System leadership viewpoints: Jan Vaughan

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Jan Vaughan has worked within the network environment since 2002, first in cardiac and stroke. Jan was appointed Director of Clinical Networks in April 2011 and the role encompassed cancer, cardiac, stroke, neurosciences, kidney care, critical care and neo-natal care networks. In 2012 she was appointed Associate Director for Strategic Clinical Networks and Senates for Cheshire and Merseyside.

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

Do you see yourself as a system leader?

Do I consider myself a system leader? I suppose if I stopped and thought about it, I would. I’ve been doing this role, or a similar role, since 2002. So it is a way of life, really. I started off in 2002 setting up the old cardiac network when nobody actually knew what a network was.

There was not much guidance coming out from the centre. So we actually all did our own thing, rather than wait to be told. And I think the essence of networks is that you have to develop a model that suits your own local economy, rather than have a top-down prescribed model that does not always fit. Sometimes things that work in London won’t work in Liverpool and Cheshire and Manchester and all those areas – because of populations, politics, personalities, history… All those sorts of things. And in these roles you have to be really mindful of that, because at the base this is all relationship work. All the work I do is around relationship-building. You could bring in PricewaterhouseCoopers to do what I do, but it would take them three times as long because it is all about relationships.

So I have a team of about 30 who work in the clinical network covering 12 disease areas, and there are 12 clinicians who work on a sessional basis and who are all either clinical directors or medical directors. But I can’t tell anyone to do anything. I think, for some of the clinical leads who work for the majority of the time in an environment where they can tell people to do things, it is quite a shock at first that they have to do all this relationship-building in the background.

I was an accountant in industry before I came into the health service to set up finance when trust status was introduced back in the 1990s. I then moved into general management within mental health and an acute trust, and then into general practice to set up fundholding, before going into a health authority doing reconfiguration – all in the north-west. I think that last was what started me down this network role without me realising it.

What skills does it take, and what qualities are needed?

You do have to unlearn things to do it. If you are in finance, it is so black and white – the books either balance or they don’t. The world in which I work now is very much the grey, fuzzy area, where there’s often not an entirely right or wrong answer.

You have to persuade people. You have to bring them along and make them think it is their idea – because they have got to own it. They don’t like people telling them what to do.

So you have to change your personality really, depending on who you’re talking to. With some people, you have to be very forthright and have direct conversations. With others, you know it’s going to take you about three months to get to the same place. Because you have to drop the seeds, work through with them, leave it alone, go back, slowly, slowly… And then all of a sudden it’s ‘do you think it would be a good idea if we did this’ and you think ‘gosh I’d never have thought of that – that’s a great idea’. That makes it sound rather Machiavellian, but it isn’t really.

You can’t have too much of an ego. Because if you are one of those people who likes to be centre stage and take the credit, these roles don’t work, because it is not about you – it is about the end game, the outcome for patients. And I should be the person in the background that people at the end of the day forget about because you’ve facilitated the change, but they have actually done the work. You’ve disappeared. But you have left them with the skills to carry on.

You need to be a good chess player, or remember in a jigsaw where all the pieces are. So if we need a bit of blue sky to finish off, you know it is over there, but you have to leave it there until it is the right time to put it in.

You also need to be flexible, because things change and politics change. You can’t just set down one road. You have to have a plan B.

The majority of the time, when you get all the clinicians in the room and you talk through an issue, they will all agree that X is the best solution for patients. That, for example, you’ve got eight trusts doing something, but the rationale is you only need five, and three of them are going to lose out. They all agree that is fine. But when they go back to their trusts and the chief executive gets involved, that becomes a different conversation. So what they say in one room together and what they say outside can be different.

So we have to make sure that everything we do is transparent – that we have the best evidence to base it on, locally, nationally and internationally. And sometimes we bring in people from outside the area to look at what is being proposed with fresh eyes, so there are no hidden agendas. And one of the really big things that makes networks work is to involve patients. It is very hard to say to a patient you are not going to do something because your trust will lose out, when the patients want good services and don’t mind travelling the extra 10 miles if they feel they are going to get the best treatment.

How do we deal with the maverick clinician who simply says ‘I am not agreeing to this’? Peer pressure mostly. The other clinicians handle them well. They come to feel isolated. And we get the clinicians to sell the changes when services move. The Daily Mail hates managers. But patients trust their clinicians. So we had to move some services from Clatterbridge on the Wirral to Liverpool, and that wasn’t entirely popular. But we had the clinicians at the public meetings who explained that some services would remain locally, but if people wanted world-class treatment we had to move some services to Liverpool because we could not attract the top-quality clinicians without a university research base. And since that was done they have worked in partnership and recruitment has gone up. So having those things to say to patients has worked. It was a rocky start, but the community has come round.

A big success was primary PCI [percutaneous coronary intervention], where patients go straight to the heart and chest hospital, and the ambulance bypasses the local one. The clinicians were passionate about it. And we involved the patients in it. We put it in the Liverpool Echo – that this was a revolutionary thing, and how many lives it would save. And I don’t think we had any opposition to that at all. Whereas with vascular surgery – which was not done by us – the Liverpool end is sorted but the Cheshire end isn’t, because they didn’t do what was done with cancer at Clatterbridge. They didn’t involve enough people. The engagement wasn’t there.

So, with diabetes we are working with patients about why they don’t take up education about their condition. That really frustrates the clinicians. And the patients say ‘well, you just talk at us, and it is too much information, too soon’. So they’ve started using social media with video clips on iPhones because a lot of people have smartphones. I am sure it’s been done elsewhere. But the clinicians now own it, and a lot of network working is about sharing learning – and there is a lot of energy around it now.

This sort of network working does not suit everyone. A lot of people are used to hierarchy and working in that linear way.

We work in a knotted ball of string, where you have to be comfortable talking to chief executives one day and patients and health care assistants the next, and where you know it is not linear like a railway track.

There are lots of branches off on the way. It is about persuading, not ordering, asking not telling, everybody’s equal – that sort of thing. You have to be comfortable with chaos. And it does need a different sort of manager with different skills, not the tubthumping showman who needs to be centre stage. You need to have people who can make connections and relationships, and that’s a totally different set of skills. Some of the things we do, people in the NHS would not traditionally have put a lot of value on.

What are some of the challenges?

I do think stability is important. I’ve worked in the north-west for 20 years, so I know a lot of people. And while a lot of us had to change jobs 18 months ago, we all still know each other in different but often similar roles. I don’t think that happened in all areas. We were very lucky because we are such a small, compact area, and we kept a lot of that history and knowledge that other people lost, which I think has been really helpful to keep us moving forward.

But this does all take time, and people have to recognise that. You can say ‘that’s the solution and we will jump to it in three months’. But I guarantee that if you do, in six months it won’t be there, because people won’t own it and it’ll just disappear. You need to take time if you are serious about change. What we do try to do is look for a quick win to start people realising that working together works – so you get more engagement and people say ‘it is starting to pay off’. If you sit people in the room and ask ‘if we had to change one thing quickly, what would it be?’ it is usually the same thing, but for some reason nobody has done it. So we do that, or rather they do it.

We do a lot of work with local authorities and police and education and one of my team was a deputy chief executive in a local authority for many years. And I’ve always thought it was vital to have that because the language is different. She’ll say to me after a meeting ‘that isn’t what they will think you have said, so you need to email them and make it plain’. It’s vital to have that engagement.

Has the money getting tighter made our job easier? I would’ve thought it would make life easier, because clinical commissioning groups are less well-resourced than the old PCTs were. So I would have thought more would be coming to us and saying ‘can you help in this area?’. But the penny has only dropped with some of them. That might be because they are only 18 months in and still finding their feet. Once they actually lift up their head, they might start looking at wider issues.

It doesn’t help that strategic clinical networks and clinical senates and all that are being reviewed at the moment. It doesn’t help people to come to us, if they think we might not be here in six months’ time. And I can see that with us, and the clinical senates and academic health science centres and networks, and the leadership academy and NHS IQ [Improving Quality] it does look a rather crowded landscape. But there is enough work there for all of us, not least because there are many fewer improvement people in trusts than there were 10 years ago. You need people with those skills, and there is a great deal of this type of work to do around reconfigurations.

What is needed is that people are clear about who is doing what, so we don’t duplicate and stamp on each other’s toes by accident.

We had been doing a lot of work round atrial fibrillation, working with pharmacists and stroke physicians and GPs around the new anti-coagulation drugs and what we do across the network – only to discover that the academic health science network was also doing a piece of work on it. So we now share our work plans, and that shouldn’t happen again. If there were some clear boundaries, that would be helpful. I don’t get the sense that they are going to pull the rug out from either clinical networks or senates.

I love doing this. No two days are the same. It swings from being incredibly satisfying to being the worst thing in the world, you know – you feel as though you’re on a rollercoaster all the time. It’s chaotic, and I like that. But I am comfortable with chaos.