Department of Health Skip to content

Please note that this website has a UK government access keys system.

You are here:

17 March 2011: Cambridge University Hospitals NHS Foundation Trust’s Leadership Forum

  • Last modified date:
    25 May 2011

I find myself in an interesting and unusual position. 

First, I am part of a coalition government – the first since the War – elected in difficult times, with a single overwhelming task that has been forced upon us – to dig the country out from under a mountain of debt and return our public finances to strong and sustainable footing.

This in itself will require leadership and determination on a grand scale.  Perhaps not what you might expect from a coalition government, but none the less, that is what you’re getting.

But neither I nor any other member of the government, from either party, entered politics for this reason. 

Despite what the reputation of politicians, we generally enter politics because we want to make our community, out country or even the whole world a better place, and we feel strongly that we have something to offer personally.

Speaking for myself, I entered politics because I believe that public services can be so much better than they are.  I felt so strongly about this that I left my previous career as a civil servant to stand up for what I believe in Parliament.

You may remember that prize winning documentary from the 1980s, Yes, Minister?  I am one of the very few who have been both Bernard and Jim Hacker!

In the same way that our economy has been transformed by the spirit of enterprise, I believe that our public services be rejuvenated by harnessing the passion, creativity and ingenuity of our many public servants.

For many years now, the focus of my political life has been the National Health Service.  I have seen for myself the incredible things its people are capable of.  Excellent care, first class treatment, incredible results. 

But I have also seen how the system can get in the way of those people.  Stamping on rather than supporting their ideas, strangling them in red tape rather than clearing the way for innovation, drowning them in a sea of bureaucracy rather than freeing them to act.

Now that I am in a position of influence, I feel very deeply that I must do everything in my power to help the NHS to be as good as I know it can be.  To help the people of the NHS achieve their full potential

What is leadership?

But before I talk about leadership within the NHS, I would like to briefly look at leadership in general.

In essence, I think it’s about setting out a clear vision and purpose that others can follow.  It’s about engaging people to that purpose and maintaining an unflinching focus on fulfilling that vision.

The American theologian and academic, Theodore Hesburgh, once said, “The very essence of leadership is that you have to have vision.  You can't blow an uncertain trumpet.”

For without that clarity, those who follow, those who implement, those who are entrusted to make that vision a reality, will face an impossible task. 

A failure of management can often be traced back to a failure of leadership.  For if the end goal is not properly thought through, if the logic of the argument is flawed or based on a false premise, then no amount of effort will ever make it work.

Leadership is therefore more than an act of will; it is an act of thought.

To a large degree, I believe that is one of the fundamental problems of the National Health Service.  It is based on the false premise that something as huge and complex as the nation’s health, that an organisation that employs more than a million people and treats over a million people every 36 hours, can best be managed from the centre.  That all we have to do is find the right combination of guidelines and targets, control a little tighter, mandate a little more and all will be well. 

I simply don’t buy that.

General Patton got it right.  He said, “Don't tell people how to do things, tell them what to do and let them surprise you with their results.”

The role of the Health Secretary should not be to tell you all how to do your jobs.  How arrogant and how ridiculous that notion is. 

The role of the Health Secretary, for the NHS at least, should be to set the objectives and then let you surprise me with the results.

The high-level objectives for the NHS will come in the form of the Outcomes Framework, setting a clear national direction, constantly improving outcomes for patients.  By making clear what success looks like it will be obvious whether a particular part of the NHS is achieving it.

But beyond that, I believe that leadership should come from within.  For beyond the high-level goals set out in the Outcomes Framework, the question remains - how to achieve those aims? 

This is where the Health Secretary, the Department of Health, the Strategic Health Authorities and the Primary Care Trusts, however skilled and well intentioned they may be, can never be as good or as effective as local clinicians.

Clinicians able to identify the needs of their local populations; to recognise the roadblocks to better patient care; and to act to put things right.

It is clinicians, from both primary and secondary care, tertiary and community care working together and with others in their local authority and in social care who can design and deliver better care for patients.

Just last Friday I was talking to Dr Liz Robin, Director of Public Health here in Cambridge.  She was telling me how, by inviting GP Commissioners into the discussions of the PCTs Senior Leadership Team, they had already “improved the overall quality of the decisions taken.”

Leadership vs. management

This is clinical leadership, and I want it to be the future of the Health Service. 

But do not confuse leadership with management, something we have always had a great deal of in the Health Service.

Management and administration are vital, but they should exist to support the decisions of leaders.  Effective management is about making sure that objectives are realised. 

In a moment I will talk a little about how our plans to modernise the NHS – through commissioning and the any willing provider reforms – hope to unlock the potential of the NHS and the people within it. 

But better care is about more than structures and mechanisms, it’s about people. 

National Leadership Council

If we are to have clinical leadership then we also need strong clinical leaders. 

The National Leadership Council is working to develop those clinicians who will need to step up under the new system and take on greater responsibility for local services.  It already started to run a coaching programme for GP consortium leaders and now offers 120 leadership fellowships, which focus on practical improvements as part of their development.

The clinical leaders of today and tomorrow will be essential in deciding the future direction of the Health Service.
• On the future of education and training,
• On achieving everything that is possible through commissioning,
• And on the continual development of quality standards and the outcomes framework.

Your voices are needed more than ever, but now, they will be heard and they will be acted upon because you will hold the power to decide.

Chief Residents’ Programme

But perhaps more important than decisions and debates taking place at the national level, is what’s happening in individual Trusts.

It’s appropriate that I’m here talking at your ‘Leadership Forum’, itself a clear sign of your commitment to clinical leadership, for in many ways Cambridge – as you might expect – is leading the way.

And not only when it comes to embracing clinical leadership, but also from pushing the boundaries of medical science through your Comprehensive Biomedical Research Centre.  Where among many other things, you’re extending what is possible for cancer patients through your new Cancer Centre or leading research into combatting osteoporosis or arthritis.

But the forward thinking does not stop there.  One particularly interesting initiative is your new Chief Residents Programme, run with the Judge Business School.  By bringing the future leaders of the hospital together with some of the greatest leadership minds in the country, you will ensure that your best clinicians are also your best leaders.

But as well as the 10-day, stripped down mini-MBA from the Judge, it is the practical projects here within the Trust which make the real difference.

• Things like improving the induction for juniors;
• making sure that every doctor is fully engaged in patient safety
• and, just to show how quickly the world changes, what to do if a consultation that went badly was filmed and ended up on YouTube?!

Example – Addenbrooke’s Renal Pilot

I was at the Healthcare Innovation Expo last week, an excellent showcase not only of some of the most advanced technology available but of some of the best and most forward thinking within the NHS.

New thinking about how to organise services, how to work across organisational boundaries, how improve clinical outcomes, improve efficiency and, often, how to do all of these things together.

There was even an example that sprung from the Chief Residents’ Programme here at Addenbrooke’s.  I think they call that serendipity.

Some of you will know this, but for some time the Trust had been aware that junior doctors have been ordering unnecessary diagnostic tests. 

So, led by renal consultant and clinical IT lead, Dr Afzal Chaudhry – who I think is here today – and with the support of a company called Care FX, a small pilot was established to test the idea. 

Basically, if two of a patient’s three previous blood tests were normal, the doctor would be asked if they were sure they had a clinical need for going ahead with the test. 

If they did, then of course they could still order it, but if they were only doing it for the sake of it, then the system would automatically cancel the test.  A simple prompt to the doctor to stop and think before acting.

Where prompted, this pilot on the 5 most common renal tests, led to a 22% fall in the number of tests carried out.  And fewer unnecessary tests mean fewer needles being put into patients. 

An uncomfortable experience for most, but for some it can be agony and blood tests can quickly lead very small babies to need a transfusion.

Fewer tests also means fewer bottles and labels produced and disposed of on the ward and in the lab, and more time freed up for the tests that really do matter.

The pilot also yielded a great deal of valuable data on the clinical behaviours of doctors at the moment decisions are made.

Now, this was more of a ‘proof of concept’ than a wide spread trial, but the results were so telling that whatever decisions the Trust makes regarding the upgrading of its IT systems, it wants to make sure it can take these benefits forward.

Modernisation

Doctors spotting a problem and being free to solve it.  This is clinical leadership in action and I hope that as we modernise the NHS, we will see a good deal more of it.

For our plans for the Health Service are about one thing and one thing only – giving patients health outcomes that are consistently among the very best in the world. 

We will do this through an unswerving focus on outcomes, by giving patients more control over their own care, including involving them in the decisions made about their own treatment, and by putting clinicians in the driving seat of the National Health Service.

I want to talk today about two principal aspects of our plans:
• The impact of clinical leadership on the design and commissioning of local health services, and
• also the impact of our provider side reforms for organisations like Addenbrooke’s.

Commissioning

First, commissioning.

For many years now, I’ve travelled around talking to clinicians the length and breadth of the country.  The one thing I would here time and time again was, “I wish they would let me get on and do the things I know will deliver better care for my patients”. 

Well ‘they’ is now me, and I am determined to give people the freedoms they have asked for.

I know that people in the health services and in all of our public services have an incredible capacity for creativity, for innovation and for success if only they have the freedom to act and make things happen. 

General Practice-led commissioning will, for the first time, make the people who hold the purse strings and the people who make the clinical decisions, one and the same.

But do not think that because commissioning will be general practice-led specialists will be somehow left out of the loop. 

Because, by paying the NHS for the quality of the outcomes it delivers and not simply for the amount of activity it undertakes, the focus will be on the pathway of care rather than on what one particular institution can do.  More than ever, integration will be the name of the game.

Clinicians from general practice will need to come together with clinicians from secondary and tertiary care, with those from community care and their colleagues in local authorities, to design and commission services that lead to the very best outcomes for patients in their area. 

When these conversations take place, the focus very quickly becomes the patient and not the institution.

These conversations are already leading to exciting new developments

Example – diabetes care pilot

Here in Cambridge, doctors from Addenbrooke’s have been working with their colleagues in general practice in East Cambridge and Fenland with dramatic results. 

By investing in community care to improve glucose control in diabetics, inpatient admissions have been reduced, almost immediately, by 40%.

Another important aspect of this work has been enlisting patients in the active management of their own condition. 

Community nurses spend time teaching people how they can do more through things like diet and self-testing, to improve their quality of life and to avoid the worst aspects of their condition.

By working together, you have produced massive improvements in patient outcomes – especially when the result of many of those prevented outcomes would have been amputation.

But you’ve also saved money through far fewer expensive hospital treatments.  Money that can be better spent elsewhere. 

Across Cambridgeshire, GPs are keen to roll this approach out.  Based on the experience of this pilot, it could save the NHS in Cambridgeshire around £5 million a year.  And if you extrapolate up for the rest of England, that could mean a huge benefic for patients and an annual saving of around £400 million.

I know that Dr David Simmons, the lead clinician for the pilot, is writing a paper which I’m sure will create a great deal of interest around the country and far further afield when it comes out.

Providers

But our plans for transforming the commissioning of services are not uniquely radical.  We will also bring real change to the provider-side of the NHS:

• opening up the provision and delivery of healthcare to any willing provider,
• publishing far more, and far more meaningful information about the quality and outcomes of particular providers,
• and, with every NHS Trust a Foundation Trust, we will also redefine what it means to be a Foundation Trust.

We will never alter the values of the National Health Service – the best available treatment, based on need and not the ability to pay, free at the point of delivery.  But as long as these values remain, then we should do everything we can to make sure that patients receive the very best standards of care.

If our goal is to have outcomes as good as the best in the world, then we should do everything we can to help patients and their doctors to choose the best available care, whoever provides it.

In the coming months, we will publish the results of our consultation on an information revolution.  Armed with a clear picture of just how good a particular institution, department or, possibly, consultant-led team really is, patients and their doctors will be able to choose the best and most appropriate care for them.

And because the money will follow the choices of the patient, how good a particular institution is will really matter. 

Some say that people don’t want choice, but think about that for a moment.  What would you do if you could see that the treatment you would receive – or your children or your parents would receive – in your local hospital was significantly worse than one further away?

What is more important to you when it comes to your own or your families health – short term convenience or the quality of healthcare?

And think about how quickly we have all become used to choice in every area of our lives.  People may not be used to having control over their own care now, but it won’t take long and there will be no going back.

For some institutions, any willing provider will, quite rightly, be cause for concern.  If you are not as good as you know you should be, if you compare poorly with others, then you will start to see patients choose to go elsewhere.  You will have a huge and very real incentive to improve, and to do so quickly.

Here good quality clinical leadership will be the only way of addressing whatever issues you face within your organisation.  For no amount of management-led cost cutting or administrative change will help.

It will take clinicians to assess the problem and come up with a solution that improves outcomes for their patents.  And if the outcomes improve, so too will the financial situation of a Trust.

But for those who provide excellent care, for those who can demonstrate that they deliver the best outcomes and the best patient experience then the rewards will be significant. 

As we give more powers to Foundation Trusts, places like Addenbrooke’s will be able to take the funds that come from excellence – both through patient choice and through a new tariff that rewards providers based on the quality of care delivered – and reinvest those funds in even better care.

That will mean more funds for you to improve further and expand your services.  Perhaps even to open a new branch of Addenbrooke’s somewhere else?  Why perhaps even an Addenbrooke’s Oxford!

New relationships

Some may want to take advantage of the removal of the private income cap to generate still more funds to invest for NHS care.

Some hospitals are already looking at expanding their private practice, at opening new branches both here and abroad. 

Moorfields Eye Hospital, for example, has opened a branch in Dubai.  Again, the money raised from this venture feeds directly back into improving their NHS operation in London. 

John Pelly, Moorfields's chief executive, has said: "Without profits [from our commercial business] our ability to invest in our clinical services would be seriously constrained.”

Example – NHS Bexley

Others are already looking at working more closely with specialist private providers to deliver better, more cost-effective care to NHS patients.

Another example on display at the Innovation Expo, was how, over the last year, Bexley NHS Care Trust in Kent has significantly improved their cardiac care by working with a private company – the European Scanning Centre in Harley Street – who own perhaps the world’s most advanced CT scanner, the £2 million Aquilion ONE.

Patients in Bexley get access to the very latest technology without the need for a significant capital investment and, working with the provider and local cardiology consultants, they have been able to redesign the entire cardiac pathway. 

This has significantly improved care for patients in the area while saving an average of £1,500 per patient.

There will be no limit to the potential improvements that the best hospitals in England can make.  So the question for you today is, what do you want the future to look like? 

Cambridge University Hospitals Trust already has a reputation for excellence on which to build.  But it will be up to you, to the clinicians supported by management, to grasp the nettle, to set your direction and to meet whatever goals you set.

Conclusion

Strong clinical leadership is not about turning a doctor into a bureaucrat. 

It’s about equipping the people who understand and have the closest relationships with patients with the skills and the authority to lead.

It’s what any organisation that wants to deliver the very best outcomes for its patients needs. 

I hope that if I were to return to address you in 4 years time, it really wouldn’t matter who was in the post of Health Secretary, as far as the NHS was concerned.  It would matter a great deal when it comes to public health, but for the NHS, I hope that it will be you who are very much running the show.

Clinicians in Cambridge have long been at the forefront of commissioning and working across boundaries.  And I have high hopes that when full responsibility is devolved to the local level and when the unnecessary layers of management bureaucracy – the PCTs and the SHA – are stripped away, the people of Cambridgeshire – who I have the honour to represent – will benefit from some of the very best care in the country, indeed, anywhere in the world.

Thank you.

Access keys