How would you run the NHS?


The NHS has 1.2 million employees, an HR staff of around 7,000 and its people issues are never out of the headlines. Personnel Today called on three private sector HR directors to find out what they would do if they were in charge, and asked the NHS to comment on their ideas

Private sector

Bruce Robertson
HR director, Levi’s

Q. If you became HR director of the NHS, what would be the first three things you would do?

I would focus on structure and process first, in terms of understanding the administrative burden on the NHS and the complexity created. Also, the head count ratio of administrative support versus patient care/support. To assist with this, I would bring in business specialists to determine where costs and processes could be cut or simplified to channel funds into patient care and facilities. Second, once the structural review had taken place, I would seek to review the compensation and benefits structure. Finally, I would focus on talent retention and attraction.

Q. What are the main challenges you would face?

From an outsider’s perspective, the main challenges would be talent retention and attraction, bureaucracy and political interference.

Q. If you were asked to take on the job of NHS HR director, would you?

Possibly. It’s difficult to ascertain, given that I don’t have full knowledge of the internal workings of the NHS and have not been able to review many of the statistics required before making a decision to move roles. The key thing that would trigger any move would be a challenge, and while the role would provide that, it would be important to determine the true level of influence that would be allowed or supported.

Q. If you took the job, what sort of salary would you expect?

Certainly a healthy six-figure package.

Q. What specific demands would you make of NHS management before you agreed to take the job?

Minimum interference for the first 12 months and total and unlimited access to information and decision-makers. A specific budget would need to be set aside for external consultants, who would assist in determining the scope of work required to improve the NHS (heavily negotiated, of course), and the guarantee that recommendations highlighted by the review would be considered and approved/ rejected within a specific period of no more than three months.

Q. How long would it take to start seeing results?

I would not expect to see significant change within the first 12 to 18 months. This role would require a tenure of more than three to five years.

Q. Overall, what would you want to achieve in the job?

The dream outcome of the role would be to establish a service NHS employees would like to see. Solid and simple administrative processes designed to support the NHS and not politicians, a sound business model that supports limited bureaucracy with maximum patient care, and support provided in up-to-date facilities by a highly-skilled, motivated and rewarded workforce.

Paul Kennedy
Group HR director, Ebookers online travel agency

Q. If you became HR director of the NHS, what would be the first three things you would do?

I would undertake a major review of the senior management team, which would consist of working on a vision and mission, and aligning the current resources to deliver against this. Then I would assess the organisation’s capability to deliver a quality experience to all patients. Within this review, I would look to de-layer the organisation, with five layers linked to pay bands based on expected competencies to do the job, as well as increasing autonomy and accountability at local level.

I would establish equity and fairness in a comprehensive pay and reward system – where doctors and nurses are working for small salaries, then this should be equated through a bonus programme where every employee has a chance to earn as much extra cash as the next. A reward scheme should also be set up to encourage as much innovation and creativity as possible bearing in mind legal and compliance issues.

Q. What are the main challenges you would face?

Maintaining staff retention and satisfaction – contented staff who are performing to their utmost and are well rewarded will have an impact on improved service, customer satisfaction and will make the NHS a great place to work.

Also, financial constraints caused by pressure to stay within budgets will lead to potential cuts in service, leading to more managers to make those cuts, leading to more constraints, further potential cuts in service, and so on. The solution would be to take cost issues out of the hands of decision-makers and leave accountability to those at local level.

Finally, the NHS’ image is one of a tired, old service splitting at the seams. Change the name, freshen up the look, create some positive press and what I call ‘burn the churn’ – release the old guard who have no long-term strategic value.

Q. If you were asked to take on the job of HR director, would you?

Love to. It would be a great challenge because you need to be the honest, happy face who is able to relate to everyone concerned. And because I enjoyed my time in local government and have private sector experience. All I can say is that it would be a challenge of a lifetime.

Q. If you took the job, what sort of salary would you expect?

One which was fair and reflected my experience and the value I would bring. One which focused on rewarding outstanding performance and that pays the mortgage! Salary isn’t the issue, though, it’s what you put into your role and get out of it at the end of the day.

Q. What specific demands would you make of NHS management before you agreed to take the job?

To give me the accountability and responsibility to deliver against a set of key objectives established and agreed at the outset. That I should have the ability to recruit a small, high-quality HR team to support me. And that I should have an agreed financial plan to support my initiatives.

Q. How long would it take to start seeing results?

If you managed the NHS like a plc, you would see results within three months. From the outset, you would need a clear and concise road map of what results you are expecting and by when. I’d suggest we should see some improvement within 24 hours of the appointment. It also depends on how you communicate success when it happens.

Q. Overall, what would you want to achieve in the job?

To leave having made a difference, leaving a readily available succession plan in place for my departure so that the work started could be continued.

Ralph Tribe
Vice-president of HR, Getty Images

Q. If you became HR director of the NHS, what would be the first three things you would do?

Remove the trust from national pay scales with a view to attracting and retaining the best employees by paying significantly better salaries. I can’t help thinking that selfishness in the early stages will serve the greater good in the longer term, while an obsession with level playing fields in relation to other NHS trusts at the starting point of change will deliver very little at grass-roots level. Higher permanent staff costs should be offset against reduced agency/locum staff costs.

I would also streamline the disciplinary procedure with a view to moving out low-quality employees in the very short-term – whether practitioners, admin staff, managers – no-one should be sacred. The local community will support tough action if tangible service improvement follows. Consider a default policy of replacing lost back office staff with front line staff only.

Finally, ask the high-quality, committed employees – particularly frontline practitioners – what the trust should do to enhance service delivery to patients and put this into practice. Ignore central government targets for two years in favour of long-term, sustainable improvements.

Q. What are the main challenges you would face?

The faddishness and ideological nature of central government health policy – including a certain lack of long-term, logical, or common sense direction. Ongoing budgetary limitations would pose problems – unlike in the private sector – and I imagine funding does not necessarily keep pace with success-generated demand, so presumably you have to work hard to avoid becoming a victim of your own success. Change fatigue could also be a challenge to overcome – why would employees believe these changes would deliver real benefits when so many before have failed to do so in the past?

Q. If you were asked to take on the job of HR director, would you?

Yes I would, if I was convinced the chief executive had a sincere and compelling vision and the stomach to support and drive it through. If you could get it right in the NHS, the benefits would almost certainly spread further than in the private sector. If you could actually deliver the goods in the NHS, with all its challenges, then you could probably cut it in any environment – the complexity of the challenge appeals to me.

Q. If you took the job, what sort of salary would you expect?

The same as in the private sector – a six-figure salary with a significant, results-oriented bonus opportunity. Unlike the private sector, there is no stock-related wealth creation option so the NHS needs to look at a big variable cash incentive if it is to attract the best people out of the private sector.

Q. What specific demands would you demand of NHS management before you agreed to take the job?

Genuine open-mindedness – to do things differently – not “like we do it in the private sector”, but not like they typically do it in the public sector either.

It’s also important to have a simple but uncompromising shared vision, a willingness to confront NHS taboos, and to bite the bullet on paying much higher salaries, while removing staff who can’t or won’t try their hardest to deliver the required changes. In addition, the courage to disregard nonsensical central government interference to the greatest degree possible.

Q. How long would it take to start seeing results?

In a medium-rated trust, with the right chief executive, it would take 18 months to see some real improvement from the staff and patients’ perspective, and four years to be the best.

Q. Overall, what would you want to achieve in the job?

The best patient care possible from the money available. The best patient care measured only by local community, patients’ and employees’ feedback.

Public sector response

Andrew Foster
HR director, NHS

As director of HR for the NHS, I was, of course, very interested to see what other HR professionals saw as the key issues and how they would tackle the job.

My top priorities are: workforce expansion, modernising working practices, making the NHS a ‘model employer’, offering ‘model careers’ to staff, and building HRM capacity.

It was a relief to see that most of your respondents would agree that this list represents the ‘what’ to do. I fear we would be less likely to see eye to eye on the ‘how’ to do it. This is because I feel it is important to go with the grain of staff culture.

The public sector, in general, and the NHS, in particular, has a very powerful culture and set of values, which bring a degree of commitment that other sectors could only dream about.

The NHS is in the middle of a major programme of reforms and I believe it can only be successful by working in accordance with staff culture and values, and through working in social partnership with the trades unions.

For example, staff feel strongly that the NHS is a national institution and that it must have a national pay system that enshrines the principles of fair pay and equal pay for work of equal value. Our challenge has been to find a national system with the right local flexibilities – to respond to local labour markets, to design and reward new jobs and to achieve local objectives. We are hoping to start a national roll-out of a new pay system for 1.2 million staff soon – probably the largest scale pay reform the world has ever known. Any further help from other HR directors (such as joining us in the NHS) would be most welcome.

Alastair Jenderson
Acting director of the employer’s organisation

Elaine way
President, association of healthcare human resource management

Responding to the views of the other HR directors, Alastair Henderson and Elaine Way commented: “It is really important that the NHS is open to new ideas and the comments are interesting. Equally, however, it is important that those coming in to the NHS understand its culture and strengths.”

“The culture of the NHS is unique. We know of HR directors who have come to it from other sectors and are very successful, but we believe they would accept that it’s critical to spend time understanding the politics and culture of the NHS.”

Henderson continues: “It’s interesting that the private sector HR directors see removing themselves from political ‘interference’ as key to their success. However, freedom to ignore central government targets will never be a reality in the NHS, and nor should it be. It is right that in a public service, Government sets the strategic policy. HR directors must ensure their interventions support this, although I support the view that organisations should have operational flexibility to implement those policies.”

 Commenting on the pay issues, Way says: “Whereas there is a suggestion that a successful employer needs to break away from national pay, I fully support the continuing focus on the ‘national’ element of the NHS. While employers need local flexibility, we want a common framework across the four countries of the UK.   Agenda for Change, the proposed new pay system, is a good example of a mixture of local flexibility within a national framework.”

Henderson agrees: “We believe it’s important that nurses doing the same job get the same basic pay, whether they’re in Derry or Derby, and that patients know that variations in pay will not lead to a two or three tier service. The idea of selfishness of employers, referred to by one of the respondents, is the complete antithesis to the public service value of ‘selflessness’ and is dangerous because of its potential for leapfrogging of pay and conditions of service among employers.”

Henderson disagrees there is excessive administration and bureaucracy.  “There are huge myths about administration in the NHS. Less than 3 per cent of NHS staff are managers and only 4p in every pound is spent on management costs.”

Way adds: “I completely support the idea of more staff involvement and it is happening to a greater or lesser extent across the country.

“The majority of frontline NHS staff are highly-qualified professionals who want to continually improve the services they provide to patients, and organisations are using initiatives such as Improving Working Lives both to support more staff involvement and improve morale. A lot of organisational development work in the NHS is promoting the idea of frontline staff as leaders.”

 Finally, Henderson and Way comment on the contribution of the trade unions: “The vast majority of staff are also members of trade unions and professional associations. It’s interesting that little mention has been made of the importance of staff-side organisations as partners in the success of the NHS.

“We believe the NHS has reaped many benefits from social partnership working in the past few years and we want to build on this.”

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