Is the NHS really full of ‘overpaid pen-pushers’? Jo Vigor talks to Dr Seema Srivastava, Deputy Medical Director at University Hospitals Bristol and Weston NHS Foundation Trust, Emma Challans-Rasool, Founder and Chair of the Proud2bOps operational network and Director of Organisational Development, Culture and Talent at Nottingham and Nottinghamshire Integrated Care System and Rachel Burnham, Director of Performance and Information at Guy's and St Thomas's NHS Foundation Trust, about the critical role of NHS managers and what it means to bring your humanity to work.
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JV: Jo Vigor
ECR: Emma Challans-Rasool
SS: Dr Seema Srivastava
RB: Rachel Burnham
JV: NHS managers are gaslighting the British public, cure the NHS with fewer managers. There are just some examples of headlines that dominate media reports and statements from politicians about management in the NHS. They are part of a popular myth that the NHS has too many managers and without them, we’d somehow solve the problems facing the health service. Unsurprisingly, it’s not that simple, evidence suggests that the NHS is actually under-managed. So, clearly there is a difference between the myth and the reality.
Welcome to The Kings Fund podcast, where we explore the big issues and ideas in health and care. I’m Jo Vigor, Assistant Director in Leadership and Organisational Development at the Kings Fund and in this episode, I’m going to be taking a closer look at NHS managers, who they are, what they do and why they matter. To help me do this, I’m joined by three very special guests, Rachel Burnham, Director of Performance and Information at Guys and St. Thomas’s NHS Foundation Trust, Emma Challans-Rasool, Founder and Chair of the Proud to be Ops Operational Network and Director of Organisational Development, Culture and Talent at Nottingham & Nottinghamshire Integrated Care System and Seema Srivastava, Deputy Medical Director at University Hospitals Bristol and Western NHS Foundation Trust. Rachel, Emma, Seema, welcome to The Kings Fund podcast.
RB: Thank you.
SS: Thank you.
ECR: Thank you, Jo.
JV: Now before we dive into our conversation, I think it’s worth us spending a moment, thinking about who we mean when we say NHS managers. In this episode, we’re thinking about NHS management, as anybody who has management responsibility, whether they’re in a clinical setting or part of corporate functions. Wherever they are, they’re essential to the organisational performance and development across the system. So, let’s just have a think about bringing this role of managers to life, Emma, I just wanted to start off with you, a lot of people, within the NHS and outside, don’t really have a clear idea about what NHS managers do. I know the role is really varied but could you give our listeners a thirty second overview of what your role or a management role entails in your words?
ECR: Thank you Jo, yes in thirty seconds, wow, when we class, particularly a management role and I can say this because I’ve been an operational manager in healthcare services. It’s often classed as a jack of all trades and really because what that means is that we can, one day be managing estates, we can one day be managing IT and information, we can one day be supporting clinical change in pathways and working with clinical teams and equally we can be out there in the community. So, the jack of all trades, often sums up a manager’s role really well.
JV: Seema and then Rachel, what’s your views on that, jack of a trades?
SS: I think Emma’s description really brings it to life and that’s my experience of working as a medical leader, really closely with operational managers in the work that I do and the ability to wear different hats is really what I experience with that. I guess for me, NHS managers are enabling us to keep the Health Service running on a daily basis to enable us to provide that high quality care that we all want, that managers are no different to clinicians, we all want to see our patients experience really good outcomes and I see that, day-to-day, across all the settings I work in.
RB: Yes, completely agree, Emma’s specific jack of all trades description is a brilliant one, I think that’s more around what I would call here, general managers and the roles beneath them in clinical operational settings. There is also specialist roles, specialists in finance, in HR and whatever that might be, typically more corporate type functions and then Emma’s role, which absolutely resonates with me, having just come from a director of ops role, is that general, do a bit of everything. I think of that role as an enabler, what do you have to unblock today, to make tomorrow better, for your clinical staff and your patients and that can be, often estates, as Emma said, but it can be a whole mix of many things.
JV: I think it goes without saying that managers don’t magically appear fully formed, they’ve all been on a journey that has brought them to where they are today and I’m just going to follow up on your point there, Rachel, and I understand you’ve just moved roles recently, what was it that inspired you to become a manager within the health and care system?
RB: I think definitely that feeling of adding value and being proud of what you do and you can do that in all sorts of jobs, I’m not saying that’s specific to the NHS but the privilege of the work that admin and operational managers and teams do in then NHS is unbelievable to me and I try to reinforce that to teams that I work with here. Even just passing by a group of people who are doing admissions and calling patients and booking them in for that operation and doing that well, is such a privilege to call someone at a huge moment in their life and invite them to come in for their surgery that they’ve waited for, for a year and a half. So, for me it’s that draw of privilege of everyone turning up, for instance, at the hospital that I work at, that’s a really huge moment in their life but it’s every day for us and I think that’s what gives it the buzz, I think.
JV: Coming to you, Seema, I can see you enthusiastically nodding there, so what would you add to that?
SS: I guess for me, as a doctor, I’m a consultant in medicine for older people, I could see in my role as a consultant, how I was making a difference on an individual patient basis and using my skills and knowledge to improve the experience and outcomes of the patients I was seeing and to a certain extent, being able to do that on a wider scale, with improvements in service. But what really engaged me in wanting to move into a medical management role was that real desire, I think as Rachel said, that enabling ability to really support people who all want to work collaboratively together. To make services better, more resilient, provide that excellent quality care and really feeling that I had a part to play in that, not only within the boundaries, as it were, of a hospital Trust, which is where I predominantly work in but in that space between organisations, with partners and being able to, not only come up with the good ideas but also actually think about how they truly will work and how they can be delivered day after day.
I think that’s the really vital bit that as a clinician, sometimes is missing and we need support, so that’s something that I’ve been on a learning journey with and really enjoy working with operational leaders and seeing what the impact we can make for people is. Really another thing I wanted to add is how managers have such a key role to play in staff wellbeing and that’s what I’m seeing, more and more, particularly after what we’ve been through, through COVID.
JV: We’ve seen some really damaging narratives in politics and in the media and often the NHS is portrayed as a bloated system or organisation, full of overpaid bureaucrats or pen-pushers but in reality, that’s far from the truth. In a system as large and as complex as the NHS, managers play a critical role in the delivery of safe and effective patient care and leading improvements around that. When you see those headlines as managers, in the newspapers or on Twitter or wherever, what impact does that have on you and your staff?
RB: It’s not so much the headlines because I think they’ve just become a bit of a trope now and I think there are headlines for everyone. They’re damaging, don’t get me wrong, it’s the interactions you have with members of the public, so just to tell a short story, Jo, if I can, during the COVID pandemic, when you were first allowed to go back to the hairdressers and obviously that was a really exciting moment for everyone, wasn’t it, I booked in, just across the river at a hairdressers I shall not name, from the hospital and was like, right, I’m going back to get my hair done and having a conversation with the hairdresser, as you do and they said, what do you do.
It’s that moment of absolute pride, it’s when everyone is doing the Thursday night claps about the NHS, I said I work in the NHS, they said, wow it’s amazing, we’re doing an NHS discount on your haircuts, what do you do and I said, I’m a manager and they said, oh someone has got to be, I suppose. It completely deflated my bubble of that pride that I was feeling, being part of the team here. We had a phenomenal COVID response, some of the work that I was doing with my teams was the most intense, emotional, difficult, stressful, longest days I’ve ever done in my life, it was the same for everyone I know.
To hear someone say, without even thinking that that could be offensive, oh I guess someone has got to be a manager, just made me really realise, that was at a moment of national pride. So, I think that’s deflated overall now, how little value there can be placed on managers and it felt really devastating. I felt embarrassed, there is so much work that I would like to see the government supporting us in and more senior leaders in the NHS speaking up about, like Emma you do, through Proud to be Ops, to be proud of the work that we do and to spread that message because it is damaging.
JV: Emma, I mean just thinking about some of your work on proud to be ops, what would you add to that?
ECR: What would I add to it? I think really from engaging with over a thousand operational managers and leaders across the country, it’s demotivating, when a person has put in fifteen, sixteen, seventeen hours, whether you’re clinical or non-clinical, to hear that you’re not respected, to hear that they think, why are you doing what you’re doing and to actually have that anxiety to say what you do. I’ve seen people deflated, feeling undervalued, I’ve seen people walk away from management careers and these are great managers as well. No-one is naïve, not every manager has got the leadership skills and capabilities, every person needs developing but we all should expect respect and we should all expect to be valued and recognised, no matter what profession we associate ourselves with.
I think that demotivation, reduced morale and even a bit of, well why should be bother, why should we keep going above and beyond when actually, we’re not valued, they’re not bothered whether I turn up tomorrow or not according to perceptions and projections. One thing I would add to that as well, that really significantly affects a person’s mental health, so from a mental health perspective, turning up each day and bringing your whole self to work and being able to do the job the best that you can do, value and recognition is a real key element of that.
JV: I was just thinking there as well, we’ve touched on the fact that there is a massive retention challenge in the NHS, in fact across the whole of health and social care, so in your experience, what impact is some of this messaging having on the pipeline of managers coming through. So, you’ve said there that through your Proud to be Ops work, you’ve reached out to over a thousand people, what’s your sense Emma, about the impact on those early in their management careers, are we going to see a lack of people coming through?
ECR: I think that’s a great, great question to be honest, Jo, because actually it is about aspiring leaders and talent and actually are we retaining and how are we ensuring that our people, who had aspirations are still interested because the longer that these perceptions and portrays of managers goes on, the greater the challenge that we are going to have. So, how can our aspiring managers actually still keep that interest, that energy, that desire, that passion for, I want to work in the NHS because, that fire in the belly is a really important element. So, we do look at ways that we can support existing operational managers but aspiring operational managers.
JV: That brings me onto my next question really, I wanted to start with you, Seema, on this but if you had some of the detractors in the room today, if they were on this podcast and you wanted to say something to them about the value of management, what would you say?
SS: What would I say if these people were in the room, I would say that I reject their ideas that they have about NHS management and the evidence is clear. We have got so much evidence to show that management in healthcare has a huge impact on performance and by performance, I don’t mean targets, I mean the quality of care that patients experience, the clinical outcomes and there are so many great case examples, both in the UK and globally that I would point to the evidence first of all. I guess whilst I was listening to what Emma said, Proud to be Ops is such a valuable network for people in management to have that safe space to share similar things that they’re experiencing and also that peer support, that mentorship that Emma spoke about.
But it also made me think about what we can do as clinical leaders and as clinicians to also do that cheerleading and there is something also about the fact that, yes people do feel that impact from what people say outside of work, whether it’s in public or in the media, but what really matters is your social bonds within the place that you work in and if the people around you, really value what you do and understand the impact it makes, that will go a long way, I think, to keeping people in their jobs because I am worried about what’s going to happen in that pipeline, if we know and I do believe this, that NHS managers contribute so significantly to patient outcomes. If we’re not getting new people coming in, that’s as much as a worry to me, as it is about doctors and nurses and pharmacists and all the other great people who work in the NHS.
JV: I just then wanted to come onto to the experiences over the last couple of years, you’ve all touched on the fact about how hard it is. We know through talking to colleagues, loved ones, friends, who work in the health and care system, what an awful few years it’s been. But I just wanted to come to this idea about bringing clinicians and people in management roles together, what does that actually feel like and look like when you’re collaborating with people who come through a clinical background route and those that have come through a general management background route. So, Rachel, what does it look like when a relationship is working well between managers from these different skills and experience?
RB: So, I think I’m really lucky that at Guys and St. Thomas’s, we’re clinically led. So, really coming back to the first point, I think I made, Jo, about being an enabler, that’s really how it feels, no matter how senior a manager you are, you’re enabling what the clinical teams and I mean clinical in its broadest sense, want to achieve for the patients that they’re responsible for patients that they’re responsible for. What that means, really practically speaking, from my position and from previous management roles is whatever I’m working on, I want to be guided by that clinical leadership.
So, even if it’s, right how are we going to tackle this waiting list challenge, who are the patient cohorts, what do you think about the urgency, how are we going to break this down, let me go off now and enable that for you. So, it’s genuinely a partnership and working out who’s got which strengths to either galvanise the teams about, this is an issue we want to fix this week, give me some insight into what’s actually going on in operating theatre X or frustration area Y. Then we can come back together and think, right how are we going to fix it. So, for me, it’s just partnership working at its best and I’m lucky enough that that’s been my experience. We would come together and then we would divide up the day and say, right you head off and discuss that clinical prioritisation but driven by the clinical vision and leadership, that for me is what makes it so brilliant and a privilege to come to work.
JV: And Seema, you’re a doctor, you’ve come up through that clinical track, what have you got to add there, to some of Rachel’s comments?
SS: I think trust is the thing that comes up for me, a big word when it came to working well with my management colleagues, is that we trusted each other. Trust in terms of that clinical direction that Rachel speaks of and listening to my clinical voice but also trust that I wasn’t going to, I say, go rouge and just do things that were just not going to work on a day-to-day basis and trusting my operational colleagues who had such vast knowledge of other emergency response projects that they had run and being able to work with each other and not feel that there was any hierarchy either. That real flat culture of really working together and there were moments of crying in store cupboards, as well as joyful moments when things worked really well. I think that ability to be vulnerable and share the highs and the lows is really what I remember as working really well in that clinically driven but collaborative space with managers and clinicians working together.
JV: I just wanted to move onto thinking about, through that time, how did you really look after yourselves and your teams, you’ve mentioned wellbeing through this podcast, a couple of times through this conversation. So, Emma, coming to you, how do you manage to look after your own wellbeing, even now, I mean it’s not like it’s all disappeared ,you’re still all under a huge amount of pressure at the moment, in the system?
ECR: I think just asking that question is often one of the hardest questions, sometimes for people to ask someone, particularly if they’re the manager because they don’t often get asked because they don’t often think that the manager needs it. So, what do I do personally, I regularly take stock and reflect at the end of each week, if I’m honest, where are my energy levels, what do I think I’ve done well this week, what do I think I could have done differently. So, I think there is an element of reflecting, being kind to self but also challenging self at the same time. But what are the things that actually recharge my batteries and re-energise me and give me that.
So, I’ve gone through a process of trying to listen to myself and understand what they are and then deliberately put them in place and get that better balance. I have found that being beneficial, I’ve also found it has given me time to actually help and support others more. Sometimes having a very quick conversation where the receiving person doesn’t really get that much out of it and then all that happens is, sometimes I’ve gone home and thought, I could have done better because I’ve not thought about it enough and really listened, really actively listened. The final thing I would say is your network, the people who you get energy from, the people who you can have a safe conversation with, use each other and optimise your own network.
JV: Definitely and I think I do a lot of that as well and I just want to say, for listeners who might be interested, The Kings Fund also has a free online course which is all about health and wellbeing and how to better support yourself and those around you. So, we’ve deliberately set that up, right across the health and care system for people who might not be able to access some of that support. So, we’ll put the link in the show notes.
I just wanted to move us onto the last stage now around the concept of bringing your humanity to work. Bringing our humanity in the workplace can mean different things to different people but I think what I’m talking about, is a greater focus on developing relationships in teams and the practice of collaborative, inclusive and compassionate leadership. The question is really about, how can we encourage others to bring their full selves to work at a time of significant challenge because I think we all have some really good intentions as managers and leaders. But often we find that things get in the way, but Seema, how do you bring your humanity to work in your role?
SS: Absolutely as you said that collaborative, inclusive, empathetic humanistic approach to management is something that is, I think before COVID, it wasn’t something necessarily we talked about so specifically. It came up really front and centre in those first few months of the pandemic and I remember feeling very strongly, how can I support people through this. I didn’t think about myself first and I think that resonates a bit of what Emma spoke about and I know much more now that looking after my own needs is really important to enable myself to support others.
I’m really clear about that with my team, I don’t shy away from it by saying that I am going to take care of what I need, to make sure that I get to okay, so that they feel that they can do the same and I encourage that and by getting to okay, that could mean, I need to go outside for a ten minute walk and just clear my head. I actually need to eat, we often, in the NHS, will forget to eat or forget to have a wee, all those sorts of things. I need to just phone a friend, just have some connection with somebody because something full-on is going on.
But being able to share these things, brings our human side to work and I think it gives the space for people who are in the teams that we lead or the people that we’re collaborating with to feel that they can do the same. I try very hard to really listen and tune in, feel my feet firmly on the floor and say, I am here, when I’m with teams. So, those are the sorts of things that I feel are really important and really then being able to pick up when someone is not okay and being able to have … I really love Prof Neil Greenburg’s psychologically savvy conversations and just getting in there quickly to know how you can help someone and not feeling that you can let that slide and then thinking about what do you need right now and being able to facilitate that.
JV: We’ve talked about some of the things that we want to be able to do and I’m going to move onto Rachel, just to say, what gets in the way of people and managers being able to bring their humanity to work, in your experience, what would you say to that?
RB: I think two really practical things from me in reflection to those deep insights from Seema and Emma, so I won’t try and match them. One is the way we’re working now, so on Teams, double screening constantly and that stops you listening and it stops you being able to achieve that connection, as Emma and Seema have just said, is so important to understand what’s going on for colleagues or if they’re having a bad day, you’ve got that physical barrier and then you’ve got the multitasking barrier. For me, if I know I need to have an important conversation with someone, I will go for a walking meeting or I’ll make sure that I’m seeing them face-to-face and my laptop is closed because I need to listen and I know that if not, I’m getting emails coming up or I’m getting things coming in or I’m double-screening.
So, there is just something about really practically making yourself available and then the second point about your barriers, Jo, is that it’s really easy, we’re all sitting here in incredibly senior, privileged positions, relative to the wider workforce, it’s easy to think that the NHS hierarchy is not as severe as it is. It’s easy to think oh that doesn’t apply to me because I’m an accessible leader and it’s just not true and you have to remove barriers constantly to you being accessible to your teams and understanding what’s going on. Be that making sure that people can book time with you directly, rather than having to go through your EA or be it making sure that you’re available in different services that you run on different mornings and you’re just having a cuppa with someone or be it that you’re taking your team out for drinks and you’re telling a funny story about yourself first to open the atmosphere.
You forget that your title has got director in it or your seven layers of the admin hierarchy from somebody else and you think, oh I’m normal, I’m approachable, it will be fine and you are not normal and approachable. So, I think that’s the barrier, don’t kid yourself, make sure that you’re proactively trying to understand what’s going on and stay connected and back to the floor type days, even if you never started on the clinical floor, that same thing, understand what’s going on for people trying to run services in your area.
JV: It so resonates with me, all of that, it so resonates with me, so thank you for that. The last thing I’m going to ask each of you is, for a little bit of hope. So, we’ve heard about what’s going on, now people are turning up every day, day in, day out, 24/7, delivering care right across the health and care system. So, what are your hopes for the future for managers in the NHS, what would be the one line or one thing you want to share with our listeners as we sign off today. So, I’m going to go to Emma and then Seema and then Rachel.
ECR: One line that I would want managers to hear, managers are an important part, they’re an important cog in the system, without that cog, the rest wouldn’t happen, you would simply seize up. At the moment, I’m envisioning, at the back of a watch and it’s got several cogs that turn round and if one of them seizes, the watch stops. As a manager, you are an important cog, don’t ever forget that and every person brings a level of expertise. So, join us and keep time ticking and keep helping us deliver great patient care.
SS: I think if I was talking to somebody who was wanting to move into NHS management, whether they were new to the NHS or already in the NHS, it would be really about that variety that Emma spoke about at the beginning. This is a role where there are so many experiences and people that you’re going to meet and working with some fantastic teams who really do value what you do and I think more and more will see that as we start working, not just within these sorts of big organisations, called hospitals or GP practices or wherever. But as we become this ecosystem of working together through these interfaces, it’s a really exciting time to be in this role and making a real impact on patient care.
JV: Thank you Seema and Rachel?
RB: Mine would be and I think this tagline has already been taken but every little helps. It’s so bleak at the moment, it feels like you can’t fix everything, actually marginal gains and that five minutes that you find to shave off the start of a theatre list or that extra patient that you get your team to book for out-patient clinics, adds up and makes a huge difference and will make improvements. It feels small and it feels like you’re that small cog that Emma described, but it’s absolutely not, you’re hugely influential over your services as a manager. So, go for it, every little helps.
JV: Brilliant, let’s go for it then. That’s all we’ve got time for today and I just want to thank Seema, Rachel and Emma for joining me, I’ve had terrific insights from all your experiences and it’s been a lovely conversation. So, let’s keep that hope going, you do amazingly critical roles and it’s been a real privilege and a real pleasure talking with you, thank you.
ECR: Thank you Jo, great to be with you, Seema and Rachel.
SS: Thank you.
JV: You can find the show notes for this episode and all of our previous episodes at kingsfund.org.uk/kfpodcast. This episode was edited by Bespoken Media, thank you also to our podcast team for this episode, Natalie Cleverley, Charlotte Wickens, Jordan Reid, Simon Newitt, Jen Thorley and Sarah Murphy. Don’t forget to subscribe, share, rate and review this episode wherever you get your podcasts. You can also get in touch with us via Twitter, our account is @thekingsfund and of course, thanks to you for listening, we hope you can join us next time.
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