The world class talent signing for team NHS

BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j1036 (Published 01 March 2017) Cite this as: BMJ 2017;356:j1036
  1. Tom Moberly, UK editor, The BMJ
  1. tmoberly{at}bmj.com

In the past two years, three of the UK’s leading hospital trusts have appointed candidates from overseas to be their chief executives. Tom Moberly looks at what these international recruits are bringing to the NHS

What links the leading acute trusts, University College London Hospitals, Great Ormond Street Hospital, and Oxford University Hospitals? Answer: they have all appointed their chief executives from overseas. Marcel Levi, from the Netherlands, is newly installed at UCLH; Peter Steer, from Australia, has joined Great Ormond Street; and Bruno Holthof, from Belgium, runs the Oxford trust.

That UK hospital trusts are buying in management talent from abroad isn’t new. Keith McNeil came from Australia to run Addenbrooke’s Hospital in 2012, Tracey Batten, also from Australia, joined Imperial College Healthcare in 2014, and Robert Bell, longtime chief at the Royal Brompton and Harefield NHS Trust, hails from Canada.

But Nigel Edwards, chief executive of the Nuffield Trust think tank, identifies a recent rise in the number of international chief executives recruited to NHS trusts. “The calibre of the people they are appointing is very impressive,” he says. “And it is undoubtedly useful to have people who bring new perspectives and who may be less hidebound by the NHS way of thinking.” Edwards says the fact the NHS has found it necessary to recruit from abroad points to a lack of suitable UK candidates. “There is an increasing difficulty among large trusts in finding people willing to take on these big roles, which might explain why some organisations have gone for international recruitment.” However, he adds: “This is relatively new, but there is not enough of this to call it a trend,” he says.

Tough space

Steer says that part of the problem in attracting UK talent to chief executive roles is the demands inherent in these roles.

“We've seen huge turnover and we still have a pretty short half-life of CEOs across the NHS,” he says. “They aren’t attractive roles when the political and media scrutiny can sadly be framed as a blame culture, rather than an instructive one where we're all actually on the same side.”

The lack of a career structure to enable chief executives to work up from smaller to larger NHS organisations also causes problems, he says. “The minute you start as a CEO, no matter where you are, it’s a tough space.”

Edwards points out that, so far, the trusts that have recruited chiefs from overseas are mainly larger and more complex NHS organisations. “They tend to already have a more international mindset due to their extensive academic activity,” he says.

In London, Levi believes one of the reasons that chief executives in larger trusts have been recruited from overseas is that the roles are sufficiently challenging to attract overseas candidates. “It is an attractive job,” Levi says. “And mostly they come from a good job and they want to develop,” he says. Levi is one of several chief executives to head abroad from the Netherlands—to Sweden, for example—leading to comparisons in the Dutch media to Premier League football players. “They said it’s usually only soccer players and business leaders that go to another country, but now we are like an export industry.” Levi says.

Steer feels he has reached a career pinnacle in joining Great Ormond Street, and that there may be nowhere else for him to go. He describes his current roles as the “best job ever.” “I don’t know what I’d do after this,” he says. “I really don’t. It’s actually quite a problem.”

Bruno Holthof

Bruno Holthof joined Oxford University Hospitals in October 2015. He was previously chief executive of Antwerp Hospital Network, in Belgium, and before that worked as a partner at the consultancy firm McKinsey.

“One of the areas where I think the NHS can learn from other health systems is in developing frontline leadership and being capable of executing change. It’s not a lack of ideas on service innovation; it’s how you get to implement them. The NHS is very well aware of the innovations happening in other healthcare systems whether that’s in the US, Europe, or Asia.

“My strong belief is that implementing innovation involves a lot of hard work, and the work happens at the frontline. If you want to change how patients are being cared for in a hospital ward, you need a lead consultant and sister responsible for the work to be driving that work. Change doesn’t happen nationally or at the board level of institutions. It happens in those frontline positions.

“The other thing I think the NHS can learn is how you do those change programmes. My experience is that successful programmes in other systems take a long time. They take at least five years to have an impact. You need to involve a lot of lead consultants and sisters in the change, and not just in a single institution, but also in general practices, community services, and social care.

“We’re not changing our healthcare system by developing presentations or filling in templates. In McKinsey I was very much involved in innovation and how innovation can increase productivity. I think productivity is the solution for the NHS. We need to be able to become the most productive system in the world, given the budget limitations of the NHS.

“For me, the solution to increasing productivity is innovation and bringing innovation from either academia or other leading healthcare companies into the NHS. But it’s a very tough job. Bringing innovation into the NHS and increasing productivity requires frontline clinical engagement and an ability to embrace innovation. I have to explain to the clinicians who are leading these services how to do it and how difficult it is.

“If you want to increase productivity of the system, it requires significant change. You can’t do that without closing capacity, reallocating capacity, redeploying the workforce, and retraining the workforce. So it has significant implications for people and infrastructure.”

Marcel Levi

Marcel Levi has been chief executive of University College London Hospitals since January. Previously, he was chair of the University of Amsterdam’s department of medicine and division of medical specialisms.

“I did a similar job in the Netherlands, so there are not many surprises in terms of the work and the people. I thought the system would be very different from the system that I was used to in the Netherlands. But I’ve been here for six weeks now and I think the biggest discovery is that there are actually more similarities than differences between the two systems.

“One of the big things in my previous job was fighting against bureaucracy. The amount of control and bureaucracy here is absolutely stunning. I’ve never experienced something like this in my entire life. Even if your trust is running okay—financially, in terms of quality and everything—you have to report every week all these stupid figures. I have at least 50 people here working on that. It’s incredible the amount of money and energy that we have to spend on it. It’s absolutely useless and it’s a waste of money.

“I think we can improve a lot of things for junior doctors. I come from a system where the junior doctors are extremely important in the hospital. I hate the idea that they are only here for one year. In the Netherlands, we mostly have three years in one hospital and then three years in another hospital. We’re trying to think about ideas about how to keep them here a little bit longer and we may be in a position to do that—for example, to combine research positions and training positions for some of them.

“One of the urgent things—and that’s what my next meeting is all about—is the lack of proper digitisation of the UK healthcare system. I go around the hospital, and it’s like going back in time 15 years. It’s incredible. There are kinds of problems that I’d almost forgotten; we just had an electronic system, so everything was there.

“If we had a good electronic system in place our consultants could access their patient information from everywhere, from their home, from their other clinics, or wherever they are. It’s such a big improvement, and we have to have it—we are so far behind.”

Peter Steer

Peter Steer has been chief executive of Great Ormond Street Hospital since January 2015. He was previously chief executive of Children’s Health Queensland Hospital and Health Service, and he has also worked in New Zealand and Canada.

“It’s interesting how often things seem very much the same despite some very significant differences in geography. Having worked in other highly charged political environments has been valuable in that it has meant that I haven’t been surprised here.

“I’ve also been fortunate to have had some experience with capital development and funding. We are in this fairly tight and brownfield inner city site in the middle of London. It’s both expensive and challenging to rebuild. So having had some of that experience before has been valuable—parachuting into that particular challenge anew and fresh, without experience, would have been quite challenging.

“One of the things that is quite challenging in the NHS is the extraordinary fragmented nature of the system. Since the last reforms it is an incredibly complex, layered, and burdensome system from the commissioning and funder end.

“One of the results of that fragmentation is that we do spread our leadership and management talent thinly. Given the complexities of commissioning healthcare for a population, to think that any country could stand up over 200 [clinical commissioning] groups of really super competent efficient bodies to do such a thing overnight is a bit of a stretch.

“To me the real challenge is that we’ve kind of lost the plot on wait times and on referral to treatment time. I think there’s a real risk, not only that we are over promising politically and bureaucratically but that there’s no way we could deliver on the promise. We’re setting ourselves up to fail.

“More importantly, I think we’re on a narrative here that is dangerous in terms of our clinician engagement. If we’re setting the system up to fail, and if our clinicians are disengaged from this story around timely clinically appropriate access, we’re going to have another bigger problem in the future. I think it’s a little bit more rational in Australia. There has been some great work done—and I’ve got a paediatric lens on this—in terms of solutions to paediatric access issues that have been genuinely consensus and clinically based and where you can get genuine buy-in from providers and clinicians.”

Discussion at Nuffield Trust summit

On Thursday 2 March, Nigel Edwards, chief executive of the Nuffield Trust, will be chairing a panel session at the Nuffield Trust summit entitled “Learning from international health systems.”

Speaking at the session will be Tracey Batten, chief executive of Imperial College Healthcare; Marcel Levi, chief executive of University College London Hospitals; Mark Pearson, deputy director of employment, labour, and social affairs at the Organisation for Economic Cooperation and Development; and Peter Steer, chief executive of Great Ormond Street Hospital for Children.

A live stream of the session will be hosted on bmj.com and the session will also be available to view after the event.

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