An interview with Brian James
Interview by: Alistair Craven
Brian James has worked in the UK’s National Health Service (NHS) for 30 years, with 20 years of that time spent at Executive or Director level. His experience spans strategy, hospital management, business development and information management and technology.
In his last post he was Director of Health Service Strategy & Innovation for South Yorkshire Strategic Health Authority. His keen interest in international health systems and new ways of working makes him a regular speaker at National conferences on contemporary issues in the NHS. He has a Masters Degree in Health Informatics.
Mr. James became Chief Executive of Rotherham General Hospital in February 2005 and inherited an annual budget of £140m, 3,300 employees and over 400,000 patients. 90 per cent of patients to the Rotherham NHS Foundation Trust wait less than three months for admission, making it one of the top performing Trusts in the country.
The modern picture of healthcare in the United Kingdom is transforming into one of competition and choice. In wanting to explore new ideas to help the Trust achieve its challenging objectives within existing resources, Mr. James took up the offer of Sir Gerry Robinson, former Chairman of Granada and Allied Domecq, to come into the Trust to see whether a “businessman” could identify alternative approaches to managing in this unique environment.
The result, broadcast by the BBC in January, was a fascinating insight into the inner workings of the modern day NHS. In Can Gerry Robinson Fix the NHS? the two protagonists worked – occasionally at loggerheads – to explore areas and suggest changes to working practices that have led to wider learning points for the whole of the NHS. The programmes received widespread critical acclaim and serve as an invaluable snapshot for any professional wishing to study the delivery of healthcare services in a challenging environment.
In this exclusive interview, read what the Chief Executive has to say about the series, his management challenges, and the differences between managing in the public and private sectors.
Hello, and welcome to Emerald Management First. You recently appeared on the BBC’s mini-series Can Gerry Robinson Fix the NHS? What are your overall reflections on Rotherham General’s participation in the series?
We went into making the programme with our eyes open. Rotherham was already a high performing hospital – we are a Foundation Trust, we are in good financial shape unlike many other parts of the NHS, and we are achieving all key targets. So although we knew that there would be some risk involved in the project, we felt that we had more to gain than to lose. The main opportunity we saw was to get someone of Gerry’s calibre to start a real debate within the organization about the nature of the changes we would need to go through on our journey to becoming a business. I was particularly keen that he worked with Consultants and by engaging with them challenge many of the archaic and arcane practices that are tolerated in the NHS, but that could simply not continue if we were to make the transition to a successful business. I don’t think we succeeded in that regard, but such a debate has now been stimulated because of the programme.
What would you say were the biggest differences between management in the public and private sectors? Do you think these differences were fully appreciated by Gerry Robinson?
I think the differences are huge; much greater than Gerry either understood or indeed recognized. The main issue is the degree of control that we have (or rather don’t have) over many of the key issues that affect the performance of the hospital, such as, for example, pay and terms and conditions of service, or the price we charge for goods and services – both of these, and indeed many of the other policies imposed on us (by Government) are out with any frame of reference that the private sector would understand. Not to mention the ritual reorganization seemingly imposed upon the NHS every three years or so, driven of course by politicians. Could any business operate successfully in such a complex and politically sensitive system where so much of the operating environment is determined not by the needs of the business, but by the wishes of politicians?
In an interview with the BBC’s Newsnight, Sir Gerry Robinson claimed that the NHS “is not a real business.” Do you agree with him?
I absolutely agree, and indeed it is inevitably the case given that the ‘market’ is cash limited. It is a managed market where normal business rules simply do not apply. If it were a real business, then undoubtedly there would already be a number of hospitals that would have folded; gone to the wall; depriving vast numbers of patients local access to acute healthcare services. The NHS is not yet mature enough to work in such an environment; the private sector is also getting its fingers burned, and the politicians know that the consequences of such events would almost certainly lose them the next election. So it is not a business in the sense that Gerry or indeed anyone in the commercial sector would recognize.
What are the key challenges of your current role and how would you describe your management style?
My key challenge is to facilitate the transformation of a public sector body into a fit for purpose business, capable of surviving and thriving in what will emerge as a very hostile operating environment for hospitals over the next few years. We need a fundamentally different mindset and culture to that normally found in the NHS, and much of my time is spent working through the strategy for achieving that transformation, and in equipping the workforce with the skills and confidence they will need to undertake the journey.
“We operate in a managed market where normal business rules simply do not apply. If it were a real business, then undoubtedly there would already be a number of hospitals that would have folded; gone to the wall; depriving vast numbers of patients local access to acute health care services.”
My management style is facilitative and empowering. The culture of the NHS does not accept an autocratic style of management, and nor does it respond to the notion of charismatic leadership – the primary quality required of leaders in the NHS is trust, quickly followed by technical competence, vision and the ability to effectively lead and manage change. Trust takes time to build, time that politicians and the Government are too impatient to give the NHS (arguably because they don’t have the time!), so we are rarely able to achieve major cultural change – half way through we get a new Secretary of State, new health ministers or even a new Government, and then it is all thrown back in the air again and a new course is set. This breeds cynicism amongst the large number of professional groups that work in the NHS, and which renders the establishment of trust very difficult to achieve.
You have said that an almost constant agenda of change is prevalent in the NHS and that the amount of change is “clearly part of the problem.” Can you elaborate?
All Governments, and the politicians in power, see it as their responsibility to change and improve things – after all that’s why they are elected. The areas over which they have most influence are the main States of Government, of which of course health is one. Politicians have very little time in which to make their mark, and they need to make a mark in order to improve their chances of promotion or indeed re-election. So, we see a constant stream of politically driven proposals for change by ministers, which are then translated into action plans by the Department of Health. Most have no evidence to suggest whether they will work or not, and they are invariably grossly under-funded. At any one time we will be dealing with dozens of new policies being introduced, whilst delivering against hundreds of targets. And let us not forget that the day job is to ensure that the 400,000 patients who cross the threshold of our hospital each year get the treatment they need safely.
As Gerry himself admitted, it is one of the most challenging things he has ever come across, and he was probably only aware of some 10 per cent of it.
One result of the TV programme was a project involving staff implementing a new service in about seven weeks, which you claim would probably otherwise have taken the best part of a year. Does this support the theory that there is too much bureaucracy within the NHS and not enough “doing”?
It’s not as simple as that. There are many reasons why it takes much longer to achieve change in the NHS than the private sector. Some of these include the need to ensure safety – changes in clinical working practices may compromise this, so have to be worked through carefully. However the biggest factor is that all of our resources are already locked in to delivering the existing services and levels of care. We have no profits, surpluses or other finance that we can immediately divert into starting something new quickly, so we have to identify what we are going to stop doing in order to finance the new development. Even stopping a clinic from running in order to free up a doctor’s time to do something different may take several months. So it’s not the bureaucracy, but the logistics (and lack of spare cash) which are the main impediments to rapid implementation.
When you started your role in February 2005, your number one priority was to make Rotherham a Foundation Trust. How did you go about this?
That’s not an easy question to answer quickly, but in broad terms I developed a vision and a strategy for the new organization aimed at securing its success as a business, with an associated restructuring and financial plan. I then consulted widely with staff within the organization and with key local stakeholders, in order to secure support for it (which happily was overwhelming) before submitting the plan to Monitor, the Independent Regulator responsible for authorizing Foundation Trusts. The plan is ambitious and not without risk. It has required substantial cost reductions, but we have managed to deliver on all of these so far, and are well on the way to delivering the plan set out in our strategy by 2008.
Sir Gerry Robinson has said that management is always about attitude “…it’s about setting a scene in which people can do things, they feel they can do things, they feel they have the space to take a chance and actually get on with it.” Would you agree with this?
Yes I would, but would also reiterate that the NHS is not like a normal business in that in our world, mistakes may literally cost lives. The key changes we need to make are without doubt mainly in areas that will impact patient care, and we must therefore proceed carefully. Nevertheless I am 100 per cent committed to devolution and empowerment of front-line staff, and our strategy not only makes that very clear, it will deliver on it.
Patient Choice has moved to the centre of the UK government’s programme of health system reform. Do you think an effective market for healthcare as a commodity can be established in practice?
Not unless politicians are willing to accept the consequences, and there is little evidence that they are. If Patient Choice really took hold, it would be the middle classes and the well off who would be able to exercise it, leaving the less fortunate in our society with even less choice as the unsuccessful hospitals collapse; the equality gap would get even wider.
“My management style is facilitative and empowering. The culture of the NHS does not accept an autocratic style of management, and nor does it respond to the notion of charismatic leadership – the primary quality required of leaders in the NHS is trust, quickly followed by technical competence, vision and the ability to effectively lead and manage change.”
It sounds fine in principle, and it’s a great mantra on which to drive change (which is really what’s at the heart of it), but I am sure that before too long (new Prime Minister, new Government?) we will see another shift in policy and a new direction will be set (here we go again!).
In his interview with us, Dr. Marcus Longley – senior fellow and associate director at the Welsh Institute for Health and Social Care – stated that for a variety of reasons, hospital care should be “the last choice – it's dangerous, inconvenient, and expensive.” How would you comment on this?
Well I can understand where he is coming from – prevention is better than cure etc.; this is nothing new, and of course the Government would say that this is precisely why they are driving the Patient Choice/Care in the Community agenda. But it is a bit disingenuous when those who are advocating the change are the same people who were responsible for creating the very system they are now so quick to condemn. The system is perfectly designed to achieve the results it gets. If you want different results then sure, you need a different system. But these things go in cycles, and I suspect that within the next decade or two, when much more care is delivered in a dispersed way in the community, some politician will say “You know what? All this distributed care for very frail, very old, very sick people is very resource intensive and expensive – what we need is a place where we can get some real economies of scale”… like, say, a hospital!
You can find out more about Rotherham General Hospital and the BBC mini-series at: