Tough job

It is two years since Tim Davison replaced Professor James Barbour at the helm of NHS Lothian in the wake of claims of manipulation of waiting times and bullying within the health board. It is also Davison’s 20th anniversary of being an NHS chief executive, and he has clearly fostered a reputation as a safe pair of hands. “For the moment!” he tells Holyrood. “When I arrived in Lothian, it was in a bit of a bad place. I think there was a significant issue with organisational culture, but it wasn’t necessarily throughout the whole of the organisation. There were some particular pressure points, and actually, the acute hospitals were the area particularly under intense pressure. But what became I think immediately apparent is there is a chronic lack of capacity in both health and social care in Lothian, and in Edinburgh city in particular.”

NHS Lothian is routinely spending more than £10m a year in the private sector because it doesn’t have in-patient capacity to cope with demand in acute emergency admissions and elective operations. In social care, Edinburgh’s relatively affluent market has pushed up prices in the city, leaving a restricted market for the public sector. This has coincided with a number of care homes closing because of Care Inspectorate concerns, and an inability to recruit adequate levels of care home staff to deal with capacity. Davison calls it a “perfect storm” in an environment shared by all health boards: a growing and ageing population. “We’re starting with inadequate acute capacity, we’re starting with an inadequate social care capacity, we’ve got a growing population and we’ve got ever tighter resources. That’s the challenge.”

Davison has said part of an overall service redesign for NHS Lothian will be about seeking “areas of disinvestment”, citing an annual shortfall of up to £40m.

During last winter, the health board opened about 227 beds, mostly at previously closed hospitals. The extra beds housed patients waiting for a care home or home care, but Davison says the “default position” of opening beds is not sustainable. “We’re in a perverse situation where a patient might be delayed in hospital waiting for let’s say 12 hours of home care, so because we can’t provide £180 worth of social care we’re spending £1100 keeping them in hospital. What we’re doing is we’re pouring more money into the expensive end.”

The recently announced plan for Lothian is to “row back” from the recently opened beds to procure an extra ten per cent increase in social care. The proposals will see the Royal Victoria Hospital in the north of the city demolished and the site established as a ‘care village’. The hospital was already replaced and the old site earmarked to be sold off for housing, “but the Royal Victoria Hospital is a fantastic site, it’s a big site. It’s in the right part of town in terms of a lack of care home facilities in northwest Edinburgh, very accessible site for public transport,” says Davison.

The care village would consist of a range of facilities to cope with differing levels of intensity of support. There would be ‘step-down’ beds for patients getting ready to transfer home, beds for people with more complex care needs such as dementia, and normal care home and residential beds. The plan would also see private housing for people with support needs at the front end of the site. “The idea would be people actually live in their own homes but there would be a level of support whether it’s care staff going in on a regular basis, or whether it’s having alarm systems with care staff on site able to intervene if need be.”

Corstorphine Hospital, which is “past its sell-by-date” according to Davison, will be marketed for capital, and Liberton Hospital too, if space can be found at the Royal Edinburgh Hospital site.

Davison believes the NHS must be more open about where savings are going to come from. He says councils have a better track record. “Everyone talks about savings, every health board has to make 3 per cent efficiency savings, but councils have tended to consult on ‘this is what we plan to do’, whether it’s closing libraries or whatever and you read it all over the press,” he says, pointing out savings of £40m a year aren’t going to be achieved through efficiency.

“I’ve worked for every shade of government. When I came into the health service it was Mrs Thatcher and then it was Mr Major in the Conservatives, then it was the Labour Party, then it was the Lib-Lab coalition here, then it was the SNP. The political problem is generally people are comfortable talking about spending more money on the health service and developing things, and extremely uncomfortable about not spending money and saving things. No matter which colour of government is in power over the next ten years there are going to have to be some very tough choices made, and I think we need to stand together and make some of those choices,” he says.

The integration of health and social care, as furthered by the recent Public Bodies (Joint Working) Bill, could be an opportunity for change. NHS Lothian has four councils to work with: Edinburgh, Midlothian, East Lothian and West Lothian. “We have got very early agreement with all four councils that we are going for a corporate body model of an integrated board. We have made a lot of progress,” says Davison. Shadow boards have already been established for each partnership area. East and Midlothian have non-executive health board members as chairs, with councillors chairing the Edinburgh and West Lothian shadow boards. Davison believes the new structure will enable a more devolved infrastructure. “To some extent, Edinburgh has always dominated because of its size but actually, this gives an opportunity for real devolved and delegated local decision making,” he says.

The Royal Infirmary of Edinburgh lies at the heart of the region, with the busiest emergency department in Scotland. The building has been criticised since its inception for not having enough beds. Thirty-one new beds were created recently in reclaimed office space, but further development of the site is planned. The medical assessment unit will be expanded, and later this year, the new Royal Hospital for Sick Children will be built which will house the Department of Clinical Neurosciences and the Child and Adolescent Mental Health Service, which currently operates at the Royal Edinburgh Hospital. Emotions always run high with children’s hospitals, and Davison acknowledges the transition may be difficult for those with memories of the current building. “My first degree is in history, and I am passionate about history and about the history of the NHS and what’s interesting is the people who built these places in the first place were building something new and different. They replaced something that had previously existed, and were not just keeping the status quo. I’ve got a lot of empathy with local hospitals and agree with all of that. However, actually what we need to be concentrating on is the health of mothers, babies and children. Basically, to co-locate the obstetric unit, the maternity unit, the neonatal intensive care unit, the paediatric intensive care unit and to have all the major services for adults and children all on the same site whether you’re an adult, a mother, a neonate or a baby, everything is co-located in a single site [and that] will bring enormous benefits.”

What about fears the children’s hospital will be assimilated into a hospital with a well-known bed shortage? “No, I can understand that but really, the paediatric beds will be ringfenced as paediatric beds. They have separate staff, so no, that is not going to be an issue,” says Davison.

Every time the private finance contract for the original ERI site is changed however, it costs the NHS money. Davison says it is a difficult legacy to live with. The new buildings will be built under the more flexible NPD model.

While buildings can be demolished and rebuilt, achieving a cultural shift is a more difficult undertaking. “Culture is enormously difficult to change. I accept my responsibility for saying it starts at the top, and so the fact is it’s how the board behaves, how the chief executive and chairman behave. We need to lead by example in terms of being open and honest and accessible, and telling it like it is.”

A management culture steering group was set up by Davison, but after criticism was replaced by a staff governance committee, chaired by an employee director elected by trade union members. The last NHS staff survey in December showed 17 per cent of staff in Lothian still reported bullying or harassment. “What was previously characterised as bullying and intimidation from managers really doesn’t feature in that staff survey. What features is actually peers harassing peers in wards. That’s the thing we’re really going to begin to focus on, which is about saying we know you’re all under enormous pressure but actually, you’re all in it together. I’m hoping when we have the staff survey next time round we’ll begin to see some benefit from it.”

And the targets on waiting times? “In my experience, we used to talk about patients waiting two years for an operation, then there were 12-month targets, then there were 26-week targets, then 18-week targets and now 12-week targets. Eventually, there have to be discussions about just how low will expectations get around waiting times.”

Targets dictate priorities and investment, according to Davison, and must be seen in the context of the ‘upstream thinking’ metaphor. “Part of the challenge of how over the next ten years are we going to literally shift multi-millions into prevention rather than treatment, the targets have to shift towards prevention,” he says.

Is the job insurmountable? “Despite the challenges, despite the fact this is definitely the toughest job I’ve ever had, it remains an absolute honour to be leading the NHS in Scotland’s capital city, and working with my four council colleagues. I spend half my life with Sue Bruce in the City of Edinburgh Council trying to resolve some of these issues, and I’m still optimistic we’ll be able to deliver our vision.”