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Brian James on... being scrutinised

Updated Monday, 8th January 2007

So what was it like being under the microscope? Brian James, chief executive of Rotherham NHS Foundation Trust, gives us his perspective on what it was like to have a management guru look at your management structure and style.

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What was your first impression of Gerry’s approach to management?

Well, Gerry mainly advocates that good management is really demonstrated by being out and about and talking to people directly, and getting them directly engaged and motivated in change. And certainly that was the style he deployed when he came to us. He was in direct communication with consultants; he was directly appealing to them to get involved in the changes that he wanted to see happen. And some of that worked reasonably well and some of it worked less well. But that was his style.

I think where it’s fundamentally different, is Gerry believes that good management is the same whether it’s running a big organisation or running a corner shop, and that really it’s about leading by example, leading from the front, mobilising and incentivising people to change. I think what is not understood by Gerry, even at the end of it, is the serious constraints that we operate under. In particular, the volume of Government policies that we are required to introduce. My job, at the end of the day, is to implement Government policy, regardless of how unpalatable that policy might be for the staff in the organisation. So I have to prepare the organisation for change to guide them through that change in ways that have minimal impact upon them and in particular on the safe care we deliver to patients. That takes time. That was time that Gerry felt was wasted time; that in fact it would be better done by just being out there and talking to people.

I think we’re just going to have to disagree on that. I think that the changes that we have to make, the policies we need to make, require very careful planning if we’re not to compromise patient safety and we’re to carry our staff with us. It can’t just be about being out there; it has to be about making sure the ship is properly prepared for the voyage. That’s not to say I don’t accept fully the importance of, having prepared the ship, getting out there and letting the troops see you on the ground floor. But at the time we did the programme, we actually weren’t really in a position to do that because we were very busy implementing our new structures for the future.

So that’s where the key differences, I think, come between his approach to doing things and mine. I am now getting out and about a lot more than I did but that’s because I have now the luxury of a full team to support me, which I didn’t have throughout the period of the filming of the programme, and our course is now very much set.

How do you think being the Chief Executive of an NHS hospital compares with the same role in other organisations?

I would love to have the level of control that Gerry would have in a business but I don’t. There are so many of the factors that, even though I’m a chief executive, I do not control. For example, I don’t control the wages of my staff so I can’t use money to incentivise people, whereas if I was a businessman in charge of my own organisation, I probably would use money to incentivise people. I don’t make decisions about what new drugs are introduced and at what cost. You know, I can’t determine how much extra money the Government makes available for health care.
As chief executive I have to juggle the interests of many audiences. I am constantly needing to look upwards to understand and interpret the policies that Government wish to introduce, without having any say in their development or introduction. I also have to manage downwards the expectations of the staff within the organisation, about their futures, about their careers, and at the end of the day I’ve got to be absolutely concerned about the safe delivery of care to patients which is the whole reason why we’re here in the first place. In the middle of all that, I have to satisfy the needs of MPs, special interest groups, the public, GPs, complainants etc. It’s a much more complex environment in which to manage than a normal business.

Do you think Gerry’s focus on theatres was a valid issue for his attention?

Yes, I do, but I think he also needs to understand the constraints we’re operating under. As much as he was encouraging us to open up all our theatres and to use them to their maximum capacity, the other constraint we have to work under is that actually our primary care trust - which is a very good primary care trust by the way – simply couldn’t actually afford the work even if we did it.
The fact is that the market we’re operating in is not a real market. It is a market that has a very clear financial cap on it which actually means that you have to control the volume of work you do very carefully. If we didn’t do that, then what we would start doing is bankrupting our primary care trust, and they’d have to make difficult decisions about other services that they would have to ration, or literally go bust, which would certainly not be in the interest of the people of Rotherham. So we must work hand in glove with them to maximise the value of the health pound in Rotherham.

So, yes there are theatres lying empty, and yes that is largely on a Friday, but actually that’s because the economics make more sense to shut all your theatres at the same time rather than have them open and shut in dribs and drabs throughout the week because the infrastructure that you have to keep on tap to support them. Why Friday? Because it is not sensible to do big operations on the day before a weekend, since we tend to run the hospital with minimal staff over the weekend. So I understand why Gerry feels that this is a most precious resource – in fact it is our most important asset – that we’re not maximising the use of. I absolutely agree with him. It is our production room, where we do the most work that earns us the most money, so of course I’d love to use it a lot more, but the fact is that nobody could afford to pay us for doing the work.

In fact our issue is not the empty theatres; our issue is the efficiency with which the existing theatres sessions are being utilised. We really need to understand what causes delays in theatre, and what could be done to resolve those delays to achieve smooth and efficient operating. We get poor value for money if our surgeons have high periods of downtime between patients arriving and patients going. Now, part of that is to do with the processes that are operated within theatre; the way that we anaesthetise patients and the way that we recover them. We are looking for ways of improving and speeding up that process and we have a number of projects running now which are aimed precisely at improving productivity through the theatre, minimising the downtime. It is absolutely vital that we do that, but the reasons why we have such issues are quite deeply embedded in the way that clinicians actually practice their craft.

To get people to change their long standing routines and practices, you have to find something that motivates them. We’ve got to find ways of incentivising people to change. But this is made more complex by the fact that we’re locked in, like every other NHS trusts, into national staff contracts, the consultant contract, for example, which makes it very difficult for us to move to a new system. It is one of the reasons why we wanted Gerry to come in, to see whether there were approaches we could take that we hadn’t thought of that might make a difference.

 

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