Leadership in the independent sector

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Our recent report Tackling variations in clinical care illustrates the impressive power of data plus discussion to catalyse improvement in clinical quality and in efficiency. It details the experiences of members of the Getting It Right First Time team who visit acute hospitals and at each hospital facilitate a constructively challenging review across a clinical specialty, using as much data as possible. The programme has already had a big impact, but it is very much an NHS-based programme and begs the question, how would you do that in an independent hospital?

Independent acute hospitals generally do not employ their consultants. If you are a self-pay patient, you will receive two bills: one from the hospital, one from the consultant. The consultant may work in more than one independent hospital and, in addition, an NHS trust. Bringing together a full set of data at consultant level for measures like volumes of surgical procedures or complication rates is difficult, although – since doctors started putting together portfolios for revalidation – not impossible. What is more challenging is who has the authority to cause a review of that data, initiate a quality improvement discussion based on the results and ensure that this process leads to changes for the better.

The archetypal hierarchy found in NHS trusts, with a leadership ‘triumvirate’ of senior manager, nurse and doctor, does not work in the same way in the independent sector. The self-employed consultants are brought together through a medical advisory committee which oversees clinical effectiveness, clinical governance and eligibility for ‘practising privileges’ (which authorise consultants to work at the hospital). The chair of this committee is almost always a voluntary and unremunerated role, without any accountability relationship with consultants.

This means that the leadership task for the hospital director and the matron are significant. They cannot rely on hierarchy or accountability to organise the essential role that consultants have in quality improvement. They need to create a culture in which reviewing one’s own data and comparing it to others’ – with all the challenge and discomfort that can involve – and giving priority to quality improvement are accepted and expected as part of ‘the way we do things around here’.

That’s easy to say, difficult to do. But there is a growing sense that it is a core part of the leadership role in independent hospitals. Recently, consultant breast surgeon Ian Paterson was prosecuted and sentenced for the unnecessary operations he carried out on a large number of patients, both in the NHS and the independent sector. When this terrible case first came to light, the hospital group where he practised privately commissioned an independent investigation, published it in full on its home page, and published its response in full. In our recollection, that was the first time a corporate independent hospital group in England was so open and transparent about learning from things that had gone wrong. It is an indication of how the culture of the sector has been changing and the increasing expectation of leadership for quality improvement at both corporate and hospital levels. This trend is likely to be further reinforced by proposals that the Care Quality Commission has been consulting on, for developing its assessment of leadership across hospital groups, and comments that Sir Mike Richards, former Chief Inspector of Hospitals, has made about continuing regulatory scrutiny.

Fundamental principles of good leadership – such as values, vision, reflexivity and a focus on results – reach across sectors. Independent hospitals also have specific features and challenges, which mean leading them is not simply the same as leadership in the NHS (and may not always be the same between 'traditional' independent hospitals, innovative new models and services that are fully contracted to the NHS). As well as obvious differences, such as how finance works and, in some cases, the need to make profits, even universal issues such as care quality, safety, culture and patient experience can have a different set of approaches and solutions.

At The King’s Fund, we have begun to recognise these challenges and we want to ensure that we do not fall into the trap of assuming that one size fits all when it comes to developing hospital leaders. Our first programme for clinical leaders in the independent health care sector starts in spring 2018, and covers all aspects of their roles including quality, safety, operational management, culture and strategy.