System leadership viewpoints: Julie Moore

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After a variety of clinical, management and director posts, Dame Julie Moore was appointed as Chief Executive of University Hospitals Birmingham (UHB) in 2006. She is a graduate nurse who worked in clinical practice before moving into management.

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

Do you see yourself as a system leader?

There is no system leadership. I’d like to take more of a role. But right now it is too fragmented, and larger teaching hospitals are usually regarded with suspicion. One of the bad side-products of the foundation trust legislation was that it created independence for its own sake, rather than to drive up quality.

So we have some very small foundation trusts – some community services and acute trusts, for example – who want foundation trust independence for its own sake rather than for the good it can do.

So we have created an army of people who fiercely guard their independence for its own sake, and people who cannot separate out their own personal position from that of the organisation, and so they defend it.

What are some of the challenges?

One of the trusts we worked with was in danger of losing a £1 million contract for some of its services. It was desperate to keep it because it needed to keep its income above a certain level because of its FT [foundation trust] status. So it had spent the better part of £2 million on management consultancy just to keep the contract there. Sometimes people believe size is the most important factor.

The 2012 [Health and Social Care] Act has compounded that. So we have some clinical commissioning groups who cannot see beyond their boundary and don’t see how changes they make in their local economy impact on surrounding services. And we have some quite senior people who believe that you have got to go out to tender on almost anything, because you have to have more than one potential provider, and because they think competition is all about tendering for services all the time. So you spend half your life just filling in huge complicated bids.

So, for example, someone decided that a screening programme had to go out to tender, when it turned out that what was wanted was common standards across the patch and some cost-cutting. It took a very senior person to intervene and the directors of the service were asked ‘can you achieve that?’ And when they said ‘yes’, it was all done without a multi-million pound tender. It was an outbreak of common sense, and it has worked really well.

And we have some problems in Birmingham that we need to sort out. So we have three pretty big acute trusts, and five smaller trusts, and several more just outside the boundaries, and everyone agrees that that is too many. And they all tend to do their own internal reconfiguration of services. As a result, patients flow elsewhere, putting pressure on other providers. At the same time, some of the clinical commissioning groups have introduced referral management systems for their local hospitals. That gets CCG numbers down and helps with their finances. But the GPs, who are smart people by and large, bypass that by referring to the other hospitals who then, due to the marginal rate, don’t get the full tariff. But when we went to the area team and said there are problems here we have to sort out, someone said to me, and I quote, ‘that would require system leadership and we don’t have that any more’.

So we haven’t got a managed system and we haven’t got a market. We’ve got neither fish nor fowl. Now, you can argue which one of those is right or wrong, and actually I don’t mind. I’d just rather have a system that actually works.

Have a managed system and say if you’re a GP in area A, you refer to this hospital or whatever. But don’t say everyone’s got free choice of where to go, when you can only have choice if money follows the patient. If the money doesn’t follow the patient, then you’re penalising the popular hospitals.

On top of that, there are so many organisations around now that it makes system leadership really hard. The King’s Fund graphic of them all is pretty impressive. But there are even more of them now than when that was drawn. There are so many interlocking circles in so many areas that you could spend your whole life just trying to negotiate with them all if you tried to work outside your area.

It is hard even for something within your area. Birmingham City Council convened a meeting about acute care in Birmingham because of some of the issues we face in A&E, and it backfired spectacularly. It started out with the three acute trusts and the ambulance service. But then the mental health trust said they had acute beds too and needed to be there. Then the community people said they needed to be there, and then the commissioners, and in the end there were 27 people in the room and it was such a big meeting that nothing was achieved. Nobody wanted to be there, but nobody didn’t want to be there. It got so involved that nothing was achieved.

There is, at the moment, no place that brings people together. I was not a fan of the SHA – I think they missed many opportunities to reconfigure and make lasting improvements.

There is now no place where people can come together with one organisation which oversees commissioning and can say ‘actually this isn’t coherent’.

We have loads of commissioners and public health people, but I don’t see anyone actually doing an assessment for a whole population and saying ‘this is how many hospital beds we need in this neighbourhood, these are the outpatient services we need and the A&E and so on, and this is where we need to buy things and send people’. It is done piecemeal on too small a scale, and instead people make the projections of demand fit their business case. So even to achieve one tiny little thing in terms of system leadership takes a phenomenal amount of effort.

How much progress have you made with 'buddying' arrangements?

All that said, purely on the provider side, we have made some progress with the ‘buddying’ arrangements in which we have been involved. But that depends crucially on whether people recognise that they have a problem or not, and whether they welcome the help. Buddying is an informal process and we have no authority to make actual changes if the trust being buddied does not agree.

Where we have had an executive team that was willing to work with us and eager to put things right, buddying has helped. When you’ve got somebody that doesn’t want to work with you, you can’t force yourself on them. At one of the trusts, they just didn’t believe they had a problem and didn’t turn up to meetings – and you haven’t got the authority to make that happen.

There are definitely things you can bring. At one trust, we were able to talk to some difficult clinicians in private and say to them ‘you can’t carry on like this. Your bad behaviour is contributing to the bad performance and you need to get your act together.’ It is easier for an outsider to come in and say things like that because we have no long-term interest in the place and we can actually tell people the truth in a way that is harder for an interim chief executive to say.

I do think, however, that we need a proper failure regime where some of these things can be dealt with earlier. And that is not a failure regime that ‘lets them go bust and close down’ because we are never going to let many of the places that do get into serious trouble close down completely.

At the moment, however, you can see somewhere is going down a slide, but we wait for them to hit rock bottom before we intervene, when it would be a lot easier to arrest things and pull them back beforehand. So trusts need to go into special measures before anyone can intervene, when it would be better if help could be brought in earlier, rather than just propping them up year after year until they go down completely.

Could chains help?

I do think that the idea of chains, as in the Dalton review, is one of the ways to go. It is not a magic bullet, when there are many causes of the problems in the NHS. But the question is, can we afford not to use the good procedures and techniques that we have in the NHS, and can we afford not to spread them out rapidly?

Everyone needs to learn from everyone. And we can’t afford to have as many organisations as we have, as many back offices and as many fiefdoms.

Plus we haven’t got enough good managers to go round. There are some people who are very good at being managing directors but don’t want to take the ultimate step to being chief executives – after all, we have 10 per cent vacancies for chief executives and finance directors. And it is hugely difficult to get good chairs and non-execs. So why don’t we spread the ones we have got around a bit better?

When I say this, people say ‘you just want to take over’ or ‘you want to suck in all the patients’. But we don’t want to suck in all the patients. Here, at UHB, we are at capacity, and I’m getting pretty near retirement. So personally I am not bothered about my personal position. But chains could indeed help, although it is not going to be easy when the chairs and chief executives of struggling trusts so fiercely guard their independence.

Read the next interview: Sue Page >