Health Management Institute Institute of Healthcare Management

1. Health Management InstituteInstitute of Healthcare Management Leadership for Service Modernisation Building New Organisations in Northern Ireland william.mckee@belfasttrust.hscni.net Dublin 15 May 2009

2. The Iron Triangle of Health and Social Care Safety and Quality Access Responsiveness Expectations Cost control Productivity

3. Presentation format • Opening comments • Political timeline • Some theory about mergers • The merger process and our approach • What worked well • Further development needed

4. Political timeline • Devolution ‘98 to ‘02 and the Review of Public Administration (RPA) “Bonfire of the Quangos” • Direct rule ministerial decisions Nov ‘05 • 18 trusts merged into 5 and operational April ’07 • 4 Boards replaced by Regional Authority April ’08 • Devolution returns May ’07 and Minister McGimpsey reviews structures • Board and Agency replaces Authority

5. Stated objectives and unintended consequences of mergers • Stated objectives • Savings • Reducing performance variation • Larger pool of staff, larger teams of specialists • Other economies of scale, training,influence

6. Unintended consequences of mergers • Remote senior managers not devoting enough time to clinical staff • Service managers remote from their services • Loss of informality and familiarity, loss of autonomy and local decision making • Unresponsive and slow decision making • Previous direct access to senior managers now with middle managers • Internal communications deteriorate • Naomi Fulop et al

7. Some advice from Machiavelli “ There is nothing more difficult to take in hand, more perilous in conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things “

8. Merging Six Trusts into One • Brief shadow period • Clarity of purpose and business • Pace and engagement • Kill the old organisations. Hold “wakes” Acknowledge grieving • Managerial posts down to 5th level by competition • Voluntary severance only after level below filled • Structuring the new organisation

9. Structuring; three basic options Professional Functional Geographic Institutional User group Population cohort

10. Social Services/ Family & Child Care Older people, Medicine & surgery Chief Executive Head and Skeletal Services Communication Head of Office Specialist Services Clinical Services 22,000 employees £1,100 million revenue 340,000 population base Mental Health & Learning disability Human Resources Organisational Development Finance Chief Operating Officer & Deputy Chief Exec Nursing & Patient Experience Planning & Development Medical

11. The Merger Iron Triangle And…….get organisational control Safety and Quality Access Responsiveness Expectations Cost control Productivity

12. People Management • Volunteers not conscripts • Staff and TU engagement and relationships management • Clarity and honesty. • Support mechanisms • Investors in People award

13. Setting a strategic direction • Business and purpose • Values • “Involving you” • “The Belfast Way” • “New Directions” • “Excellence and Choice”

14. SETTING A STRATEGIC DIRECTION The Belfast Way • SAFETY • Provide safe high • quality effective care • Standards • Outcomes • HCAI • Continuous • improvement • Assurance PURPOSE Improve health and wellbeing and reduce health inequalities BUSINESS In partnership with others, and by engaging with staff, deliver safe, improving, modernising, cost effective health and social care 5 CORPORATE OBJECTIVES • MODERNISATION • Reform and renew our health and social • Services • Access • “Localise where • possible, centralise • where necessary” • Service reviews • Aligned capital plans • PARTNERSHIPS • Improve health and wellbeing through partnership with users, communities and • partners • Citizen centred • Joint working • Civic leadership • STAFF • Show leadership and • excellence through • organisational and • workforce development • Investors in People • Staff engagement • Leadership • Learning + development • Team effectiveness • RESOURCES • Make best use of • resources by improving • performance and • Productivity • MORE • Workforce diagnostics • Process improvement • Resource utilisation • VFM • Performance management VALUES AND BEHAVIOURS Respect and dignity Accountabilities Openness and trust Learning and development

15. Financial challenges • CSR and efficiencies “2.5% 3.0% and 3.5% pa • £90 millions plus a £30 m underlying deficit • Not “turnaround” but MORE; maximising outcomes resources and efficiencies • Integrated into performance management and mainstreamed. Improvement and modernisation led • The right patient getting the right treatment at the right time in the right place by the right person

16. Performance management • External top down pace setting approach at odds with internal culture • Waiting time successes • Sustaining improvements • Board Assurance

17. Senior team setting a tone • Chief Executive or Chief Leadership and Engagement Officer • A steady developmental journey; weekly and monthly meetings and workshops • Managing time and pace • Setting the tone for the organisation; respect, trust, boldness, diligence and fun • Trust-risk-change-improvement • Let purpose be our guide

18. People and systems • Success is 80% people and culture and 20% systems protocols etc • But choose your systems carefully • “Toyota have average managers made good by great systems. The NHS has good managers made average by poor systems”

19. Areas for Improvement • Moving from start up to sustainable progress • Pareto’s 80/20 rule and wicked problems • Systems, scheduling and capacity management • Creating some headroom time out and support • Making promotion attractive again • Political leadership • System commitment to stepped productivity • Engagement especially clinical engagement

20. “Getting started, keeping going, getting started again – in art and in life, it seems to me this is the essential rhythm not only of achievement but of survival, the ground of convinced action, the basis of self-esteem and the guarantee of credibility in your lives, credibility to your selves as well as others.” Seamus Heaney