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Published 16 March 2021
Covid-19 has disrupted strategic healthcare management plans as well as day-to-day operations. That the health service has coped as well as it has is testament to the dedication and lateral thinking of front-line staff and leadership – both within the NHS and in the independent sector. We have seen radical innovation in terms of leadership practices and approaches, some of which will re-shape the oversight and implementation of care provision permanently.
Understanding what changes have been made for the better and identifying which areas remain ripe for an overhaul is vital if the sector is to come back fitter and stronger from the pandemic. We spoke to key figures in the NHS and private healthcare to find out what leadership lessons have been learned from the crisis and what the live issues are going forward.
Listening is a fundamental marker of good leadership and an essential part of collaboration. Just as national leadership figures rightly listened to, and gave a public platform to, healthcare specialists, the industry as a whole opened its eyes and ears to the potential solutions that could be achieved if everyone within it worked more effectively together.
For Karen Prins, Chief Operating Officer of Circle Health Group, Covid-19 threw up some important challenges around how the public and private sectors work together – but also created some lasting positive consequences for future co-operation as a result. As BMI and Circle facilities welcomed a cohort of NHS staff into its hospitals, workforce dynamics inevitably altered. Suddenly there were more staff in its operating theatres and in wards, complicated by the fact that working methods were not necessarily the same. Despite this, collaboration came to the fore. While these new teams found ways to assimilate, the crisis also created a more cohesive ‘coming-together’ between different hospitals, including private healthcare providers transferring vital equipment to other sites at risk of being overwhelmed by demand.
“In the healthcare sector, you always put patient needs first, so if another hospital urgently requires a piece of kit, you’ll send it,” explains Prins. “That willingness to support each other became even greater given the common purpose of fighting Covid-19. I’ve never seen clinical collaboration like it before.”
Mehdi Erfan, General Counsel at Ramsay Health Care, echoes the sentiment that real, seamless, patient-focused collaboration has sprung up like never before. A ‘needs-must’ approach also saw the sensible sidestepping of any bureaucratic measures that risked slowing processes when speed was truly of the essence.
“When NHSE called, all providers stepped up to the mark very quickly,” says Erfan. “There wasn’t a reliance on contracts, things started with trust.”
The impact of this necessary shift in dynamics should not be underestimated.
“It’s had a profound effect on how the independent sector and the NHS work together. Many NHS clinicians have seen a different side to private providers and it has changed the landscape for the better,” adds Prins. “We’re now having conversations with NHS Trusts around what the future looks like and how we can work together differently.”
The trick is in using shared knowledge and resources efficiently, to move together for the greater good of the health system in crisis, and to benefit patients, while maintaining a healthy sense of competition to drive lasting improvements.
“It’s important to leverage those relationships, but in a way that doesn’t lose the innovation and competition between private providers that we need to maintain continuous improvement,” adds Prins.
Rob Walsh, CEO of North East Lincolnshire Council and CCG, agrees that a culture of collaboration by leaders has been essential to the pandemic response, to recovery approaches, and to new operating models that are emerging. He points out that this was not just public and private coming together; the voluntary and community sector also played a key role.
“They stepped up, adapted, led, got us out the way at times where it was needed. Without them, we certainly would be in a less strong position,” says Walsh.
"Collaboration is the biggest learning we can take away. It sounds a bit corny but we achieved a method of working where we were genuinely in it together.”
British Medical Association (BMA) research has found that 41% of doctors are suffering from depression, anxiety or stress and that the pandemic has made it worse for around one in three. Filtered to intensive care staff, nearly half are experiencing impact on their mental wellbeing due to the pandemic. At a time of heightened risk, both in a physical sense in terms of virus exposure and in a psychological sense in terms of dealing with the pressure of an intensifying, traumatic workload, leadership has had an ever more critical role to play in providing support to, and engaging with, the workforce.
As David Wrigley, BMA council deputy chair has pointed out, “The effects of Covid-19 will be felt for a long time to come, both in terms of the impact on the NHS, and the long-term mental wellbeing of our healthcare staff. Even as the number of Covid-19 cases fall, doctors and their colleagues will continue to feel the pressure as the health service faces the anticipated surge in demand for non-Covid-related treatments. Therefore, supporting the wellbeing of the health workforce must be a top priority in the long-term.”
Installing a direct line to the top is one solution that BMI Healthcare came up with during the initial peak of the pandemic. Senior executives, the CEO included, took turns to answer an internal helpline, taking calls from staff to answer their questions and listen to their concerns. Not only did this provide comfort by empowering staff and increasing management accountability, it also meant that communication could more easily cascade down through the workforce. BMI saw the benefits that having such direct accessibility can have and is using its experience to inform future communications and support strategies.
Clearly, maintaining a fit and healthy workforce is critical, both on the clinical frontline and for those newly grappling with remote working. For BMI healthcare, wellbeing covers a range of issues including financial health and physical fitness as well as mental health and job satisfaction. From running art competitions to introducing ‘virtual’ gym membership with online sessions, supporting staff outside of the working environment has been hugely well-received by staff.
Making sure that such a stressful situation does not spill over into poor management practices remains a priority. It is vital, then, that targeted training is provided and governance frameworks are adapted and audited for the realities of this new environment, in which decision making is necessarily dynamic and at pace.
Chief Executive of the NHS Confederation Niall Dickson urges leaders not to overlook their own needs. He said recently: “This may not seem the right time to be asking executive leaders in the NHS how they are coping. At times like this, protecting those treating patients directly has to be the first priority. But leaders matter too, and what is now being asked of ours is exceptional. The evidence suggests that crises of this magnitude … expose and test our coping strategies. For everyone in a senior position, the emotional rollercoaster, the fact that it touches so many aspects of personal and family life, these are bound to affect performance and levels of resilience.”
The pandemic has resulted in a necessary command and control model for rapid decision-making from the centre, replicated by Gold Command arrangements locally in NHS providers, and similar approaches by independent sector providers where the key decision-makers and settings in which those decisions have been made, have changed beyond recognition. Meeting frequencies have changed to at least daily, papers to Board are more focussed, and the evidence base for some decisions have become necessarily lighter due to the agility required in managing the risk in question. Risk profiles have changed, corporate risk registers are unlikely to have kept up with these and less likely to be updated as those risks change to a more managed state.
The pressure on maintaining good governance and assurance for leaders in healthcare is unprecedented. And yet, has this crisis provided a potential pathway for more streamlined governance for the future – both internally in organisations, and externally in integrated care systems, where leadership figures have worked together across organisations to deliver rapid solutions to the capacity pressures?
These are positive outcomes of a dreadful, challenging emergency faced by the health system. But leaders need to not only grasp the positive elements for future change, but also reinstate elements of good governance and assurance in decision-making that ensures appropriate and justifiable decisions are made, to reset some of the ‘norms’ that give confidence in leadership. Good governance is of course a facilitator not a barrier, and whilst there have been some ‘freeing’ aspects of pandemic decision-making, the basics need to be reinstated as soon as possible, to maintain the sustainable and credible decision making for leaders facing difficult decisions as they manage the medium- and longer-term impact of COVID 19.
As the pandemic continues to unfold, adaptability has become a leadership mantra. Given the significant number of ‘unknowns’ about the virus, and with official guidance continuing to change rapidly, predicting and planning even the short-term remains a tall order. Modelling has become harder, yet more vital, than ever to determine the shape of operating models and service delivery.
Responding to the state of emergency showed how quickly things can be done when they need to be but has also brought into the spotlight how governance should be retrofitted appropriately. For example, when NHS and private healthcare staff work together, where workaround solutions to problems developed in the crisis continue to be used or when it comes to sharing data securely.
More immediate leadership challenges lie ahead despite the potential hope created by the speed of the vaccination programme nationally. Walsh urges leaders not to take their eye off the ball. He sees local-level decision-making and, vitally, communication, as essential.
“There’s a lot of change still to come, and we must engage and communicate at the most local level possible. That’s how you inform policy development,” says Walsh. “With so much going on, we mustn’t lose sight of what matters most: the health and wellbeing of the local population.”
Some fear a return to old ways. Failing to seize the positive momentum that currently exists would be a catastrophic mis-step from healthcare leaders.
“We risk slowly creeping back to the land of the difficult; we must maintain the can-do attitude. Let’s not build barriers up again,” says Erfan. “If we don’t prioritise this, the moment will be lost. This is a big opportunity.”
With this in mind, healthcare leaders must push for the continuation of a judicious reset of the system whether that is through legislative reform and how Integrated Care Systems could be embedded in legislation or guidance or less formal local arrangements. That means addressing lingering issues that increase friction or removing ways of doing things that are simply no longer necessary, and celebrating and embedding better practices rather than rushing back to business as usual. Prins argues that the outlook needs to be pragmatic, yet positive. “Overall, Covid has been a powerful learning experience,” she says. “It has changed the workforce and people’s behaviour forever. We need to look at the world around us and re-emerge stronger.”
For healthcare leaders whether public or private, that’s a compelling call-to-arms.
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Anne Crofts, Alistair Robertson
Anne Crofts, Dr Alexandra von Westernhagen, Udara Ranasinghe