System leadership viewpoints: David Fish

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Professor Sir David Fish has been Managing Director of UCLPartners since it was established in June 2009. Under David’s leadership, UCLPartners has been designated both an academic health science centre and an academic health science network and is a lead provider of medical and dental education for more than 2,000 trainees.

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

Do you see yourself as a system leader?

Do I think of myself as a system leader? No. I don’t see UCLPartners as a system leader, I don’t see myself as a system leader, absolutely not. I think you put yourself 40-love down before you start if you claim that. It can have very negative connotations. It implies we are trying to get people to do what we want them to do – ‘Oh, it’s bloody UCLPartners telling us what to do’.

What do you understand by the term 'system leadership'?

System leadership comes from Simon Stevens – the direction setting. What we are trying to do is get things to happen at scale and pace, to provide a tool to help delivery. There are plenty of other people providing strategic direction, so I would not describe what we do as leadership but as being catalytic, or enabling… Trying to help good things go quicker.

There is no shortage of good ideas, and some of them are rolled out in individual places. The question is how do you go faster and scale them up? We use the word ‘catalyse’ a lot round here – and in a chemical sense, catalysts can make things go orders of magnitude faster.

So it is about co-ownership, about assembling thought leaders who are attractive enough to their peers to get recruitment going… Finding a cadre of people who want to be more innovative about the integration agenda, and who will make this appealing to a wider audience, so people get excited about the superordinate goal – improving health for their populations – rather than just looking down at their boots.

And we don’t try to claim the credit. It wouldn’t be appropriate anyway because it is others who are delivering this on the ground. It’s not helpful. Do you want to claim the credit or do you want others to do that and stick to the values we are talking about and deliver?

You have to have a frame that excites people, and you have to co-create and develop it with them, not tell them it’s yours and will they now take it on?

I think it is important that people have some skin in the game. So each organisation in UCLPartners makes a contribution – £50,000 a year for each organisation and a further £50,000 for those who are the most biomedical research-intensive as this requires additional infrastructure support. Not a lot, but enough to have some skin in the game. And as soon as you are looking to deliver any sort of programme – our cardiovascular programme for example – you are talking about the more than 100,000 people who work across UCLPartners in the partner organisations, not the 70 people who work here.

What are some of the challenges?

We all recognise that there is a tension between the individual building blocks of the organisations which deliver health care, whether it is University College London Hospitals [UCLH] or the Royal Free or the GP practice or whatever. There is an obvious tension that you have your own legal entity, with your own values and aspirations and goals and legal requirements and targets, and your desire to work within the system. So you have to ask: how does that fit together and align?

You need to build the case for change. That was done with the reconfiguration of hyperacute stroke services across London. People are rightly very proud of that. If you look at one of the people who really championed that – Dr Charlie Davie at the Royal Free, who is now Director of our Academic Health Science Network – he had some of the best results for stroke in London. But he said ‘you know, we could do even better if we stopped doing this at the Royal Free and consolidated with UCLH’. Now that’s what I call leadership. But that’s not the point of the story. Stroke reconfiguration saves about 100 lives a year. And maybe, if we had not achieved that, he and we could not then have moved on to the harder problem which he and we ask: ‘wouldn’t it be better to look at prevention?’ There are some 700 avoidable strokes a year across the 6 million population served by UCLPartners. So what’s the best way to minimise that number?

It’s a very compelling thing. Someone needs to stand up and tell me why you wouldn’t want to do that. There can’t possibly be a person who could stand up and say ‘well, that’s a bad thing to do’.

But it is difficult to do, very laborious. There is NICE [National Institute for Health and Care Excellence] guidance on it. But if I sent out a note to every GP pointing that out, the response would be close to zero. I am not criticising GPs; the same would happen in secondary care. So we went out to 35 GP practices in Camden and found the GPs interested in atrial fibrillation, which significantly increases your risk of stroke. There is a quite simple screening algorithm for it, and if you switch people to the right anti-coagulation therapy, you reduce their risk by 67 per cent. So identify these people and call them in. It is one of the highest priority things you can do if you want to save lives in the community. And interestingly, the clinical commissioning group supported us in this, even though it does not have any formal role in telling GPs what they should or should not do. And now we are helping to roll this out across another three CCGs in north central London alone.

It is important in this business that you get runs on the board – that people can see that they are making a difference. And you need constancy of purpose. We tried something similar elsewhere, and we were not making much progress. So we didn’t change the goal, we changed the methodology. And in some places we have now been able to deliver in six months what it previously took us two to three years to do. You build your credibility by delivering. As soon as you stop delivering, people will say, ‘well, why should we align with these people?’.

It is very important that you see things through, even if you have to change how you do them as you go along – however long it takes, almost. Because, if you do that, people actually believe what you say, and maybe the resistance to change is less the next time.

If people see you start and then abandon something, they say, ‘oh, well, if we’re a bit difficult they’ll abandon it’. So you adjust your methodology; you don’t adjust your objectives.

It is a bit like building a social movement. But social movements are more structured than people often imagine. You think it happens spontaneously, but you have to be quite organised to make it work. A lot of work in the background… People there to answer the phones and be responsive. And you have to walk in other people’s shoes – understanding the world they are in, and the pressures they are under, so that you can frame this in a way that gets their attention.

What would make it easier?

Well, some changes to the regulation. We asked elderly people in West Hertfordshire – people you would term frail and elderly – what they wanted from health care. They started by saying they didn’t like being called frail, and they wanted as many useful days at home per year as possible. It is not rocket science; you and I would want the same. But when the CQC goes and inspects all the organisations in West Hertfordshire, it asks whether the individual building blocks are meeting their targets, quite rightly. But they are not inspecting against what the patient, who interacts with many building blocks, actually wants – ‘how many days did I spend at home?’. So the regulation of individual organisations can miss the point. It can drive people away from the co-ordinated care they want to deliver.

The CQC and I are very aligned on this. So we have a piece of work going on to see if we can help to create a regulatory framework for partnership working, so that it would be inspecting what the patients actually want, not just the individual building blocks. You can’t get away from the individual building blocks. But can we look at what the patient wants and the population health outcomes, which seem, to someone like me, more important than some of the other targets for which people are held to account? I’d be slightly pushed towards thinking that if you saved all those strokes, I wouldn’t mind waiting an extra minute or two in A&E and not have had my stroke in the first place. But that is for others to judge. It helps that West Hertfordshire just happens to be one large CCG – one acute provider with social and primary care, so it is a good place to start to look at this.

And if you want to deliver at pace the Forward View, with its proposals for several different models of care, you need a change in the regulatory framework – rather than if you miss your four-hour target for the trolley wait, ‘well, I’m sorry, but you have lost your job’. That will not encourage partnership.

For me, you’re not going to succeed unless the regulatory framework aligns with your goals and ambitions.

When I show a picture on UCLPartners these days, I always start with the 6 million people they cover, and not organisations – because it’s the people and their problems that produce the alignment, not the organisations.

How do we develop more system leaders?

For our part, we’ve just launched, with the Health Foundation and NHS England, an NHS Innovator Acceleration Programme, the NIA. It is offering fellowships to up to 20 people from around the world to help create the conditions and cultural change necessary for proven innovations to be adopted faster and more systematically in the NHS. And we will be working with all sorts of other people on that, from patients to other academic health science networks to international experts. And again we will be working with a co-ownership and co-funding model. Applicants can be founders, leaders or representatives of such innovations – people who want to take a high impact innovation to benefit a wider population. And we’ll support them in that. We have a high-powered set of mentors who will help them. That’s one way of helping develop a cadre of people who are going to be more innovative about the integration agenda.

Does this get easier as the finances get tighter? It might. It crystallises the issue. There is always a risk that financial pressures will drive rational organisational behaviours that are irrational for the system. But the cake is only so big, and the crisis is not purely local. So if we don’t collaborate in partnership, in the end, although we might triumph in the short term, we can’t in the long term. The more we can get over the narrative that there is no point in being the last man standing, the better the chance. And anyway it is not what taxpayers are paying for – they are paying for a healthier population and having their needs met, not the individual organisation. But you could easily lose track of that when you look at the regulatory framework.

Read the next interview: Kim Holt >