Nursing us through the bad times

“I have a depth of knowledge, because I’ve done it. I have the blood stains, as it were.”

Patients and staff will be relieved to know that Sir Jonathan Michael, the new chief executive of the Oxford Radcliffe Hospitals NHS Trust, was not reflecting on any reputation for wielding the cost-cutting axe and slashing services.

Rather, in his no-nonsense manner, he was making the point that he is that rarest of things — a hospital trust boss with a long and impressive medical background.

In other words, someone whose experience extends beyond balance sheets to treating patients; a doctor rather than someone from Sainsbury’s.

To say he has had a hands-on role down the years would be something of an understatement. He qualified as a doctor at London’s St Thomas’ Hospital Medical School in 1970 and his 37 years in the NHS include ten as a doctor and 20 as a consultant, during which time he developed what became the UK’s largest kidney dialysis and transplant programme.

But he had thought his NHS days were long behind him, having become managing director of BT Health, which provides IT services to the NHS. Only the chance to take charge of Oxfordshire’s biggest hospital trust could have tempted him back, he says.

You suspect the appeal would not have been so irresistible to other high-flyers in the telecommunications industry, even before David Cameron’s election pledge that public sector chiefs shouldn’t earn more than 20 times that of the lowest-paid person in their organisation.

The years of plenty, with record levels of investment in our hospitals, are truly over, and Sir Jonathan arrived at his desk in April to find a trust under severe financial pressure, grappling with a savings target of £44m.

The John Radcliffe — the trust’s main hospital — had also been struggling to meet either the Government’s 18-week target (requiring patients to have their first hospital treatment within 18 weeks of referral by their GP) or the four-hour performance target for emergency departments.

His predecessor, Paul Farenden, who arrived following the surprise departure of chief executive Trevor Campbell Davis, had been obliged to call in NHS ‘intensive support teams’ to help resolve the problems.

And if that were not enough, the John Radcliffe was making national news, with paediatric surgery at the hospital being suspended following the deaths of four children. But, in Oxford, Sir Jonathan sees a trust that has been underperforming for years.

“I’m a bit of a car buff,” he said in his first full interview since arriving at the ORH Trust. “I look at this organisation and liken it to a Ferrari with 12 cylinders that is only firing on eight. It could do much better. I want to get this organisation firing on 12 cylinders, at the same time.”

As firstly clinical director, then medical director and finally chief executive of the University Hospitals Birmingham NHS Trust and then as chief executive of Guy’s and St Thomas’ Hospitals NHS Trust in London, he became intrigued by Oxford.

“I have been involved in the management of university hospitals for a long time. Throughout that time Oxford Radcliffe Hospitals was always part of that group. Oxford University is one of the top ten universities in the world. But the thing that always surprised me was that the Oxford Radcliffe Hospitals Trust was not doing better. It is good, but not as good as it could be.

“ I have never worked in Oxford before. It has a special reputation. Oxford stands for quality and excellence What attracted me here was the opportunity to work with really committed people here, at the university, in the wider NHS and local community to ensure that the ORH provides the highest quality of care for patients, and plays its proper part in the delivery of excellent education, training and research.

“I want to build on the vision that Oxford has for its health service, to try to fulfil the expectations staff and patients have of their health service.

“It will be the third university hospital that I have run. I managed to do it in the other two. And I won’t be beaten by Oxford.”

You wonder why he wanted to stop looking after patients in order to be faced with wielding the axe?

“I get the same satisfaction from being a chief executive as I did from being a doctor. I never had any management training but learnt on the job. I went into it because I decided that I could do a better job than the people who were doing it.

“But I retained the same ethos and beliefs. As a doctor I would be looking after 20 patients, but this was an opportunity to bring improvements to a wider population. It just means doing it through other people, rather than yourself.”

And what about the prospect of the Cameron coalition applying the axe to his salary?

“I did not hear what he said. It sounds like a good soundbite. But I did not come back to the NHS for reasons related to salary.”

His main message to staff is that they should seek to provide the sort of quality of care that they would wish to receive.

“Society has changed a lot since I qualified as a doctor in 1970. People have greater expectations of the service.

“Part of what I learnt from my three years in the private sector is the importance of the consumer. The NHS has not historically thought of patients as consumers, but actually that is what they are.

“We are in a time when public services are under great pressure. But to me this presents an opportunity to do things in different ways to improve efficiency and quality of care.”

He notes that improvement often conspicuously failed to match the millions pumped into the NHS by Gordon Brown.

“When I was asked to come and work in Oxford, I looked at the trust’s books. The reality is that funding doubled over the last ten years — a very significant increase. But during that time the amount of work done only increased by 50 per cent.”

His focus will be firmly set on the size of the trust’s workforce.

“Any organisation like ours, where 65 per cent of our costs lie with the staff, has to look at the cost of the workforce. You have to look at agency and supplementary staff, the number of wards and opportunities to redeploy staff.”

With a workforce of about 6,500, annual turnover of ten per cent means 650 people can expected to leave the organisation.

“We have no alternative but to reduce the cost of the workforce. How we do that still has to be worked through. I hope that we can avoid redundancies, but I cannot promise that at this stage. But I would not recommend to the trust board any savings that I believe would impact on the safety of care we provide.”

Or the quality of care?

“It depends where you draw the line on quality. All these things are relative. I cannot guarantee that the quality of what we do will not change. But I will make sure that it does not drop below acceptable levels.”

He does not dissent from my suggestion that non-replacement of staff will mean hard-pressed hospital staff having to work even harder.

“We are all going to have to work harder. It isn’t just us, the whole public sector is going to have to tighten its belt. Most people would recognise that we will have to roll up our sleeves and do what is necessary.”

There will be savings from the closure of some of the ageing buildings at Oxford’s Churchill Hospital.

“We have three sites and we have to make sure we use our new buildings to the maximum. I hope we can vacate some of the old buildings, dating from the 1940s.”

Procurement will be looked at. And he will be determined to avoid contractual mistakes of the past, which resulted in the trust having to effectively provide services for free.

Sir Jonathan finally confirmed how financially damaging the deal with Oxfordshire Primary Care Trust had been.

Last year, the contract with the PCT was capped, putting a ceiling on the extra money the hospitals would receive if the PCT’s attempt to manage demand was not successful.

“The end result was that we didn’t get paid for the work that we did in 2009-10,” said Sir Jonathan. “We will not renew that contract.”

Little wonder after Oxfordshire hospitals paid such a heavy financial price for successfully bringing down waiting lists, leaving the hospitals the victims of their own success.

Now the trust is having to rely on ensuring fewer hospital admissions and shorter lengths of stay, along with fewer outpatient appointments and more people cared for in their own homes. GPs will be encouraged to reduce the number of patients referred to hospital and undertake, whenever possible, diagnostic tests and minor surgical procedures in their own surgeries.

The problem is that the number of patients arriving at the ORH’s hospitals continues to rise and rise. In fact, increasing patient numbers were just three weeks ago given as an explanation for a rise in the number of cancelled operations.

As the man who ensured the trust at Guy’s and St Thomas’ was in the first wave of foundation trust hospitals, it should come as no surprise that Sir Jonathan is determined to secure foundation trust status, which supporters say would make the trust more accountable and independent.

After many false dawns, the new man expects to progress an ORH bid within two years, as long as tough financial and operational targets are all met.

The ORH Trust has also been disappointed in its bid, with the university and others, to create an academic health science centre in Oxford to harness the world-class research expertise of the university, to attract foreign investment and world-class staff.

His approach here is typically direct. The trust and the university need to simply act as though it had already secured AHSC status and the benefits will surely follow. Nor has he given up that the John Radcliffe might yet retain its children’s heart surgery services, suspended at present with the outcome of the children’s deaths still awaited.

There has been speculation that the centre might never reopen, with the Government signalling that it wants to reduce the number of specialist units.

As the smallest of the 11 centres, the Oxford unit was thought to be vulnerable. But Sir Jonathan believes the presence of a large maternity unit in Oxford and expertise in congenital heart disease means the John Radcliffe will continue to fight its case.

But there are many other battles to be won, with an unlikely measure of success — fewer hospital staff and fewer patients being treated in our hospitals.