Based on a lengthy interview at the John Radcliffe hospital with Sir Jonathan Michael, chief executive of what is now Oxford University Hospitals NHS trust.
This article titled “Doctors and nurses turn managers in Oxford” was written by SA Mathieson, for The Guardian on Wednesday 10th November 2010 07.15 UTC
Putting clinicians in charge of management at one of England’s most prestigious hospital trusts is enthusiastically promoted by Sir Jonathan Michael, the chief executive since February of Oxford Radcliffe hospitals NHS trust. The six new division heads – each of whom will be practising clinicians – will be accountable for delivering those services, such as surgery and oncology or cardiac, thoracic and vascular.
“I’ve always been a very strong proponent of integrated clinical management, by which I mean you have clinicians and managers working in a single team,” says Michael. “I’m a great believer that the people who know how best to run a service are the people who actually deliver them.”
At first sight, this might seem like turning the NHS clock back almost 30 years before the introduction of general management. But the late Sir Roy Griffiths, the adviser to the then Conservative government who recommended that change, was clear that clinicians should be involved more closely in management and “must participate fully in decisions about priorities in the use of resources”.
Michael concurs: “As a consultant in Birmingham, looking after people with kidney failure at a time of very limited resources, I was having that debate about patients [needing treatment],” he says. “There will always be those tensions in any healthcare system.
“You need the experts in the field to be given devolved responsibility for managing their services, but they have to accept the accountability for running those services, in the manner and to the standards and within the resources that are defined.”
The reorganisation is part of Michael’s plan to cure the trust of its chronic management underperformance. His period in charge of the trust so far has been overshadowed by the suspension in March of its child heart surgery unit after the death of four babies within 10 weeks, all patients of one surgeon, Caner Salih.
On 14 October, the NHS’s safe and sustainable review recommended the permanent closure of child heart surgery at John Radcliffe hospital, saying it was the least likely of 11 centres to meet new quality standards – although others also look likely to close.
Oxford Radcliffe hospitals (ORH) trust had argued that despite the small size of the child heart surgery unit, the trust offered a wide range of associated services, allowing it to provide care to those with congenital heart disease from before birth through into adulthood. Of the closure decision, Michael says: “What we’ve got to do is see how we work in partnership with other places to maintain the integrity of the lifelong treatment.” Otherwise, fragile patients may be “spending their whole time on the train”.
And this conflict, between patients wanting the best care but close to their homes is pertinent elsewhere in the trust. Referring to national plans to reorganise trauma units, under which the trust’s main John Radcliffe hospital in Oxford may become a major centre for the Thames Valley area, Michael says: “The evidence base, in terms of centralisation, is reasonably good – in most areas there is a critical mass if you’re dealing with complex treatments, whether it’s surgery or other things.
“If you only do one or two a year, you and your team is likely to be less experienced and, to be quite honest, less competent than if you do 50 a year. That’s the rationale. But of course, local access and availability of services is very important.”
ORH also runs Horton general hospital in Banbury and had planned to concentrate some services at John Radcliffe due to low levels of work at the smaller hospital. But, explains Michael, “the trust failed to convince GPs and the population in Banbury that this was the right thing for their local health service. There was quite a lot of work over the following two years over what the model should look like, and to be quite honest, some compromises.”
Horton general, then, will maintain its services and has started outpatient chemotherapy to save cancer patients from travelling, and is looking at offering dialysis. “You can’t impose things on a community and a healthcare system if you haven’t convinced them that actually it’s the best thing for them and their services,” says Michael.
The trust has a very good reputation for clinical services – it recently gained the top “excellent” rating from the Care Quality Commission (CQC) for services to patients for the second year running. But relations with other parts of the public sector, including local authorities, other NHS bodies and the university “were not as strong as they might have been”, admits Michael.
The trust had missed performance targets, and was not able to establish either a joint venture with Oxford University to create an Oxford Academic Health Sciences Centre, or become a foundation trust – a status that Michael values, having run Guy’s and St Thomas’ hospital, which became one of the first foundation trusts.
ORH also had what Michael described as “a sort of chronic problem with finances, and had struggled to make the books balance over the years”. The CQC gave the trust its lowest “weak” rating two years running for its financial management, although the commission’s latest rating is the second best: “good”.
Soon after joining the trust, in an interview with the Oxford Times, he said: “I look at this organisation and liken it to a Ferrari with 12 cylinders that is only firing on eight.” Any further improvements will need to be made with the financial challenges facing the NHS in mind.
The trust needs to make savings of £47m this financial year and at least the same in each of the next three years in line with national targets to reduce NHS spending by £20bn. It says it is too early to say how many managers have left the organisation as a result of the restructure as some may take on new roles and the appointment process is not yet complete.
It also plans to merge with the city’s specialist Nuffield Orthopaedic Centre, with the aim of cutting more management and administration posts as well as boosting the joint trust’s chance of gaining foundation status.
However, Michael says that other parts of the workforce will also be affected and redundancies cannot be ruled out. “We have an imbalance between income and cost base, and 65% of our cost base is staff,” he says. The trust is minimising the use of temporary agency staff, but that will not go far enough: “The hope is that we will be able to manage the necessary changes in workforce cost by natural turnover and redeployment of staff into vacancies as they arise.”
During a career spanning 40 years in the health service, Michael, 65, feels that society’s expectations have changed. “The NHS was very focused on the needs of the organisation, and patients were almost there as supplicants,” he says. “Patients now expect to be treated like customers. We’re in the healthcare business.”
As for the coalition government’s GP commissioning consortiums, Michael sees advantages: “I think it’s an opportunity to see a movement towards more integration of care for patients, rather than having these rather artificial divides between acute hospitals and community services.” ORH is already examining how it might provide services such as diagnostics to patients in the county’s community hospitals.
“I’ve been in the NHS long enough to have been through so many reorganisations that I’m fairly relaxed about it,” he says.
Lives Surrey and Oxford.
Status Married with three daughters, one stepdaughter and one son.
Education Bristol grammar school; St Thomas’ hospital medical school.
Career February 2010-present: chief executive, Oxford Radcliffe hospitals NHS trust; 2007-10: managing director, BT Health; 2000-07: chief executive, Guy’s and St Thomas’ NHS foundation trust; 1980-2000: consultant physician and nephrologist, Queen Elizabeth hospital, Birmingham, also medical director (1994-97), chief executive (1997-2000), University hospitals Birmingham NHS trust.
Public life Knighted in 2005. Chaired inquiry into healthcare access for learning disabled people, published 2008.
Interests Time with family and friends.
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