New challenges

As chief executive of NHSScotland, Derek Feeley stood at the helm of an organisation that employs over 150,000 staff and is responsible for the protection and improvement of the health of a population of about 5.3 million.

People often ask him what such a job entails, and when they do, he responds with a simple explanation:
“My job has got two bits, I always say to them. One: making the right thing easier to do. And two: giving people the right environment in which to flourish. If you can do those two things then you can sleep easy at night,” he says.

Feeley took over as Chief Executive and the Scottish Government’s Director General for Health and Social Care following the departure of his predecessor, Kevin Woods, in late 2011. It has been a “great privilege” to get the chance to do so, he says. However, earlier this year, he announced that he would stand down from the job to take up a new challenge as the executive vice-president of the Institute for Healthcare Improvement in Boston – a role that was simply too hard to turn down, he says.

“I think it is one of those opportunities that just come up once in a career. IHI does fantastic work the world over – and lots of different work in different settings. So if you look at the kind of work they do in Africa, for example, which is focused around reducing infant mortality and reducing the transmission of HIV and AIDS from mother to child, and then when you compare that with some of the things they do in the very best hospitals in the United States, you just get a chance to work in a much broader, worldwide environment.”

The move seems a good fit for both parties as the two organisations are already familiar and supportive of the other’s work. The IHI’s current CEO, Maureen Bisognano, told the NHSScotland annual event in June that healthcare in Scotland is “incredibly excellent” and “amongst the best” in terms of reliability; while its former president, Professor Don Berwick, has previously stated that Scotland’s patient safety programme, which was informed by the work of IHI, “marks Scotland as a leader, second to no nation on earth, in its commitment to reducing harm to patients, dramatically and continually.” Recently, Berwick, a former adviser to President Obama, was asked by Prime Minister David Cameron to look at how to improve the safety and quality of care in the NHS south of the border. His report was published earlier this month, in which he argued that patient safety must become the top priority for the NHS in England and urged senior government officials and health service executives to focus on the culture that they want to nurture, rather than more rules, regulations and reorganisation.

Here, Scotland appears ahead of the game as Feeley points out that its world-leading Scottish Patient Safety Programme (SPSP) has become “just part of the way we are going to do our business now in the NHS in Scotland.” Since the programme’s introduction in 2008 and the change in culture in Scotland’s hospitals that it helped bring about, the mortality rate there has fallen by 12.4 per cent – a saving of 8,500 lives. The SPSP is now a family of programmes as, in addition to the original acute hospital programme, this group now includes mental health, maternity, and primary and community care programmes, making Scotland the first country in the world to have a recognised safety programme throughout the whole patient journey. This collaborative way of working has also informed spin-offs in early years and person-centred health and care, and is now being discussed as a possible method for bringing about improvements in physical activity, violence reduction and education. Feeley says their experience with the SPSP showed them that if you did “common things uncommonly well, you would get the right kind of results.” And so, having found a method that works for them, they are sticking with it.

“One of the things that the Permanent Secretary asked me to do was to lead on improvement across the Government, not just in health. So that is why we’ve got an improvement framework that we are trying to apply reliably, not just in health but across the whole of the Scottish Government’s work.”

Feeley identifies the achievements of the SPSP as one of his personal highlights during his time in health. However, he adds that the “relentless” focus on quality has become another strength of the Scottish health service, and shares his conviction that improving quality is the best response to the current economic and financial challenges. The Scottish Government published its Quality Strategy in 2010 and Feeley says that it, combined with its 2020 vision document that sets out the strategic narrative and context of its implementation, provides “a little bit of certainty in uncertain times”.

“That is what we organise things around,” he explains.

“Does this make care safer, more effective and more patient-centred? If it does, we are trying to do it. And if it doesn’t, it gives you a basis for taking those kind of decisions.”
He identifies a “very, very solid” financial performance as another strength of Scotland’s health service, and says he is also proud that Scotland has “stayed bold and ambitious” in its approach to public health, such as through policies like minimum pricing for alcohol, and that it is now tackling longstanding conundrums such as the integration of health and social care, where he says they are making “real progress”.

Challenges remain and Feeley insists he is not trying to underplay them. However, he maintains that Scotland is well equipped to meet these head on.

“Every healthcare system everywhere in the world is having to face up to some combination of economic, demographic, epidemiological – this growth in multi-morbidity, plus the pace of change, patients’ expectations changing all the time, big population health challenges. There are a set of challenges that are real and will be difficult to grapple with but I think we’ve got ourselves into a reasonably good place to try and address some of those challenges.”

Another test Feeley faced during his tenure was the revelation of waiting list manipulation at NHS Lothian. The scandal attracted significant media and political attention and led to Feeley being called to answer tough questions before the Parliament’s Audit Committee about wider practice. What reassurances can he offer the public now?

“I think what really matters to people is, has our performance been improving on waiting times? Can they get better access to care? And the answer to that question is yes,” he responds.
“If you look back at the last five or ten years, people are getting quicker access to care than they used to. Ten years ago, people were regularly waiting far too long for care. Now they are not. The medium wait has come way down. So I think that is the key thing to remember. Audit Scotland’s report recognised that. Th e Parliament’s report recognised that; the NHS was performing well on waiting. So, I think that is a key thing to bear in mind when you think about what happened in NHS Lothian, which I’ve been very clear, again to the Parliament and anybody else who has asked me, was unacceptable. That lack of transparency isn’t the way we should be doing our business in the NHS in Scotland. But that has now been subject to, I think, the most robust, wide ranging scrutiny that we’ve ever had about any issue. And no one has found evidence that what went on in Lothian was replicated elsewhere. So I think people should take some confidence from that and some comfort from it that after that huge amount of scrutiny from Audit Scotland and the Parliament, no one has found evidence that there is deliberate manipulation of waiting times beyond NHS Lothian.”

As for ensuring it doesn’t happen again, he explains they have also taken the opportunity to learn from what occurred. Feeley believes that fundamentally, what transpired in Lothian were issues around culture, values and behaviours, and so over the last year, he says they have been asking staff to think about what really matters to them. The result was the publication of its 2020 workforce vision, ‘Everyone Matters’, which set out these shared values as: care and compassion; dignity and respect; openness, honesty and responsibility; and quality and teamwork.
“I think as a leader, for your staff to tell you these are our values, that’s a fantastic opportunity,” Feeley says, proudly.

“I couldn’t have written a better set of values. But that is ten thousand of our staff who have told us those are their values. And I think now that is what we need to build on and focus on.” Feeley has spent his final weeks in the role visiting health boards and says that throughout his time in post, he has valued the opportunities to get out of St Andrew’s House to speak with staff directly and hear their ideas. When Feeley and I sit down for this final interview, he has only a few days left in the country before his successor, John Connaghan, takes over as acting chief executive and director general, so I ask if he has any further advice for the man stepping into his shoes?

“Hold your nerve, persevere and persist,” comes the reply.

“And keep the focus on quality,” he adds, “because it is what unites us all.”