timely then don't bother, and I think that just requires us sometimes to say, "I couldn't prove this necessarily but this must be a good…” and I'll give you an example, some of the stuff that we're arguing now around international recruitment, could I prove or forecast exactly the number of new nurses that we might get by revising the way that we try and attract nurses from abroad and we recruit them? Well no I couldn't. Am I convinced that this is definitely going to be better than not doing it? Well yes I am. So that the evidence base takes me so far, but by being clear about a bit of logical reasoning behind that you can still make recommendations and still comment and suggest things, but it does mean you need to be clear when you're moving between one and the other.

HM: Yes, and going beyond the evidence then for you, what would your non evidence-based vision for the health and care system be?

RM: (Laughter)

HM: - if you were to pick out a couple of things that you couldn't back-up, but you think that's where it should be headed?

RM: So… and of course you ask me the things that I couldn't back-up, so of course there's lot of things I would suggest that we do that I absolutely could back up. One of the ones that I think is most current is the role, the potential role, for taxation and regulation. We've seen a little bit in the sugar tax, and one of the pushbacks that often comes back is, well we don't know what effects it will have ultimately on health, what's the evidence base? And I do understand that, but if you're thinking about, shall I put a tax on saturated fat? Well to be honest you're not going to kill anybody by doing it, if it doesn't work well then change it.

HM: Try something else, yes.

RM: Do something else. It's actually I think a bit easier in some areas of tax policy to be a bit more innovative. Be careful if you're training up lots of new doctors that take years, are hugely expensive and then might find out you've made the wrong decision, it's difficult to go back, it's even more difficult if you haven't trained them to suddenly find new ones. Tax policy you can change it year on year. It's not the end of the world and I do think a bit more imagination about how those other levers are used to help people's health would be a good thing and I do think the sugar tax was one of those perhaps slightly surprising innovations that does seem to have worked. So I'd probably pick on that one.

HM: And I guess inaction has an opportunity cost as well.

RM: I mean Helen, absolutely, I think that is so true. Not doing something has in economic terms has an opportunity cost and can be incredibly damaging. When you can see a deep workforce crisis in the NHS, inaction is probably the most dangerous thing of all. If you can see, as we can at the moment, some of our success over the last few years, over the recent decades rather, in reducing cardiovascular disease, inaction might be the most dangerous thing because you're basically sitting on top of a trend going in the wrong direction. So I'm not suggesting running off and doing 10,000 things all at the same time, but people really need to think through that inaction, however easy it might be to say no, is sometimes the most dangerous thing of all.

HM: And you mentioned tax and regulation there, my team is currently writing a briefing on tax and regulation that should be out in the next month or so, though listeners watch out for that. So one criticism of thinktanks and the wider charity sector is that they lack diversity particularly at senior levels, and obviously you're involved in the work we're doing internally here at the Fund to improve our own diversity but we still have lots to do, and I wanted to ask you about what this work means to you and also from your perspective, when it comes to organisations like us that are focused on research, what impact that lack of diversity has.

RM: So I think part of the problem I think sometimes for charities is slightly the belief that we're on the side of the angels, aren't we good people and so why would we have done this? Surely you don't mean us. But of course when you actually look at the numbers and the data you think, oh god it must mean us, mustn't it? Of course it's us, what have we done that has made us either unattractive as an employer or that when people have joined us people's careers haven't flourished as well as they should do? So we're doing a lot on that and that's both an issue about justice, of course it's also just a dreadful waste of people's skills if they can't flourish within an organisation, and the Fund obviously speaks to the service about diversity and you kind of think, well put your own house in order first. I should say in many ways on a personal basis that is sometimes quite challenging. I'm a middle-aged gay man, I grew up in the '80s, so sometimes to think that we've not done well on diversity is on a personal basis quite a challenging thing to accept again slightly because I saw myself sometimes on the other side of the fence. The challenge I think for us we're not very big so it's difficult to employ every group that you would wish to across society. So we really need to make sure that we are listening and an open organisation.

HM: So you mentioned that you've grown up in the '80s as a gay man, and I just wondered when we're thinking about our work on inclusivity given the work that we're doing, you're now the Chief Executive of The King's Fund, did you face obstacles along the way in your own career in relation to your sexuality?

RM: What I think like quite a few people from the '80s and well into the '90s, what you did is learnt to edit your life at work and so you had a choice, if you wanted to be you could be really out and be really open but if you did then that could make sure you never got promoted and end your career quite sharply and it was made quite clear from things that people said that that was what would happen, or you did that classic thing about not referring to… you didn't use sexual pronouns when you spoke about things and tried to keep some distance from people at work, particularly older people because that's where that was most visible, until you were sure what the lay of the land was. Now I think in the organisations I've worked in that was always quite feasible, it was quite a possible thing to do and I've, to be honest, worked in organisations that actually were at the better end of that sea change in society. It does colour sometimes the things that you do and you think we had a big event here, of course a huge London Pride this year that's enormous, and I look back and it's such a sea change from when… even well into the 1990s I remember walking down Victoria Street trying to get a cab and cab drivers would look at me and my friends and just drive off.

HM: Wow!

RM: They wouldn't pick you up and pubs in Soho would have big signs outside saying 'no gays' and nightclubs would say 'no gays' on the doors and nowadays of course they're all chasing the pink pound and the pound, the pinkish pound of their allies, but it's been a huge… such a change. Of course I'm older and I'm a Chief Executive and I've got a degree of white privilege that removes some of those other problems. As I understand some of those experiences are quite personal to me and to the generation that grew up around me. It's sometimes just to try and remember that when other people speak about the things that they've gone through I just need to recognise that how different people's things are and I should know that because mine was, and so for me it's just to remember that I ought to listen to other people as well as sometimes thinking about how the world changed for me and the people around me.

HM: Thanks for sharing that and the point about self-editing is really, really interesting in terms of, yes, how that shapes who you are at work.

RM: Yes, yes, absolutely. Absolutely.

HM: Our listeners may or may not know that it's a time of change at The King's Fund and January 2020 marks the start of our new five year strategy, can you very briefly run us through The King's Fund's new strategic priorities?

RM: Yes, so very quickly three key priorities helping places and communities work better together to improve health and care, this is growing out to things that we've done before on integrated care but this really looks to join together health service, local government, the voluntary sector to try and do the things that working together can really improve people's health. It's a big cultural and organisational challenge. I've mentioned workforce and leadership, we've worked in leadership for a long time, I'm really pleased to see how that's raised up the agenda. We now recognise this is an absolute call on the resources of the Fund both to help those leaders but also to help the people that work within the system whether they work in health care or whether they work in social care or whether they're volunteers and I think we'll take a particular focus on primary care and community services to begin with; and then also to try and improve the health of people with some of the really worst health outcomes. We do know of course that wider determinates determine generally health inequalities, but particularly there are some people, rough sleepers, people with learning disabilities, who really get a very, very poor service sometimes from NHS, from local government and from other parts of the system. When you're in those very difficult situations often it is those bodies that have the answer and it's an onus on them to try and work out how to make those services accessible and to work really well for some of these most poorly treated groups, and I think again that plays to some of our skill sets in being able to draw those things together. Doesn't mean to say we step away from the truth to power, about thinking and trying to explain the very, very complicated world to people out there as well. So people still continue to see us do that and indeed we do recognise that as a really important call. The only thing again I wouldn't want to lose, those are our external priorities, but we are trying to be a more diverse organisation, we are trying to work well with others and when we speak to people outside in the system about the importance of distributing models of leadership, I'm getting more technical now, but really trying to give people responsibility and power, do the best and we're also trying to do that internally, and so alongside a set of external priorities we are trying to change the way we do things internally as well.

HM: If we could fast forward to the end of 2024 and the end of the strategy cycle, where would you like The King's Fund to be?

RM: I'd like us to be recognised, across all those priorities, of having made a real difference. When I say recognised that means that's because we did it. So (a) we did it and (b) it had an impact and alongside it that people do think that on some of the things that we're talking to people about that we've walked the walk as well as talked the talk. So if we are speaking to people about issues around diversity it's because we've been on that journey with them, we know how hard it is and we've tried to learn alongside them as we've done it.

HM: And of course in December we had the general election and we now have a Conservative government with a clear majority in parliament, what do you think the new government's top priority should be for the NHS and social care?

RM: So one of them really is to confront the workforce crisis across all of health and social care and by health I mean that in the genuine sense of health that includes charities, third sector volunteers, that are also contributing to health in this country, and we know that the People Plan hopefully will come out quite soon that should take us a big step forward on that I really do hope, and I would leave no stone unturned to advise the government whatever it can do, and we have to be clear a lot of this sits with local employers and local organisations, but whatever it can do to help it should do. Secondly of course is a long-term solution to social care. I really do want a long-term solution to social care and the government has got a big majority it's probably the first time in more than a decade that it could push something through if it wanted to. My only thought for them as they do that is absolutely do do it but don't forget to fund social care in the meantime. The existing system is there, even with the fastest reform in the world we are going to be living with the existing system for a while longer, so make sure that that gets the money it needs in the short-term and possibly be a bit careful about shiny exciting new policies and structures. Governments with big majorities sometimes get drawn into organisational reform in the NHS. I'm not saying no organisational reform but be wary of it. I don't think that figured in any things the Conservatives said in the run up to the election, but then I'm not too sure people thought they'd end up with quite such a substantial majority at the end of it.

HM: I want to talk to you about your role as a leader and your leadership style. So if I were to ask you to describe your leadership style in, let's start with three words, what would it be?

RM: I'm going to cheat Helen and say three words, you tell me -

HM: (Laughter)

RM: – and I say –

HM: That is so awful.

RM: - do you know what, I've sat with other leaders who have… and I'm not going to mention any names who said, "I've got an inclusive leadership style, really want to hear people's voices and build up from staff," and then you quite quickly learn after about a month or two that if any way you disagree with them your career is over and they're really vindictive and they never like being contradicted, and so there's something about the style that leaders, the way that they think that they come across and there's another one about well what do they actually come across? So I think if I was being truly evidence-based I'd say, "Look at the next staff survey for The King's Fund and see what people say about me and then you'll know what my leadership style is." What I try to do is be an inclusive leader, I mean who doesn't say that these days, but within the Fund where I recognise on any one issue almost certainly there's somebody else in this building that knows more about it than I do, is provide enough of the strategic direction and oversight so that people have the tools and understanding and then to make way for them to do well themselves. Now there are some organisations that don’t have the luxury that we have here, or I have here, to be surrounded by dedicated people who really want to do well, but I do and so it's to make the most of that. It does mean sometimes being ready to say no when either they haven't got the relevant information to hand or that you've got competing views within the organisation. So you can't abdicate being Chief Executive, there are times you have to say that, "Look, I know none of you can agree this, this is what's it's going to have to be," but most of the time that's not the way to do it, not in an organisation where you really need people to own the message to really believe in it, you can't do that by telling them.

HM: Can you tell us about a time in your career when you felt that you'd failed and what you learnt from that experience?

RM: I'll give you a very quick one and then I'll give you a slightly longer one. So my interview answer to that question is the workforce crisis in the NHS has been growing for a long time as a slow burn. I do feel responsible that The King's Fund turned to this slightly late in the day. We were hearing it, people were telling us, but I think partly because we weren't all coming in the room together and just sitting down and saying, "What are the top things that people are telling you?" and I think if we'd done that we would have realised that everybody was being told that there's a workforce crisis here. We knew it but I just don't think we recognised how deep it was and that that wasn't part of our strategy at the time to do anything about it, that wasn't the areas we were working on, but we probably needed to think again and probably weren't drawing in making the most of all the things that we knew. Of course we tried to overcome that now. If I think of one that I failed in (laughter) and probably left more scars on, it was probably I was Chief Analyst for the Department of Health, the Chief Economist as well, and for NHS England too, and as the reform system was set up and A or Bs appeared and teams got split up, I knew and began to try and get to a place where there was commonality over methodologies, over assumptions, so you don't get people just arguing about the data or arguing about the analysis, it's just so unhelpful and most of the time it's because a spreadsheet has made a minor difference to somebody else's spreadsheet and there's nothing materially different and you trap people into arguments about what's going on. I think there was a real chance when those bodies were set up to have really brought back a common view across all the bodies on analytical work and I did begin to do that and successors will continue to do it and they're making more progress on that now but this is some years later. Why did I fail? I think there's a thing for everybody, for everyone, and I think particularly for leaders about the urgent and the important, and I felt at the time there was a lot of urgent things to do and I mistakenly thought I had more time than I did and so I left it as unfinished business and if I could go back I would have sorted that out and recognised that some of the other things that were urgent were urgent but, you know what, they could be allowed to slip and just don't do them and I kind of lost a bit of sight of that.

HM: I really like the workforce example because it just shows how seriously you take the responsibility of a thinktank, our role in the system to be looking at those issues -

RM: Yes.

HM: - and raising them to the fore of the system. So just before we finish, we've talked a lot about your working life, but when it comes to your time outside of the office, what do you do to relax, Richard?

RM: Oh my god, what do I do to relax? Rather just what everybody says, I read. Well I do actually and people always say, "Oh god, you've got to go into work on the Northern line and the Victoria line," but I just stand on the tube and read my book and my secret Santa this year was James Bond, it was Casino Royale and I've never read any and I'll tell you, I'm at risk of missing my tube stop.

HM: Really?

RM: Genuinely, and I nearly ended up at Warren Street today by accident. So that. With my partner because we live in London we do try, and also because we enjoy it, to see probably more live music now than we did. So we're not out very, very late at night in dark nightclubs without a seat listening to the latest…

HM: You're doing the older person's version.

RM: We're doing the older people's version, exactly. If you look at it and think, hang on a minute, this ticket hasn't got a chair and seat number on it, I begin to get a little bit suspicious. So we go out and see quite a lot of music. We like jazz, then everybody my age likes jazz, but also we try quite a lot to make the most of being in London which means you can hear music from other countries too. So we're great fans of Fado, which is Portuguese.

HM: Nice.

RM: So really recommend that to people. I also by the way, which has really shocked everybody in The King's Fund, is that I like bird watching and a nameless member of staff came up and said, "Well I just can't believe that's true, you're the last person I would have thought would ever cared anything about birds," and I kind of thought I don't know quite what (a) you thought I did and (b) what's the image in your head of a bird watcher?

HM: And is the technical term for that twitching, is that…

RM: That's if you're really… that's if you really do it properly.

HM: Right.

RM: I'm an amateur, so I'm not… I claim no great skills at doing it, and my husband the first time we ever met was about to go on holiday and he did say where he was going that there was a nature reserve behind it and he did say, "Oh my god, it will just be full of all those really boring bird watchers," and I thought oh dear, this relationship is really getting off to a bad start. Anyway.

HM: So Richard, thank you so much, that's it from us. You can find the show notes for this episode and all our previous episodes at I'm Helen McKenna and thanks as always to our producers Ian Ford and Sarah Murphy. If you enjoyed this episode please subscribe, rate and review us, we'd really love to know what you think and what you'd like to hear more about. So please tell us by leaving a review on Apple podcasts or get in touch either on Twitter @TheKingsFund or my account @helenamacarena. Thank you for listening. Hope you can join us next time.