By Dr. Andy Phillips, Regional Executive Officer, HSE South West
My management and leadership career in healthcare has been strongly influenced by my experiences as a clinician and working in a number of different countries, learning on the way.
Back in the day, I was very much taught the ‘medical model’ of patient consultation, very similar to the Hogwarts ‘sorting hat’ where people were reduced to diagnostic categories and we were told to take an approach of ‘professional detachment,’ never to show empathy for patients.
Having just been fitted with my first white coat on the first day of the job in an NHS hospital in Southampton, I was told that I was also responsible for the operational management of the department. At this time, I was working with research scientists, world leaders in their field who appeared impossibly gifted. The job of operational management was not highly valued, but I learnt that by understanding and controlling costs, investing in the best computers and software and using staff time most effectively, we could do better research that had more impact.
This was a time in the mid 1980s when we were lucky enough to have secure funding that enabled us to be highly innovative and create new knowledge, diagnostic tests and treatments without needing to submit grant proposals, so there was a strong leadership element to the work also. What I really enjoyed about these early days was bringing knowledge from outside my speciality into the service of the patient, whether it was using laser physics to treat port-wine stain birthmarks, mathematics from radar science to develop rapid test techniques, materials science to create tactile computer interfaces as employment enablers for people without sight or hearing to access computers or creating computer programs to write four dimensional matrices to understand how to get the most effective use of staff time.
These early operational and leadership experiences helped me to get my first Consultant Clinical Scientist, Head of Department post at the tender age of 28. Of course, at this stage I had an enormous amount to learn about management, leadership and clinical practice and it was the relationships I had formed that meant friends were willing to help me out by providing me and my new department with advanced clinical training and supporting me to develop my management skills.
In this first role on the Senior Leadership Team of a hospital, I learnt about the importance of supporting managers outside my own department, making a wider contribution and started coming to grips with health service politics. Some of my assumptions about universal commitment to achieving best patient outcomes were challenged as I began to better understand some of the personal motivations of clinicians and managers.
When I look back, I realise that I moved on from this role and other similar roles across the UK because I felt unable to work within unsupportive management cultures. In the fourth and last of these roles, I was more successful both in creating a culture within my own department and influencing the culture of the organisation by serving on the board.
My realisation was that I was more successful in carefully selecting new people with similar values and training them than changing the ways of working of people who had already been many years in a particular organisational culture. Over these years I took the opportunities of working for a broad range of organisations such as the Departments of Health in England, Wales and Scotland, organisations such as Kings Fund, Commission for Health Improvement, Universities, Charities, Professional Organisations, Registration Bodies that developed skills in governance and leadership. To develop my operational management skills, I undertook a distance learning MBA at Warwick University Business School.
Those years leading an outstanding clinical department at the cutting edge of clinical practice and delivering great outcomes with an amazing group of people were incredibly rewarding and enjoyable. As a department, we were very successful financially and providing person-centred clinical services and consultancy to many different places in the UK and Ireland. We first published the ‘Getting it Right First Time’ methodology in 2005, integrating lean and agile work processes with relational models of patient partnership. In the end, I got out-evolved because the young leaders and clinicians that I’d trained became both more accomplished and better leaders of their generation. Time for me to get out of the way.
Luckily, at that time the NHS in Wales was moving to integrate all of the hospital and community organisations into a smaller number of Health Boards and they needed Executive Directors who also were members of the unitary boards. I was lucky enough to get an Executive Director role and learnt much over five years about putting integrated care into place, working in partnership with local authorities, codesigning system transformation. Since this was a strategic leadership role, I thought I’d better learn some new skills, so I got sponsorship from the Welsh Government and subsequently completed a Doctor of Business Administration in Public Service Management and also qualified in executive coaching and mentoring. The best learning experiences were from building relationships with leaders from across public services who had different perspectives than those in the health service. The work I’d initially done and taught in building better clinical interactions between clinicians and patients, moving away from the medical model, broadened into a model that was equally successful in codesigning transformation of entire countries’ health systems as it was applicable to interactions with a single patient.
After five years there was another realisation that I had little further contribution to make. After 27 years of being thoroughly annoying in the NHS realised that I’d better get as far out of colleagues’ way as I could. St Helena and then the Falklands were appropriately remote, but my long-suffering wife Lynne thought that Hawke’s Bay in New Zealand might suit her better. So the night we put the last coat of paint on the house we’d being doing up with every penny we owned and unable to sell in the Neath Valley we rented it out and set off for the Antipodes.
In New Zealand I was very lucky to have understanding bosses who asked me to work in clinical leadership, commissioning, public health and indigenous health, operational management, service improvement and supported secondments to the Ministry of Health and then for a year to the Department of Prime Minister and Cabinet to work on the transformation of the NZ health system.
Some of the best leadership learning experiences in NZ though were from working in partnership with Maori. This taught me so much about the importance of building strong trusting relationships with communities and valuing their wisdom and autonomy over their wellbeing and health. In my own wellbeing I built mindfulness practice into indigenous models of health and wellbeing that included use of resources such as water and energy, mental and spiritual health, family health and wider contribution to community life. Working on the ‘smell of an oily rag’ as trustee and then chair of an environmental charity using the UN Sustainable Development Goals and on the committee of a soccer club made me realise how public services can reduce their environmental impact, reduce wasteful use of resource and use their significant impact to effectively improve the wider determinants of health as shown by the NHS Anchors programme.
When we were in NZ we learnt that the tenants of our lovely home in Wales had mistaken the terms of their contract to mean that they could keep horses in the house and that when they left they could both take everything that wasn’t nailed down and commit criminal damage. Luckily our next tenants were lovely, looked after the place as if it was their own and after a while we sold it to them at a discount. The work I’m most proud of in NZ was aligned with the Marmot principles in working to abolish health inequity and establishing social inclusion. This meant spending time with local people in their communities, meeting places, learning about their culture, eating with them, attending community events such as funerals, focusing on creating fairer societies and healthy lives. This work focussed on supporting young families to give every child the best start in life, providing a living wage, allocating resources to communities to develop their health and wellbeing on their own terms and intentional resource allocation to those with the poorest health outcomes. This was all designed to give the best social return on investment. Work complete on the health transformation programme and after nearly eight years it was time to move on, this time to Aus.
We had lived in a rural community in NZ and Hawke’s Bay is often thought of as an ‘island’, so when an opportunity came up working for Victorian Government, Lynne being a city girl at heart, it was off to Melbourne. We had come to think of Aotearoa as home and had a very lovely home ,so it was a big wrench to move again. Renting out the house with considerable trepidation (we needn’t have worried, the tenants were lovely), we moved to what must be the best city in the world to live in. What can I say – amazing food, brilliant opportunities to watch and play sport, incredible culture, outstanding architecture and public transport, best shopping anywhere. And, of course, the job. Again, very supportive bosses who wanted transformational change in outcomes and value for money. A role at the heart of government, playing to my strengths in finding out the most significant improvement opportunities and then building the relationships to make it happen. Along the way, my first CEO role and a whirlwind for 18 months. An amazing job in an incredible city. But….
Slaintecare. I had applied for a role in Slaintecare when it first came out in about 2017 maybe. Immediately it was clear that Ireland was serious about integrated care. This was policy that had synthesised all the learning from integrating care across the world and had true government commitment. Bad news for Lynne – my dream job had come up in Ireland. Even worse for her, on a trip to the UK to see family, I had extended my leave and somehow whilst doing the CEO job at Safer Care Victoria during business hours in Australia, I’d got through all of the many stages of the Public Appointments process and been offered my first choice as REO in Cork and Kerry. It was my first choice because although I’d done a little work in Dublin, I’d led a team that worked for six months in Cork and had spent many summers walking and climbing in the mountains of Kerry. But most importantly I felt at home in the South West of Ireland. It spoke to my Celtic roots which are in Wales and Asturias in Northern Spain.
So, coming up to two years in the job. It truly has been a privilege to be a part of the community and to lead the health service in the SW through organisational restructure whilst needing to significantly improve performance. Together we’ve crafted our purpose ‘that the people of Cork and Kerry will be proud of their health service’. To make good on this we’ve made personal and organisational commitments aligned with the HSE values:
In my day to day work, I’m delivering on six requirements. The first is to deliver high quality health services that are safe, timely, effective, productive and most importantly, person-centred. These services have to provide good value for money, that is the best possible outcomes at lowest system cost. And as REO, I not only have service delivery responsibilities but also for overall health and wellbeing of the community which means I work with other public services on improving housing and employment as well as improving health behaviours. Working with the Marmot principles I need to deliver more equitable health outcomes and there are unacceptable differences in life expectancy, which for males in general is around 80 years, but male travellers can only expect to live for around 60 years and homeless men die around 40 years of age. This means that we need to use our Population Based Resource Allocation to shift how we use our resources to resolve these completely unacceptable inequities.
The next part of my job is improving staff experience of work. With high levels of sickness absence and the results of our staff survey there’s much to do. And then the HSE is truly an anchor organisation in our community with energy use, our waste products, the way we buy goods and services, who we employ, how we deliver services, we have a responsibility to improve climate sustainability. In particular, we need to work with local developers to ensure that low cost housing is built to offset the impact on those most in need of housing who might be displaced by the growth in HSE staffing.
In healthcare, we have many people who identify as leaders and we need to continue to develop our people able to inspire and motivate. However, imho, across the world, the most pressing need is to improve operational management at all levels of our organisations. We simply have to get much better at the basics of planning, organising, and effectively delivering day-to-day operations through productive use of resources, and staff.
Of all the six deliverables I work on each day, the most important to me is making healthcare more person-centred by working with the capabilities that each person brings to their interaction with health services, to respect their expertise and autonomy and their responsibilities for their own health and well being. In all management work, relationships are key and the quality of experience that staff have at work is key to patients receiving good outcomes and experience. I was particularly influenced by the work of Mike Nolan and colleagues, who argue that providers should aim to create an ‘enriched environment’ in which patients and staff experience the six ‘senses’
- Security – to feel safe physically, psychologically, essentially
- Belonging – to feel part of a valued group, to maintain or form important relationships
- Continuity – to be able to make links between the past, present and future
- Purpose – to enjoy meaningful activity, to have valued goals
- Achievement – to reach valued goals to satisfaction of self and/or others
- Significance – to feel that you ‘matter’ and are accorded value and status
Patients have previously experienced care as arranged for the convenience of the provider, aligned around sickness and a specific disease condition. In delivering Slaintecare we are empowering people, acting with compassion and seeing the whole life of the person, rather than a lists of tasks or a specific condition. Together, we have so many opportunities to deliver services that are more productive with better patient outcomes and experience. When we codesign services centred around people, we ask the person to set the agenda, say what they would like to achieve, give them support to make health behaviour changes and ultimately take responsibility for their own health and well being. As active and equal partners people can achieve the outcomes and have the experience they want, rather than giving over the responsibility and power to the provider.
I’m a person who would like to be supported to make informed choices about his own health and well being. It’s also self interest because my work has shown that this is a very successful way of working for provider organisations with better patient outcomes, better experience and lower cost. In a humanistic way it seems the ‘right thing to do’, but through release of resources also helps providers deliver the best current care and introduce the latest innovative technology and treatments.
One thing we really need to change as championed by Brian Dolan, is ending “PJ paralysis” in hospitals where older patients have been largely confined to their beds or the areas around them and assumed they have no ability to care for themselves as inpatients. Anyone who has tried to make themselves a cup of tea or a slice of toast on a ward will understand what I’m talking about here. Then we need to be better organised to get people home quicker. Older people who have been living independent lives at home, with networks of friends, relatives and their community need us to deliver more of our services at weekends and in the evenings to become more person-centred.
If as clinicians we are to recognise the expertise, power and autonomy of patients, then we need to give up some of these ourselves, and this is no small thing. Staff also need support from regulatory and professional bodies and to be free from concern about medico-legal consequences of patients exercising their options. Of course, both patients and staff need better and joint access to health records and sources of expertise held electronically. Then there is the pace-complexity issue, that is, how can staff consider the ‘whole person’ when they have so little time for each individual interaction and the demand keeps growing year on year. In my work, I found that supporting patients to set the agenda, coaching them to make health behaviour choices, supporting them to make preference-sensitive choices has been highly successful in managing demand and reducing time pressures.
Another example of this is in elective operations where knowledge demonstrates that clinicians supporting patients to make informed choices reduces the operative rate by around one third. We just do too many things ‘to’ people, because from our narrow perspective of mentor, we believe that this is the option we would choose if in their shoes. We need to support clinicians to coach patients more and mentor them less. Here is a quote from Zeus and Skiffington (2002) “Mentoring invents a future based on the expertise and the wisdom of another, whereas coaching is about inventing a future from the individual’s own possibilities… Mentors freely give advice and opinions regarding strategies and policies, whereas coaching is about evoking answers from the individual… Mentors convey and instil the standards, norms and values of the profession/organisation.”
Health services across the world are ‘late adopters’ in many ways. You only need to consider the sort of IT infrastructure and use of information systems that your bank has, compared with the health system. It is said that in health services it takes around 14 years between a procedure being universally acknowledged as ‘best practice’ to it being implemented universally. There can be very significant inertia in institutions, but also individual practitioners have great autonomy in the way they practise and of course power to delay changes in practice -t his is provider-centred care. Then clinicians perceive managers threatening clinician autonomy by seeking to reduce healthcare to a simple linear system, introduce standard packages, or pathways to limit freedom of movement and variation that seeks to see patients as having one or more standard needs that can be broken down into a series of processes. But of course, people are complex and individuals have infinite variety in their capabilities and requirements and health services are complex adaptive systems. That is, a collection of individual agents with the freedom to act in ways that are not always predictable and whose actions are interconnected so that one agent’s actions changes the context for other agents.
People often say that providing great care isn’t rocket science. Of course it isn’t – its far more complex than that. I have seen this illustrated as where we are at the moment, in systems thinking terms we are currently trying to manage all care as a simple system, like baking bread. Of course, having a recipe (pathway, process, standard operating procedure) is essential, recipes are tested to assure replicability of later efforts (we apply policy handed down without always understanding the thinking or context) no particular expertise is required but knowing how to cook increases success (approach to training managers), recipes produce standard products (and ignore individuals requirements) and there is certainty of same results every time (not always good).. We are starting to think in terms of care being complicated, like rocket science where formulae (care bundles) are critical and necessary, sending one rocket increases assurance that next will be ok (improvement science, PDSA cycles), we see the need for high level of expertise in many specialized fields and co-ordination (improved leadership and management training), we see that rockets (factors leading to good care) are similar in critical ways and we aspire to a high degree of certainty of outcome.
However, providing person-centred care is complex, analogous to raising a child, where formulae (care bundles) are helpful but don’t guarantee good outcome, raising one child (delivering care in one area) gives no assurance of success with the next, expertise (of staff) can help but is not sufficient, every individual is unique and uncertainty of outcome remains. The most important characteristic of working in complex adaptive systems is the quality of trusting relationships where an organisation can develop its staff and create the infrastructure, culture and flexibility to enable it to innovate quickly in response to or in anticipation of stakeholder needs and changes in its working environment while still controlling costs and continuously improving quality.
So, it’s taken me far too long to answer the exam question – why as a clinician did I move over to the dark side and become a health service manager ? Because I passionately believe in person-centred care as a system property and being a manager gives me the best opportunities to put this into practice for the largest number of people with whom I’m privileged to serve and to work with.
