This time it's personal

24 March 2016

NHS Improvement chair, Ed Smith, writes that non-executives need to focus on the people who make our public services tick. Nowhere is this clearer than in the NHS.

What makes for a really effective public sector non-executive? Probably one of the most important qualities they need is resilience. The ability to relentlessly facilitate change, the staying power to cut through process and bureaucracy, and focus on what’s important – this, in my experience, is worth its weight in gold.

A successful non-executive director (NED) also needs a special kind of wisdom, one based on deep knowledge gleaned from on-the-ground experience in many different business and operational settings. This means understanding the overriding importance of people – as distinct from process and structure – and of change mechanisms, such as digital transformation.

A good non-executive chair gets all this, and focuses single-mindedly on the people and change agendas. Picking the right CEO, choosing the right team and creating the right culture are key ways to make organisations effective, promote collaboration and break down boundaries.

A successful non-executive director needs a special kind of wisdom, one based on deep knowledge gleaned from on-the-ground experience in many different business and operational settings.
NEDs are potentially in pole position to facilitate these improvements. They work in what I call the ‘grey zone’ – engaging with stakeholders and policy-makers through the back door, going behind the scenes, influencing, enabling and mentoring.

There are some fantastic examples of non-executives doing precisely this, right across the public sector. In my own experience – for example, in transport, higher education and the NHS – I’ve seen just how transformative their input can be. They understand, deep in their DNA, that there’s a lot more to the job than just tick-box governance; that the skills required are more anthropological than technological.

However, it also has to be said that the non-exec community has its fair share of ‘badge collectors’, and is still too pale, male, stale – and middle-aged. It has yet to fully reflect the multicultural, heterogeneous, digitally driven world we live in.

Improvement agenda

So how do these general observations translate in the context of the health sector, an area facing some enormous challenges at the present time? Monitor and the NHS Trust Development Authority are merging to form a new regulatory body, NHS Improvement, which has an ambitious agenda to face up to these challenges and drive change.

As chair of the new organisation, I am acutely aware that our 1,500 non-executives have an enormous contribution to make, whether at the national or local trust level.

The problems facing NHS trusts are well documented: soaring demand on already severely stretched services, particularly from a rapidly ageing population; fragmentation and lack of flow within the system, most notably between health and social care; inadequate workforce planning; and failure to harness the potential of digital technology – all against a backdrop of what NHS Improvement’s CEO, Jim Mackey, predicts will be a “firebreak” financial year.

It may not be within the gift of NHS NEDs to resolve many of these highly charged and very political issues. Yet the sheer scale of the health service – 1.2 million employees in England delivering over 250 million contacts with patients every year on a budget in excess of £116bn – means that the non-executive input can have a disproportionately large impact on the public.

This is particularly true when it comes to improving the quality of patient care. The very best NEDs (often those from customer-facing backgrounds) clearly articulate the voice of the health service consumer. They roll up their sleeves, visit wards and talk to patients, clinicians and staff about what is good, bad or indifferent in their localities.

They cut through all the data-driven targets and metrics and, instead, sniff out best practice – and ask why it isn’t happening elsewhere.

If NEDs are smart and enquiring they can play a critically important role in disseminating cost-effective good practice throughout the service.

Why aren’t there more trusts like Luton and Dunstable, bringing primary care into accident and emergency departments? Or like Yeovil, serving its ageing population by building residential care facilities next to hospitals? And why isn’t everyone following the example of University Hospitals Birmingham, which has vastly improved the flow of patient data through the simple tactic of getting its nurses to use iPads?

If NEDs are smart and enquiring – in other words, if they actually talk to people as opposed to glad-handing them – they can play a critically important role in disseminating cost-effective good practice throughout the service.

They also need to apply this spirit of forensic enquiry to the financial challenges the NHS faces. Two thirds of health trust costs go on paying their people. NEDs should be asking more questions about, for example, the costs of agency staff, about savings to be made from shared back-office services, about the supply chain – and about the reserves finance directors keep in their right-hand drawers. We need greater transparency all round if we are to get NHS budgets back in balance.

Do health service NEDs have the necessary skill sets to do this? Some do, some don’t, and there is certainly scope here for more mentoring, training and hands-on input to boards from the best leaders across every sector.
However, all non-executives are capable of at least asking the right “why not?” questions about efficiencies and savings, and encouraging and cajoling their colleagues to rethink these issues.

These generic skills – focusing on behaviour rather than structures – are ones that many NEDs have in spades, thanks to their backgrounds in business, commerce and professions. They bring a fresh perspective to deeply entrenched problems, and can potentially help break down some of the silos and boundaries that hold back progress in the NHS.

Bridging the divide

One of the most intractable is the damaging disconnect between health and social care that, as everyone knows, creates huge logjams in both hospital and community settings. At the root of this cultural and professional divide are profound funding issues, which NEDs can do very little to affect.

Nevertheless, attempts are being made to bridge the financial divide between the health system and local authorities, whether through the Better Care Fund, joint planning within local health economies or the new NHS vanguards. NHS non-executives can do much to promote these initiatives, working across boundaries to improve co‑operation and encourage conversations, for example about population-based pricing mechanisms.

There are no quick fixes, but there is widespread recognition that health and social care integration is now an urgent national necessity. NEDs, in this area as in so many others, can help to catalyse that change.

There are no quick fixes, but there is widespread recognition that health and social care integration is now an urgent national necessity. NEDs, in this area as in so many others, can help to catalyse that change.

One other area where, optimistically, silos are breaking down is within the arm’s-length organisations that monitor, inspect and regulate our health and care services. NHS Improvement, as already mentioned, is on a long-term journey to engage with providers, create greater capability and drive change within the health ecosystem.

Part of this process will involve engaging much more closely with clinicians, nurses, managers, patients – in fact, everyone intimately involved with the system. We particularly want to do this at a regional level, bringing grassroots knowledge to bear on the challenges the NHS faces.

The Care Quality Commission, the Health Service Ombudsman, HealthWatch and many others are all on board with this grand ambition. Ironically, the pressures the NHS is having to confront have created the best chance in years of promoting a people-centred strategy across all agencies, thereby improving collaboration and shared functions.

It’s an exciting time to be driving NHS improvement. And NEDs, without a doubt, are a vital part of the story.

This blog was first published by Public Finance as part of a collection of articles focusing on the role of non-executives.

All Comments (0)