Review of Health and Community Services Leadership and Management Capacity

Review of Health and Community Services Leadership and Management Capacity

R.148/2023

Introduction

This paper sets out the outcome of a review of Health and Community Services' ("the Department") leadership and management capacity, including the numbers of managers, by the Chief Officer for the Department.

It should be noted that there will continue to be a robust approach to identifying management / administration cost savings as part of the Department's Financial Recovery Plan.

This report does not consider leadership/management capability.

Context

Globally, healthcare organisations are seen as some of the most complex with much academic literature supporting this assertion. Whilst the Island's health system is small relative to many other jurisdictions, the level of complexity is very similar to much larger systems.

Like other modern health systems, the Department has high levels of interdependence and connectivity, competing and changing demands, unpredictability, uncertainty, a myriad of relationships and power bases as well as the need to work with emergence. Also, like many other jurisdictions the Island must manage within the complexity of a mixed health economy, i.e., public, and private services.

Being an island adds another layer of complexity as the Island must cooperate with and use off-island healthcare providers, which requires the management and coordination of transport, accommodation, clinical exchange, information sharing, and finance.

Leaders in healthcare must have the capability to operate in this challenging and complex environment, however, any investment in leadership and management must provide value for money.

Those health systems that are largely funded by taxation, in addition to ensuring high quality services, also need to have the capacity to ensure public accountability through supporting the democratic systems of that jurisdiction.

In larger jurisdictions much of the capacity needed to effectively support and service the democratic processes is provided by intermediate tiers', for example, in parts of the British Isles there will be a department with responsibility for health with supporting structures, such as Integrated Care Boards.

In small jurisdictions it is unrealistic and unaffordable to establish such structures. As such, this means that the Department needs to have the management capacity to not only lead and manage health and community services, but also to serve the important government accountability frameworks, which in larger systems would often fall to the non-operational structures. This must be taken into account when reviewing the management capacity of the Department.

The Department clearly requires significant transformation and there is a need for continuous quality improvement beyond the twelve months that the Turnaround Team have been engaged and, therefore, the Department must have the ongoing leadership and management capacity and capability to deliver improvement over the coming years for the Island.

The Department's leadership Team must also undertake the responsibilities of client'. Firstly, to a major healthcare estates programme that will increasingly require additional capacity and, secondly, to a portfolio of services that it must directly commission and manage[1]. These again requires management capacity to do well.

Benchmarking management costs is always problematic. Comparing the Department with other jurisdictions is difficult due to their differing requirements arising from their management structures, e.g., those that operate in an insurance-based system tend to have relatively high management costs to those that don't. However, this report does consider the Department's management costs in its conclusions.

What is a Manager'?

Being clear about this question is important when considering capacity (numbers). Like many health systems, the Department's aim is to be a clinically led organisation, which means that many of the leadership roles are undertaken by clinicians of differing professions.

It is true of many healthcare organisations that this is initially achieved through the appointment of clinical staff into key leadership roles[2] which brings with it a need to support and develop these leaders (as with non-clinical managers) so they can be effective. In particular, it is important that clinical leaders are provided with time to lead; notably, this is a challenge for the role of Clinical/Specialty Leads (consultant medical staff) which will be considered in the consultant job planning process.

The Department's clinical leadership structure is similar to what would be found in the health systems of other jurisdictions and therefore is, in numbers, not an area of concern.

In the Department there has been some leadership development/training but there is a need to continue this investment to ensure all leaders/managers are able to perform effectively. The circa 2700 people working in the Department deserve outstanding leadership.

This review has focussed on the Department's non-clinical leaders/managers which is often the focus of political and the public interest[3]. Therefore, the report considers the following definitions:

• Executive Directors (Tiers 1 and 2);

• General Management (e.g., operational managers who support the Chiefs of Service and the day-to-day management of services) (Tiers 3 and 4); and

• Specialist Managers (e.g., Estates, Health and Safety, Complaints) (Tiers 3 and 4).

This group of 45 management' staff make up 1.7% of the total substantive staff working for the Department.

Executive Directors

The Department has 5 Executive Directors ("the Senior Leadership Team" (SLT)) accountable to the Chief Officer:

1. Medical Director (part time);
2. Chief Nurse;
3. Director of Clinical Services;
4. Director of Mental Health and Adult Social Care; and
5. Director of Improvement and Innovation.

The Department does not have either a Finance or Workforce (HR) Director as these services, like Digital Services, are centrally provided by corporate services. The Chief Officer, Turnaround Team, and SLT consider this a weakness for the Department and are of the view that consideration should be given to changing this arrangement.

General Management

The Department has 17 General Management roles who provide operational management support to the Care Groups or provide management for the Department's non- clinical support services, such as facilities, housekeeping, and estates.

These roles are:

• Head of Access;

• Head of Operational Resilience[1];

• Head of Non-Clinical Support Services;

• General Manager – Unscheduled Care;

• Speciality Manager (x2) – Unscheduled Care;

• General Manager - Mental Health;

• General Manager – Primary Care, Prevention and Therapies;

• General Manager – Adult Social Care;

• General Manager – Women's and Children's Care Group;

• Planned Care Lead;

• Speciality Manager (x2) – Planned Care;

• Change Delivery Lead;

• Operations Manager – Non-Clinical Support Services;

• Soft Facilities Manager; and

• Head of Housekeeping.

Specialist Managers

The Department has 23 Specialist Management roles which require specialist knowledge and/or qualifications.

• Director of Culture and Staff Engagement[2];

• Deputy Medical Director (part time);

• Head of Nursing, Midwifery and AHP Education;

• Estates and Hard Facilities Manager;

• Head of HCS Business Intelligence;

• Head of Quality Improvement;

• Head of Quality and Safety;

• Policy & Quality Improvement Manager;

• Risk Manager;

• Information Governance Lead;

• Legal Services Manager;

• Chief Pharmacist;

• Service User Manager;

• Compliance and Sustainability Manager;

• Deputy Divisional Lead Operations;

• Health and Safety Manager;

• Catering Services Manager;

• Safeguarding Manager;

• Social Care Governance Manager;

• Speciality Manager Private Patient;

• Associate Director Improvement and Innovation;

• Associate Director Digital Health; and

• Head of Commissioning and Partnerships.

Reduction of Non-clinical Functions as Part of Jersey Care Model (JCM) Programme Review

Following the review of the Jersey Care Model programme by the Minister for Health and Social Services[1], there has been a reduction of 27 roles in total. Additional roles had been created at the start of the programme in 2021 to support and deliver the envisioned re- design and creation of new community services. These roles included functions such as project and change management, communication support, data analysts, administrative support, and business planning. Two FTE CS14 permanent management roles were also converted into lower graded operational supportive roles to reduce the overall management overheads.

It should be noted that the Department is short of change and project management capacity and capability in the context of the major transformation needed in healthcare. This has been identified as part of the Finance Recovery Programme and the wider Turnaround Team's work programmes as hindering progress with the Department's transformation.

Management Costs

The cost of these non-clinical leadership/management roles is 2% of the total HCS budget. This is some £5,113,000 of the total budget of £255,560,000. As mentioned in the context section of this report, benchmarking is problematic as there are many variables, however, by comparison with the 1.7% ratio for the Department, managers, directors and senior officials' in the UK make up 9.5% of the workforce[2].

Approval of management posts

In addition to those posts that require States Employment Board (SEB) approval, all posts whether replacement or new are subject to the Financial Recovery Plan Vacancy Control

Panel' scrutiny and with Tier 2 and 3 management posts requiring approval by the Chief Officer. At each stage of the process, the Department looks to find ways in which to reduce management and administration costs. The existing systems need to be agile in in responding to the approval process.

Performance Management

This report does not make any assessment on management capability in either the clinical or non-clinical group of leaders/managers. However, the low levels of recorded objectives and appraisals is a cause for concern and needs to improve. The reason for these low levels is multifactorial and can be seen in other healthcare settings including cultural and logistical. For example, in some areas high staff to manager ratios makes the process time consuming and understanding new HR systems takes time (corporate HR will be providing training during 2023 to help improve compliance). There is a clear senior leadership objective to improve this situation at all levels; see response to a Written Question on this topic[1].

Conclusions

There is clearly a perception among the general public both on the Island but also in other jurisdictions that managers are largely irrelevant for the delivery of healthcare. Spending money on managers is viewed as wasteful, with little attention given to the ways that managers routinely support and enable the work of clinical professionals to deliver services and in Jersey the democratic process.

In my time as Chief Officer, I have met with clinical staff who believe that the Department has too many managers but also many who are looking for more management support. The truth is that we need the capacity and capability to deliver what the Government of Jersey requires of its health services.

In making this statement we need to recognise that managers vary in experience, ability and capability and the senior leadership of the Department must hold individuals to account for delivery and where required, support their training and development, to ensure that we have the effective leadership and management of the Department.

This is a significant challenge not least because attracting and retaining high quality leaders and managers is a critical issue for the Island, as it is for other staff, and our recruitment and retention efforts must also take this into consideration. In parallel, there must be a rigorous approach to identifying savings in management and administration costs where these do not impact on the safety, efficiency, and effectiveness of services.

The departure at the end of 2023/early 2024 of the Department's Turnaround Team is a particular risk to the progress being made, and the Minister for Health and Social Services with their Chief Officer will need to consider and establish appropriate mitigations. It is clear that the turnaround of the Department to a standard of the best in healthcare providers will take a number of years and require ongoing and strong leadership, investment, change capacity, and political support.

This report concludes that - recognising the context in which they undertake their responsibilities and with an employee to management ratio of 1.7% - the Department is not over managed in terms of the numbers.

Indeed, the management capacity is currently less than you would expect to see in the delivery of a major healthcare transformation programme, and this has been identified by the HCS Change Team as a significant barrier to making progress.

Going forward, the Chief Officer and the SLT will focus on ensuring that staff and Islanders benefit from highly effective leadership and management that can support clinicians in the delivery of the day-to-day services, support continuous quality improvement, and continue to support the democratic process.