Does the NHS work for those who need it most? What does it really mean to lead a system? Helen McKenna sits down with Lord Victor Adebowale, Chief Executive of Turning Point.
- System leadership
- Diversity should be a strategic priority
- Health inequalities: the NHS plan needs to take more responsibility
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- I: Interviewer (Helen McKenna)
- R: Respondent (Victor Adebowale)
I: 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 policy adviser here at the King's Fund and I'm your host for this episode. Today we're doing something a little bit different to our normal format. We're going to be sitting down with just one guest, something we'll be doing from time to time on the podcast and the idea behind this is to talk to a range of leaders in health and care to understand their leadership journey, to understand what makes them great leaders, and also discuss their views on the big challenges in the health and care sector. So I'm honoured to be joined today by Lord Victor Adebowale who has worked on a wide range of issues in his career, all of which are relevant to health. Victor, welcome to the King's Fund podcast.
R: Thank you very much, the honour is all mine I think.
I: As an introduction, can you tell us a bit more about who you are and what you do?
R: Crikey, that’s an introduction that could last quite a while. Well I'm the chief exec of Turning Point which is a social enterprise that provides health and social care interventions for people at the sharp end of the inverse care law basically. We operate in and about 260-odd places in England. We employ 3,580 staff in those locations and we provide services across mental health, learning disabilities, substance misuse, the odd primary care service and all points in between.
I: Wow, so a huge job. So tell us a little bit more about day to day life as chief exec.
R: I don’t spend every day doing podcasts at the King's Fund. As chief exec I deal with bad news and every now and then there's good news. So my days are filled with phone calls and emails and visits to services and I have fantastic people in my team. I know chief execs always say that but I really do, and they run the business. My job is to add value and I do that by understanding where the business is going and triangulating information and synthesising that and asking good questions and you know, preparing for the future, trying to stay ahead of the now actually.
I: So you're also a non-exec director at NHS England?
I: Tell me what is a NED and what's it like sitting on the NHS England Board?
R: So non-executive directors are just that. We are not executives, i.e. we don’t have direct day to day operational responsibility for the business but what we do have responsibility for is owning the strategy of that business, i.e. what is going to happen next or where are we going and the choices that fall out of that question and the values of the business, you know, what do we stand for and what don’t we stand for. We have legal responsibilities, so when things go wrong, we need to have coherent answers.
I: And so, you know, you talk about the values and the importance of setting the strategy, what's your experience of doing that in NHS England?
R: Well like most large complex organisations it's challenging and it was formed as a result of a huge shift in health and social care policy and done in record time. I mean six years I've been on the board but it took 18 months forming the structures. As the last chief exec of the NHS had pointed out, the reforms could be seen from space, so there's been a lot of moving parts, attempt to formulate the whole picture or whole statute in a very short space of time. So it's been like building an aeroplane in mid air and that's quite challenging and the political environment has also shifted and changed and ebbed and flowed with varying degrees of alacrity. So yeah, it's been challenging and I think will be for the next, whoever replaces me.
I: And in some ways, it sounds like you're saying NHS England has basically had this huge task of trying to recover from the impact of the Lansley Reforms. Is that what you're saying it's spent it's time doing?
R: Well I think my personal view is just that. I mean it's been trying to stay whole against a policy which was in favour of fragmentation. Now whether that was the intention of the policy, it certainly has had that effect and so the risk created by the Health and Social Care Bill, and there was some issues before then, was that we were moving towards becoming a system anyway rather than a service in the sense of a hierarchal structure. There was lots of push towards becoming a system. The Health and Social Care Bill gave that a real boost. The problem is that how do you remain coherent if you dissipate and the risk to the central tenant of the NHS which is health and social care, but certainly health, free at the point of access and quality being consistent throughout the country. So the Health and Social Care Bill I think injected a huge amount of… It depends on where you come from. You could argue creativity or chaos into the system.
I: And so actually it sounds like you're saying NHS England's strategy has been one of survival and preservation of a coherent NHS system? Is that…
R: Yeah I would say it's been both of those things and an attempt to map the future. So you know, the five-year forward view, it's been an attempt to pour some coherence out of, I think, what many perceived as potentially chaotic situation and to retain the focus on its purpose.
I: Yeah. So let's talk a bit about leadership. What are your values as a leader and those values that drove you into the roles that you've held?
R: I have a number of principles that have driven my professional choices. The first is Julian Tudor Hart, God rest his soul, he expressed it beautifully actually in his inverse care law, for those people in need of health and social care the most tend to get it the least. You can apply that to virtually everything. So pretty much.
I: When you say everything, everything everything?
R: Virtually everything, yeah. Virtually everything. So those people in need of justice the most tend to get it the least, those people in need of money the most tend to get it the least, etc, etc. It's certainly the case in health and social care and my concern is that it will become the case. So the NHS was started by poor people in Tredegar for poor people. The middle classes and the wealthy have benefitted as a direct result of that over the 70 years of the NHS. What I don’t want to see is a situation where the NHS becomes a service which was established by the poor for the poor that benefits the middle classes and the rich.
I: And do you think that's where it's getting to?
R: At the expense of the poor. Well it's a risk. You only have to look at the gap between active life expectancy in middle class areas and middle class people, it's 70. In poor areas with poor people, it's 50. That’s a 20-year difference. Unacceptable. It should make people angry because that was not the purpose for which the NHS was formed. So that’s one of the things that drives my professional choices. The other is that I just think leadership is about what happens when you're not in the room, so it's not about being present. It's about influencing others to lead basically. I do believe in the leader as servant. I don’t believe that it's about me. It's about my ability to, or the ability of any leader to take people from wherever they are to where they haven't been yet.
I: That’s really interesting but you define where they need to go?
R: Well sometimes, but actually I'm always suspicious of people, particularly the western form of leadership, usually white and usually male in which the leader stands on the hill and says over there, you know, but actually lots of those, that formulation of direction, is obtained as a result or should be obtained as a result of listening to lots of people and observing where we need to go. So the consolidation of a strategy or a plan to go there is usually as a result acknowledged or not and should be as a result of listening and knowing and sensing and taking in data and information and consolidating that into a positional statement about the future direction in the hope that you will get followship, right, and that’s the complicated bit. But I am wary of the notion of people waking up with a vision. I mean I'm not saying that that never happens but generally visions are formed as a result of information data taken in through the unconscious and becoming… All that sort of stuff. I think it's a much more interactive process than we give it credit for and certainly in the west we have a particular form of lead guitar leadership which can sometimes make a very pleasant noise, but in other occasions is simply ear splitting.
I: And so in terms of interactive leadership, I assume you mean both the staff that work with you and for you and also your clients who you serve?
R: My staff work with me, you know, because honestly most of them don’t have to work with me, they can make choices and they do. I suppose what I'm referring to is this notion of system leadership which has become very fashionable and in the NHS these things become, NHS and social care, I've noticed that these terms become adapted to what people want them to be rather than what they actually are. But system leadership involves a leader learning on behalf of a system, rather than being the omphalos of all learning.
I: That’s really interesting. I was reading something that you'd written I think a while ago about the system leadership for, I think it was for the King's Fund actually. You'd been talking to Nick Timmins?
R: Oh yes, yes.
I: I think we did a publication a few years ago.
R: Oh yes you did, yeah.
I: They were interviewing you because actually in your role at Turning Point you kind of are already doing system leadership, whereas in the NHS, as you pointed out, system leadership has kind of become very fashionable as a term. But actually what you do and the services that you provide to your client group, they span so many different service boundaries and sectors. What is system leadership to you and what do you need to do to get it right?
R: Well the fact of the matter is that the implications of being a system leader are quite profound for the leader. So you are in a situation, I don’t think I am a system leader, I'm trying to be and I think it involves being humble enough to know what you don’t know. I mean there's lots I don’t know.
I: Because you can't possibly be everywhere?
R: Well you can't and you can’t know everything and that’s a problem because we live in a world where leaders, particularly of public organisations, are expected to know everything and so they basically lie. They pretend to know everything and it's impossible to know everything. That’s impossible. I'm happy to admit that I don’t know everything, so I need to learn and if I'm not learning then no one else is. So the first thing is you need to learn. You need to be humble enough and learn. The second thing is that my role at Turning Point, whether Turning Point is large enough to be a system, I think it is because it's distributed across geographies and across services as we said. So that implies that the leadership needs to be systemic and needs to understand the system, but more to the point, I exist at the boundary between Turning Point and other organisations in local government, in the NHS, in national government and system leadership is about being the boundaries. It's not about protecting boundaries of which there is a lot of protecting boundaries in both the health and social care system, usually with finance being the excuse - my budget, your budget, etc. System leadership involves risking, opening boundaries, more porous boundaries in the interests of the individuals that pay for all of this. So you know, at the end of the day the system leaders need to understand that they need to work at the boundaries which is a really difficult place to be because you have to protect… Protect is the wrong term, but you have to be cognisant of the purpose of your organisation in relation to others. So there's terms like betrayal have become quite common in the system leadership world, but actually it's about knowing what the end point of all this is about and being… It's about building relationships and I guess that's the third point actually. It's about knowing that relationships tend to get more important than objectives.
I: Absolutely, and so where do you think the NHS is on that journey I guess in terms of particularly provider, hospital provider, chief execs and the challenges they are facing in terms of having to do this shift to system leadership? Do you think they're making progress?
R: They're on a journey. Some are, some aren't. They're on a journey. My experience is that it's not just about hospitals. It's not just about hospitals or the acutes, it's about the interface with local government, it's about the interface with communities, it's about interface with organisations like mine. Let me give you an example precisely of what I mean. Turning Point operates in locations where the people that we work with are the illest people walking. Any iller and you are in hospital. So an individual comes to our substances misuse service coughing their lungs out and I employ doctors, GPs, specialist GPs and GPs and nurses and consultant psychiatrists. This individual comes into our service and I assume that we're able to prescribe antibiotics and look after their cough and look after them in one place. We can't, so we have to refer that person to a primary care service to which they're unlikely to go even if they're registered which means that they're going to end up in a hospital suffering, possibly dying at great expense to the tax payer when in fact we could have prevented all that in one place.
I: With better outcomes.
R: With better outcomes for the person, better outcomes for the health system, better outcomes for the country. Now that happens thousands and thousands of times in a place we are the creation of the wrong kind of demand in A&E. The lack of system leadership means that CCGs rarely contract, in fact I haven't got one contract with a CCG where they've sat down with me and said look, how do we stop these people coming into A&E by providing them with holistic health response where they are Victor? Just ask that question. Now that’s a system leadership for you and how do we learn how to do that? What would that tell us that would help the system both locally and nationally about how you work with people at the sharp end of the inverse care law? Now that’s a system, that’s a practical example of how system leadership should work and it's also an example about how it rarely does.
I: And given how you do work with people on the sharp end who are coming to you with those multiple problems that need a whole system response, how frustrating is it that the system isn’t yet able to deal with those people, particularly as the consequences for people like that are going to be incredibly bad?
R: Well it's very frustrating. I mean not only is it very frustrating, but it's also very expensive. So I’ll refer you to work done by York University Centre for Health Economics on this very subject. I've shared the paper with Simon Stevens and others where they've worked out that the cost to the NHS of not providing services that would prevent their need to be in hospital in communities, the cost just in hospital admissions alone, like A&E, not the rest of it just A&E is £4.8 billion. So you're looking at 25% nearly of the 20-odd billion we've got to save resulting from a lack of system leadership and a lack of focus on what I consider to be low hanging fruit. So a lot of the cost in the health and social care system is driven by negative value transfer, i.e. people going to several different places for the same thing when in fact, as much as possible, it needs to be dealt with in one place in front of one or two people and that is hugely frustrating and massively expensive and frankly immoral.
I: And with serious consequences for those people who like you say, aren't going to then go on and take themselves to the GP for the prescription that they need?
R: No, but even if they do, the notion of negative value transfer applies to primary care as it does to any other service.
I: Yeah okay. Obviously you have many roles, many hats. You're a full-time senior leader. You're also a dad is that right?
R: I'm busy. Yeah I am a father, yeah, a very proud one.
I: How do you manage those different roles and also how do you relax? How do you look after yourself?
R: I chill. Well to be honest when people ask me the question how do I relax, I'm often tempted to answer by saying I don’t really. I have very understanding people and I do look after myself. These roles are coherent in my mind, they're not different things. They're all focused as we've discussed. So I have understanding friends, an understanding wife and really cool kids. That’s the only way it works, it's not about what I do, it's about what they understand and I do spend time with them and they're alright, they're cool. They understand why I do it, yeah, what I'm about.
I: But it sounds like yeah, your whole life approach brings all of those things in?
R: Well yeah. I'm very lucky. I live in a first world country. I'm paid well. What have I got to complain about? As for relaxation, well I like to read. I like to read, I like to spend time with friends, collect the odd graphic novel.
I: And is it true you play the saxophone?
R: Really badly. Everyone in life should do something that’s worth doing and if it's worth doing, it's worth doing badly.
I: I totally agreeing with doing some things in your life very badly. I've perfected that actually on several fronts.
R: Do you play an instrument?
I: I do play an instrument, yeah, I play the piano and I sing. I sing very badly, yeah, it's great.
R: Exactly, you know and you should.
I: And I enjoy doing that out of work, it's good, yeah.
R: That’s exactly the point.
I: So we've talked a bit about different elements of health policy and the impact on service users. I wanted to ask given you've been in NHS England since 2014 and you've seen the impact of various big pieces of policy, tell me about what you think the impact of the five-year forward view has been on your, on the client group that you work with at Turning Point?
R: Well I think the five-year forward view has yet to spread. It's intentions were clear. Its impact is yet to be felt I think everywhere. The NHS is a universal service, so the five-year forward view with the universal plan, it has to have a universal impact. It's yet to have that impact. The example that I told you is an example that exists, so we've got some way to go I think. I mean if I was to say what I'm leaving NHS England with, it's a sense that they understand inequality, not inequity actually which we need to understand more about, the two are different and the impacts of inequality, both financially and morally and you know, in health and social care outcomes. That needs to be reflected in the next plan. I think the other thing that I'd like to think has happened in the lifetime of the five-year plan is that we've started to understand the impact of diversity. Now you would expect a six foot black guy to talk about diversity, but actually it's not my problem. I'm used to living with it, both negative and positive, but it is a problem for the NHS and for the people it serves and for the leadership of the NHS for these reasons. What we know about organisations is that diversity of thought and cognitive diversity is one of the predicators of success. In the terms of the NHS that should be obvious but we also know that it impacts directly on the quality of patient care, both in the community and in hospitals. So I would hope that the five-year forward view started the conversation about that and certainly Simon Stevens has indicated his leadership of that issue. So in short, I would say in the five-year forward view started a conversation. It's indicated some changes, certainly through the vanguards of which there are examples in pockets around the country, certainly around elderly care and primary care. But it's yet to become normative, it's yet to become the shift, the thing and some of those notions need to be taken forward into the next five-year view and in the next 10-year view because otherwise what we have is episodic change which is not very useful and quite expensive.
I: So yeah, it needs to be part of a broader strategy?
I: And you mentioned the long term plan, having a strategy that tries to sort out inequalities and also diversity, what else does the long term plan need to include?
R: Well it needs to reverse the inverse care law. I mean there's two views which I've come to understand. There's my view which is that you need to focus on those people at the sharp end. The test of any policy, of any strategy, of any service design must be does it impact positively on those that are furthest away from health and social care? If it doesn’t, it's the wrong policy. So the intention should be to do that. If the process doesn’t match the intention, you're in the wrong place, right. There's another view which just says the rising tide lifts all ships. So yes, by all means pay attention to the sharp end of the inverse care law but actually focus on the bigger picture, on hitting the targets. So the problem I have with that is that the evidence is that it doesn’t quite work. So if you look at cancer, for instance, we're doing really well. I mean it's brilliant in terms of the cancer programme. However I'm told reliably that if you live in any one of the poorest bits of the UK, well in England, you are still more likely to have your cancer diagnosed in A&E. So there's a question for me about the impact. If you are black, from a minority ethnic group, not only will your experience of cancer care be worse, but your outcomes will be worse and that is the case across all the disease priorities that we've set. So that begs a question about the design of those programmes, the intention, the process and the outcomes.
I: And that potentially also comes back to the leadership points as well?
R: The cost.
I: The diversity of leadership.
R: Yes it does, but you know, I think the challenges, I sense there are two opposing views. I take one view, the system I suspect takes another.
I: And just back to, because we talked about diversity in NHS leadership and obviously the impact that it has on the service and on patients and on outcomes, where do you think we're headed on that? I know that Simon Stevens takes it seriously, does the workforce race equality standard headed by Yvonne Coghill. Do you think we're going in the right direction?
R: Well I mean I worked on the creation of the workforce race equality standard and development of the RES and Yvonne Coghill and I have to tell you that it wasn't easy. It was one of the hardest things I've done in 30 years because I think it met with a lot of resistance for some good reasons and for a lot of not so good reasons. But it's here now and we need to put our weight behind it and number 10 have taken interest in it, NHS England has taken an interest in it. So the signs are good, however, I am concerned about the RES remaining consistent and being supported both in terms of resource and leadership as we go through the next set of changes. NHS E merging with NHS I. The implications of the five-year forward view, five-year plan and the 10-year plan. These things are not resolved in a couple of years. They require consistent, long term leadership, so my concern is that the RES gets that leadership. It's already starting to make change and it's already started to work with people in systems, but we need to maintain that leadership.
I: So on the race equality standard, do you think that the system gets it now though in terms of protecting, hoping that it survives through any changes?
R: I don’t know is the short answer. I honestly don’t know. I look around me and I really worry about whether the system has got it. The research that I've read about how change happens around diversity, some aspects of it are quite depressing because some of it is about power and there are people in the system who really feel strongly that they're not going to give up power. I don't see it like that but it's about power and you have to ask the question of a system which is predominantly led by men, white men of a certain age over a period of 70 years as to what that's about. I asked the question why we've never had a black chief nurse ever in 70 years of the NHS. My mum was a nurse for 40 years. What is going on? So anybody who thinks that this is an easy shift is fooling themselves and there are people who hang on to power regardless. They feel it is theirs by right and in large systems like the NHS, I'm afraid that is also true. So regardless of the evidence and regardless of that evidence being absolutely clear about the benefits to patients, the system money, leadership. There are people who feel that it's a political question and for them, that political question is about their right to be a holder of power. That’s really challenging.
I: And challenging for individuals who have that power isn't it?
R: Well it's certainly challenging for individuals who have that power and I have some sympathy for them actually. But I've got more sympathy for the people who need the NHS and need the NHS to work.
I: Absolutely. So you've started out in housing associations?
R: Well local government housing actually.
I: Local government. And now you work across many different services including health. I guess I'm interested in the impact of the wider determinants on health and your experience of seeing that first hand?
R: I am staggered actually. I mean I find it amazing that we know so much about the determinants of health. We know so much and yet I don’t know whether it's a political blind spot or a policy blind spot or a culture blind spot. We've yet to integrate that in our thinking. We haven't yet done enough and there is an interface between public policy. So if you take alcohol for instance, we know that pricing affects consumption. We know that and yet we've not done anything about it. We know that gambling is one of the key determinants around mental health. We know that alcohol, drugs, we know that poverty, we know that the welfare benefits system actually generates disease mentally and physically. We know all this. We know the education system contributes to, or can mitigate towards or against health and emotional well being. We know all this and yet… So I think we're a long way from having a situation where every public service needs to be measured on its contribution to the well being of its users.
I: Yeah, and when you say well being, you mean in its kind of wider sense?
R: In the wider sense. And the NHS has been carrying a heavy load for 70 years and I don’t think it can carry that load much longer and the execution mover is what we know about the determinants of health. It's not about hospitals, it really isn't. The last thing it's about is hospitals. It's about what happens in the community. So we need a set of measures and this is for you policy people, you know, smarter people than me, that actually force public services to show what their contribution is to the health and well being of the people that use them as a prerequisite for our investment in them. If they're not doing that and they can't show what their positive measure is in a locality, in a system, why are we paying for it?
I: So well being in every policy should be built in?
R: Yeah. If you're going to have an education system or a school or whatever, part of its measure should be are kids leaving a school and going straight into the mental health system? Is the social care system or the welfare system generating disease locally/nationally? Those are measures that every leader of a public health system or a public service should be held accountable for and if it's in the negative then the question should be asked, why are we paying for you? It's not just about money, it's about how some of these systems are run, designed. It's about the leadership and it's about the money, but actually those things need to be, people should be held accountable for them. Why would we do it any other way?
I: Especially when we're potentially pouring money and effort into the wrong bits?
R: Well you're pouring money into a leaky bucket and it's wasting my money, it's wasting your money. So there's something about the NHS being part of a discussion about how we design measures for services that assist us in spending less basically on health. It's about well being, it's about healthy, it's about staying healthy for as long as possible. It's not about having a service which is pushed to being almost a universal urgent care system.
I: What’s your biggest fear and greatest hope for the long term plan, the NHS long term plan that's due to be published?
R: Well I'll say the five-year forward view was successful in getting some money. My view is that that argument was too hard. It's obvious, right. Health is actually an economic benefit, the NHS is a huge economic benefit. Say well done Simon, we got the money. My fear is that it becomes all about money and it all becomes about cuts and we lose the sense of purpose. The money is a symptom of behaviour, so my fear is that it becomes an argument about slicing and dicing rather than intention, purpose, vision, outcomes. My hope is that we develop in this country a vision for a holistic health and social care system that’s truly integrated and that is focused on reversing the inverse care law because what we know historically and what is evidence based is that if you do that, everybody benefits
I: And you'll have seen some drafts presumably because it must be almost written by now?
R: My lips are sealed I don’t know what you're talking about.
I: Do you know if it's on a trajectory to delivering your hopes?
R: If I told you I'd have to kill you I'm afraid. I couldn’t possibly. You might possibly think that, I could not comment
I: Well then I think Victor you've brought the podcast to a beautiful ending. Thank you so much for being here today.
R: Thank you, thank you very much.
I: Well that’s it from us. Thanks for listening. Please subscribe, rate and review us on iTunes and if you have feedback or ideas for topics you'd like to hear covered in future episodes then please get in touch either on Twitter @theKingsFund or my account @helenamacarena or you can leave feedback on our website which is www.kingsfund.org.uk . I hope you can join us next time, thank you for listening