Dilemmas of leadership at the NHS

September 2, 2012

Leaders in the UK’s National Health Service are facing a new (but curiously old) set of challenges, as another Government initiative is introduced to set up international profit-making hospital services

Tudor Rickards & Susan Moger

Officials from the Department of Health and UK Trade and Industry will launch the joint scheme this autumn, [2012] which will aim to build links between hospitals wishing to expand, and foreign governments which want access to British health services.

Hospitals including Great Ormond Street, the Royal Marsden and Guy’s and St Thomas’ could create new branches. The proposal draws on initiatives occurring in America, including Baltimore’s John Hopkins, Hospital.

Health Minister Anne Milton is quoted as saying:

“This is good news for NHS patients who will get better services at their local hospital as a result of the work the NHS is doing abroad and the extra investment that will generate. This is also good news for the economy, which will benefit from the extra jobs and revenue created by our highly successful life sciences industries as they trade more across the globe.

The NHS has a world-class reputation, and this exciting development will make the most of that to deliver real benefits for both patients and taxpayers”.

Unsurprisingly, the announcement [21st August, 2012] attracted criticisms

Katherine Murphy, chief executive of the Patients Association, said:

“The guiding principle of the NHS must be to ensure that outcomes and care for patients come before profits. At a time of huge upheaval in the health service, when waiting times are rising and trusts are being asked to make £20 billion of efficiency savings, this is another concerning distraction. The priority of the Government, hospital trusts and clinicians should be NHS patients.”

New and curiously old dilemmas

The dilemmas for NHS leaders are in some ways new, for example in the sense that the implementation of such a scheme will involve addressing problems of untested technologies impacting on clinical, informational, and managerial actions.

In other ways the dilemmas are curiously old. There have been a series of ‘revolutions’ announced by successive Governments to reform, update, transform, the NHS. The shocks and repeated initiatives led one distinguished commentator, Professor Andrew Pettigrew, to refer to the process as one of “churning not changing”.

It would hardly be surprising if some hospital leaders will see the plan as a further temporary burden to be shouldered, or one further storm to be weathered, rather than an opportunity to be seized.

Investment from private patient profits

A deeper analysis can be found in The Independent. The proposed initiative attempts to anticipate some of the dilemmas. Investment will be allowed only if drawn from income received from private patients; and any profits made abroad would be channelled back to the UK.

Areas of the world identified as key to the success of the project include the Gulf, where British medical brands already have high recognition, and China, Brazil, Libya and India.

The marketing of the NHS ‘brand’

Media comment is describing and evaluating the intiative as an attempt to market the MBS brand. It has echoes of marketing UK plc. The enthusiasm for business school language is not without dangers. Effective implementation of innovation may require a strtegic evaluation of what the ‘brand’ will look like in th future.

An example from a related service sector is that of the universities who are discovering the challenges of establishing outposts in various international locations. The learning curve is steep and competition ferocious. The most successful UK example is the Open University, and that has one unique advantage. Its knowhow (brand?) is precisely of a kind which makes such international ventures attractive to its undergraduate students.

Earlier LWD posts of interest

Health policy

Creative leadership

Distributed leadership

Antonio Horta-Osorio: Charisma and the fate of the heroic leader

January 8, 2012

by Paul Hinks

Antonio Horta-Osorio returns to his position as a CEO of Lloyds Bank on 9th Jan 2012 after his break suffering from serious fatigue and insomnia. It seems that even charismatic leaders suffer human weaknesses

When Lloyds Banking Group appointed Antonio Horta-Osorio as CEO in March 2011, they looked beyond their immediate internal pool of talent. What leadership traits were apparent in Mr Horta-Osorio, and not immediately obvious in an internal candidate?

A serial achiever

Mr Horta-Osorio’s impressive CV suggests he is a serial achiever; an individual whose energy is infectious, and clearly somebody who is very passionate in his quest for success. In short, a charismatic leader. Such individuals can be portrayed as all-conquering, with boundless energy when persuing their passions, often supported by a highly impressive list of achievements. They often appear unstoppable in their quest for success.

The Special One of the Banking Industry

Described as ‘The Special One’ or ‘The Mourinho’ of the banking industry, Antonio Horta-Osorio’s is seen as energetic, enthusiastic and completely at the top of his game. So when Mr Hotra-Osorio took extended leave in November 2011 citing extreme fatigue, there was understandable interest and analysis from the media:

The move by Lloyds to appoint Mr Horta-Osorio as its CEO in March 2011 had initially been warmly received by various stakeholders, and yet just eight months later – with Lloyds missing Q3 2011 targets – Mr Horta-Osorio was sidelined on medical advice.

Antonio Horta-Osorio versus Insomnia

Previous to his medical leave, it was widely reported that Mr Horta-Osorio had not slept for five days. He’s not alone though. Other famous leaders including Margret Thatcher & Napoleon are reported to have survived on little sleep [but did they ‘thrive or dive’ on it? Ed.]

In an article published in The Independent Mr Horta-Osorio alluded to treatment that he’s undertaken. It also provided an insight into the seriousness of his condition:

Mr Horta-Osorio said it was his wife who urged him to seek help: “I sought medical advice and went to see a specialist. He told me that in effect my battery was so run down that it was virtually on zero. I went to the Priory for a week just to rest. Then I went home and was immediately sleeping eight hours a day. By then I felt extremely well and was telling the chairman I wanted to come back to work. I spent the next five weeks in London and Portugal and took a few restful trips.

The treatment involved medicine to help me sleep and I am still on mild doses of that, which I expect to come off in the next few weeks.”

Mr Horta-Osorio’s treatment was paid for under the bank’s private medical insurance. He was astonished to learn how common insomnia is. “The official figures are that 30 per cent of the population suffers from sleep deprivation at some time but my specialist told me it was more like 50 per cent,” he said.

Unanswered questions

It’s interesting to consider why Mr Horta-Osorio would suddenly find himself suffering from insomnia. Was the job just too big? Did he feel isolated or threatened in the board room? Did external (media) pressure contribute to increased pressure in the job? Could there have been more support internally?

Expectation levels were understandable high, perhaps Mr Horta-Osorio felt an unnecessary urge to prove himself to his new colleagues, perhaps establish a power-base before he could build trust?

It was only a false start

As 2012 unfolds, spare a thought for Mr Horta-Osorio as he re-evaluates his own priorities and leadership style. Perhaps Mr Horta-Osorio’s false start at Lloyds is another blow to the theory of ‘super-hero’ leaders . As The Telegraph reported “Working until you drop” is no way to run a company. More recently, The Telegraph ran an article where Mr Horta-Osorio acknowledges he needs to change his Leadership style and delegate more. Perhaps power and control will need to make way for more trust-based and distributed leadership?

About the author

Paul writes: “I work for a subsidiary of Hewlett Packard where my career to date has been focused in the Enterprise Computing space. I have experience of working with businesses that operate globally, and I find cultural diversity another interesting dimension of leadership.

I really look forward to exchanging views and opinions with readers of LWD. I first became aware of the website when studying the Global Events and Leadership module at Manchester Business School in Jan 2011. I’m increasingly curious about leaders and the dilemmas they face. I have interests in Business, Politics, Sport and Technology. Having started as a passive reader of LWD, I decided it was time to make a contribution”.

Mersey Care Health Trust: An example of distributed leadership

May 28, 2009
DIY Handbook for Action Learning

DIY Handbook for Action Learning

Mersey Care NHS Trust is developing an international reputation as a creative organization through a range of innovative projects. It also serves as an exemplar for distributed leadership processes

Mersey Care is a major National Health Service (NHS) Trust serving the sprawling region of Merseyside in North West England, and incorporating Liverpool as its major city.

Chief Executive Alan Yates realised a few years ago that a creative organisation needs more than one creative leader. In formulating and implementing a strategy for one of the country’s largest NHS institutions, he realised he would need to find ways of stimulating creativity across the organization, and out into the community. Rather that setting up a formal structure, he encouraged informal networks, giving special responsibilities to Assistant Chief Executive Mandy Chivers. Senior figures at the Trust such as Medical Director David Fearnley were to offer considerable support as the creative initiatives grew.

Liverpool: European Capital of Culture

The trust recognised special opportunities with the regional efforts to promote Liverpool as the 2008-9 European City of Culture. By working closely with other community organisations, Chivers identified a like-minded group of people interested in stimulating creativity with focus on mental health and well-being.

Julie Hanna was quick to see the benefits of such a collaboration in her role as manager for health and well-being programmes:

Creativity, arts and culture are positively impacting on people’s health and well being. Liverpool, as European Capital of Culture 2008, has acted as a catalyst bringing together artists, cultural partners, health and care practitioners. There is a willingness to explore and develop possibilities of working in partnership in a pioneering spirit of “seizing the moment” of Liverpool’s cultural significance. This is another story to tell underneath the large and crowd-pulling events. Through culture and the arts we can find meaning, make sense of our experiences, express our thoughts and emotions, make and sustain relationships, discover skills and qualities in our selves and others. These experiences provide an opportunity to integrate body, mind and spirit; to learn and to make changes in lifestyle

The work included a variety of local and regional events, and an international partnership with Stavager in Norway.

The Creativity Network

Chivers began to find like-minded individuals in and beyond her own organisation, and encouraged a range of creative initiatives grounded in the professional activities of the trust. With strong leadership from Judith Mawer, an informal creativity network developed through which individual efforts were encouraged and supported. In the period of a few years over fifty people became associated with the informal network, sharing ideas, and offering various public events.

The Action Learning Initiatives

Externally, links with Universities were strengthened, and projects sponsored. The focus was to achieve learning through doing, innovative achievements as well as spin-off staff development gains.

The involvement with the Liverpool Year of Culture projects enhanced the strategic efforts both of the trust and the Culture initiative itself.

A similar mutual reinforcement occurred when Mersey Care became involved in another regional initiative, this time around action learning. The heirs to the work of action learning pioneer Reg Revans had being trying to establish a Revans Institute. The trust was to play a major part in the formation of the institute through the efforts of an international network of action learning practitioners which established a home base at Manchester Business School.

Chivers had obtained her doctorate within an active action learning group at nearby Salford University which still houses extensive archives of the papers of Reg Revans. The Trust helped advance the cause of Action Learning substantially, and has produced a practical handbook to initiate action learning efforts.

As indicated on the Mersey Care website:

Action Learning is a simple but powerful approach and a discipline that supports transformational change. It is an effective way that people can learn with and from each other. Groups or sets as they are sometimes called, work through questions and challenge to understand and develop insight in order to take actions that progress complex issues [applying] a rigorous blend of critical thinking, questioning, practical action and emotional intelligence. It does not work instantly or because of something clever outside of ourselves, but because we commit to this discipline and take personal responsibility to act.

Creativity, Health and well-being

The multiplicity of activities under the creativity initiatives were captured in a document by Judith Mawer which lists no fewer than seventeen projects each demonstrating creativity being applied within the context of health and well-being.

Among them, LWD was particularly fascinated by the therapeutic applications of creativity such as the work with Judith of Lynn King and Julie Hannah. The powerful image of a treasure chest as a means of capturing creative ideas is one particularly vivid illustration of a creative methodology.

The creative organization and its leadership

Can we learn something from Mersey Care about the creative organization and creative leadership? Something interesting and rather special is emerging there. The close links between action, innovation and learning mirror the case reports of the celebrated creative organization Ideo.

Both Mersey Care and Ideo have informal structures (as well as the necessary formal ones, required by Health Service statute in the Mersey Care case) . The informal activities enable individuals to introduce creative changes within their individual professional responsibilities, from clinical dispensing innovations to imaginative ways of delivery of service care

Overall, the work of The Trust is increasingly and rightfully being recognised internationally, winning awards, and earning recognition for Mersey Care as a creative organization.

TV Review: Professor Regan’s Medicine Cabinet

April 24, 2009
Lesley Regan

Lesley Regan

I enjoyed watching Professor Regan’s Medicine Cabinet. It was well-packaged, reassuring, and came across as mostly authentic. Come to think of it, such claims are a bit like those made of some of the products examined in the programme

Professor Regan’s Medicine Cabinet went out on BBC2 [2100 BST, April 23rd 2009]. Lesley Regan (I learn) is a celebrity medic. Bit like a Joan Bakewell with (metaphoric) stethoscope. Just in case her own charisma is not enough, she is filmed doing lots of legitimizing things, like going to hushed libraries and making notes with a deeply expensive pen (surely not a product placement). Or consulting other well-polished authorities across well-polished table surfaces. Or explaning the checklist of criteria that serve as credentials for taking a medical document seriously in a scientific court.

On trial in the show were various pharmaceutical remedies. Yes, even up-market programmes have to put someone or something on trial. You don’t have to be posh to play this game, as Joanna Lumley might say, but it don’t ’arf ’elp.

Anyway, the case for blind peer reviews, double blind product studies, and statistical significance tests was well-made. If I have just the teeniest of concerns, it is that Professor Regan did not always keep up to the gold standard with the demonstrations she set up. Perhaps gold-standard double blind product testing was never going to be possible, but in which case a little disclaimer would have done no harm. This is the sort of thing researchers are expected to make even if their studies pass the other scientific criteria. Even the notorious initial publication sparking the MMR clinical disaster at least acknowledged that the study implied causality not proved it.

So when it came to evaluating homoeopathy Professor R was rather stuck. Current theories of physical chemistry deny the possibility that any such approach can have any possibility of working. On the other hand, supporters provided reports which suggested that something might be achieved by the methodology. Fortunately for scientific theory, a very well-qualified statistician was brought in to review the evidence and confirm that large scale studies did not demonstrate such statistically convincing results. That’s OK then. It’s a polite way of saying the small-scale studies were a bit dodgy, or maybe ‘outliers’. And just to add to the damaging evidence, we got some notion into how the placebo effect works, and how homeopathy might be no more than a placebo effect in action

I’m about as convinced that we really understand the phenomenon labeled the placebo effect as we understand the bundle of practices called as homeopathy. But perhaps that’s a positive result from watching the charming Professor Regan. She is helping me develop a healthy scientific skepticism about product claims. Even those of her own brand of TV product.

PS the rugby players sticking their hands into ice water were very watchable too, but the demonstration left me wishing we had a bit more explanation of why that sort of approach would not exactly get the results into the top medical journals. At least, I hope it wouldn’t. I assume the statistician had served his purpose and left before offering his views on study design and sample size.

It is all very tricky, trying to communicate scientific facts and working in the mass media.


The author has consulted no authorities in research methods, medical statistics, or epistemology in preparing this review. All opinions are based solely on personal experience.

Innocent in a naughty world

April 8, 2009


The Innocent company has accepted an equity deal with Coca-Cola and risks damaging its valued image as an ethical organization

The story has an appealing simplicity to it. Innocent has built a brand as an ethical company from its UK base with its range of smoothies and a branding message that its products are 100% wholesome and good for you. Its decision to accept a £ 30 million equity investment from Coca-Cola seems to risk that image. It was the theme of a BBC interview with co-founder Richard Reed [7th April 2009]. PM’s Eddie Mair brought a tone of righteous indignation to his interview. He dismissed Coca-Cola as the sort of company that any self-respecting organization should avoid at all costs.

The Wall Street Journal offered a more balanced view of the deal . Journalists Patrick and Bauerlein outlined the financials, suggesting that Coke would own between 10% to 20% of the corporation which places its value around £150 – £300 million sterling. They pointed to the ‘quirkiness’ of Innocent, contrasting it to the staid old lady of Atlanta.

Coca-Cola’s investment in British smoothie maker Innocent not only connects the beverage giant to a fast-growing product but also to a company known for good social and environmental behavior. By giving 10% of its profits to charity and using recycled bottles, Innocent was one of the first consumer brands launched in Britain to develop a big following through ethical marketing. Innocent cuts a quirky public figure. Some of its trucks are covered in fake grass and daisies. Those trucks are mounted on hydraulics that make them appear to dance, with drop-down windows for giving away samples.
The deal’s structure should allow Innocent to keep its funky attitude rather than risk being assimilated into a vast corporate culture whose focus remains carbonated soft drinks. Coca-Cola won’t have any management control over Innocent, but Innocent will share its expertise with the Atlanta-based beverage company, Mr. Reed says. The Coca-Cola money will be used to expand Innocent’s operations in Europe, where only 25% of European supermarkets sell smoothies to pay for distribution, stocking fees, sales staff and advertising.

While Innocent has run TV- and newspaper-ad campaigns, it has also specialized in less-traditional advertising. Some 200,000 people turned up to a Innocent musical concert in London named Fruitstock in 2006. In following years it replaced the event with smaller village fetes. Its Web site features a “Daily Thoughts” blog where employees not only post items about new products, but also offer random tips such as what to feed tadpoles. Next month, [May 2009] Innocent is inviting customers to come to an AGM (A Grown-up Meeting), to solicit feedback.

Innocent’s charitable giving is also interactive. Volunteers knitted more than 506,000 little hats for smoothie bottles last year, which were then sold, raising £250,000 in proceeds to provide meals, blankets and other help for older people during the winter.

To be sure, Coke has been sporting its good deeds, expanding its recycling plants, reducing water consumption and using environmentally friendly coolants in vending machines and coolers. Coke and its foundation made more than $82 million in charitable donations in 2008, in areas ranging from college scholarships to water stewardship and disaster relief. But the 123-year-old company has been known to kill ads that were deemed too edgy and is vastly bigger and more buttoned-up than a closely held newcomer such as Innocent.

Coke appears to be embracing the model of taking a stake rather than buying outright, after previously struggling to integrate niche nonsoda companies. Most notably, Coke bought Planet Java coffee drinks and Mad River Traders teas and juices with great fanfare in 2001, only to phase them out two years later. Coke has had more success with its 2001 purchase of Odwalla Inc., a maker of premium refrigerated fruit and vegetable juices whose product line is closest to Innocent’s line

An Independent

Janet Street Porter provided an informed view for The Independent drawing on research she had carried out for a channel four film. She pointed out the dangers of treating Innocent as a totally altruistic venture.

Innocent, the company that made its name on two points of difference, ethical credentials and healthy products, has sold a large chunk of the business to Coca-Cola – a predictable move. Coca-Cola makes money flogging sugary drinks that are brilliantly packaged as part of an attractive lifestyle option – and so does Innocent.

What’s the deal?

It’s no big deal for the mighty Coca-Cola which may have reached the conclusion that its evolution lies in responding to increasing agitation against products on like style and health grounds. Innocent epitomizes values that Coke admires, but for all its efforts finds hard to build into its brand.

But this is a big decision for Innocent. Despite the robust defense offered by Reed, the dilemma of leadership was clear. Together with co-founders Adam Balon and Jon Wright, Reed has the strategic goal of building a global corporation with all the ethical values that are captured in Innocent’s products and activities. To do so he has to accept the financial reality of obtaining funding from sponsors. Increasingly, investors are being assessed for their ethical credentials. Would Innocent have preferred investment from a different source? Probably. The contrast with Coke makes for an easy story of lost innocence.

I have likened strategic business decisions to difficult chess moves. Sometimes you make a decision because you want to, sometimes because the opportunity and timing seems right, and sometimes because you have no obvious better alternative.

This seems to fall into the final of the three categories.