Transcript of Radio Ombudsman #21: Lord Adebowale on leadership, tackling health inequalities and reshaping the NHS after COVID

IIn this episode of Radio Ombudsman our guest is Lord Victor Adebowale, Chair of NHS Confederation. He talks to Ombudsman Rob Behrens about the impact of COVID on the NHS and the Confederation’s plans to reshape the health and care system in its aftermath. He also discusses the role NHS leaders have to play in taking complaints seriously and in addressing health inequalities.

You can also download a pdf of the transcript (345 KB) or listen and subscribe to the podcast on SoundCloudiTunes or Spotify.

Rob Behrens: Hello and welcome to Radio Ombudsman in lockdown. This is Rob Behrens saying hello from a sunny northwest London and I’m delighted to say that we have a very distinguished guest today, Lord Victor Adebowale. You’re very welcome. I hope I’ve got that right. Probably not.

Victor Adebowale: It’s a good attempt. It’s good old Yorkshire there but it’s pronounced Adebowale. But that…

Rob Behrens: Adebowale, thank you. Our guest is very well known. He’ll be known to lots of you. I was just saying he’s the first guest on Radio Ombudsman to have already appeared on Desert Island Discs. And I think he must be the first person on Desert Island Discs to have chosen a combination of Edward Elgar and The Stranglers which is a great combination.

Victor Adebowale: (Laughter)

Rob Behrens: He has had a magnificent career which we’ll talk about. He’s been the dynamic force behind the social care charity, Turning Point. He was the boss of Centrepoint. He is now a member of the House of Lords, a crossbench peer. And most important for us, he is the chair of the NHS Confederation. And the Chief Executive, Niall Dickson, says of him, “Victor is an experienced, passionate and exceptional ambassador for integration and for tackling health inequalities.” So, we’ve got the person we want to talk today. Thank you very much for joining us.

We always start off by asking people about their background, where they came from and the kind of values they were brought up with. So, would you mind starting there?

Victor Adebowale: Well, I mean, I was brought up by a nurse, pretty much single parent in Wakefield. She is still very much alive and she taught us all actually the hard work, integrity, strong values of fairness and, well, what can I say? She’s a nurse, right. She taught me about what matters in life. Taught us all actually. And those lessons have stuck with us. Stuck with me anyway.

Rob Behrens: You’re one of those very famous people who didn’t do very well in their A levels. Or maybe that’s just a rumour. I don’t know.

Victor Adebowale: I did well enough. But no, I’m not a… one who does interviews that start off with, “And then you went off to Oxbridge.”

Rob Behrens: When did you begin to feel that you knew what you were going to do?

Victor Adebowale: Actually, I’ve always had a notion of what I wasn’t going to do. (Laughter) Deciding what it is that you don’t want to do rules out quite a lot basically. So that kind of ruled out a load of things that I didn’t want to do. I ended up doing something that I did want to do. And then luck played a big role, you know, and a bit of hard work and chance favouring the prepared mind. But actually, it was more a list of what I didn’t want to do. I’ve done quite a few things in my life but ones that I didn’t want to do, I’m afraid I’ve left in the past.

Rob Behrens: Yes. So, you clearly had a passion for the voluntary sector and for social care from a very early age.

Victor Adebowale: It was a case of I want to do something that matters and that’s something to do with Maslow’s hierarchy. So, that’s what I did, the voluntary sector, as you put it and social care, health, housing. They’re all means to an end really. You know, I would have done it in any sector. That was the sector that spoke to me, spoke to my values.

Rob Behrens: So, I’m interested in the fact that you didn’t go into government or the civil service or local government. You went into the third sector. Was that deliberate or… ?

Victor Adebowale: It was, well, deliberate. I’m always a bit suspicious of career plans. But I did work for local government for many years. I worked for Newham as a housing officer and I enjoyed it probably a lot.

The voluntary sector, for me, I guess I left and worked for Patchwork and Centrepoint. You know, they offered a greater sense of freedom, I guess. Entrepreneurialism. Didn’t seem like something that was possible. It’s really odd actually but it never crossed my radar as an endeavour. And I actually had a sneaky feeling I probably wouldn’t have progressed in the civil service. I certainly wasn’t on fast stream. Not much chance.

Rob Behrens: Yes. So, you went to Centrepoint but then you went to Turning Point. And, in some sense, Turning Point was a defining moment for you because you transformed an organisation that was in a very difficult place.

Victor Adebowale: Well, it’s kind of you to say that. I always think that I’ve put together a series of teams who transformed the organisation over many years. Turning Point is a social enterprise. I know you referred to it as a charity and it is a registered charity. But it doesn’t fundraise. It operates. It’s a business. It just doesn’t have shareholders and dividends.

But over 20 years, we did grow the business. We did extend its reach to more people. I think, at the moment, it’s looking at, what, 100,000 clients including locations and employees. I think it was damn near 4,000 people which is some growth over a period of time.

But, you know, I worked with an amazing group of people over that time and there are amazing people running it. I don’t think it was down to me and me alone just being the hero standing wide legged. It was a great organisation with a great team, and I was lucky enough to work with them.

Rob Behrens: What is it about the culture of that organisation that is so people-centred? Because that’s unusual.

Victor Adebowale: I don’t know. I mean, for me, the culture, it’s… There’s a saying, isn’t there? Culture eats structure for breakfast. Well, I’ve always believed that ultimately, it’s about the vision. It’s about the values. It’s about, you know, the culture, structure, operation. They have to be aligned. I’ve always believed that to be empathetic, what you leave behind as a leader are the values that you inculcate in a system or an organisation. So, I always started there. I always end there basically. You know, it’s about leadership. That’s what they’re paying me for. That’s what I try and do.

Rob Behrens: So, we’ve been doing this big project on complaints handling in the NHS and what we’ve found when we’ve gone around is that the people who actually handle complaints don’t have a great deal of confidence with the leaders in NHS organisations, understand the difficulty of what they have to do and don’t put enough support or resource into improving it. And that stops them doing the best that they think they can do.

So, clearly leaders have a key role to play in encouraging the NHS to take complaints more seriously than is currently the case. How do you think we can address that together with the NHS?

Victor Adebowale: Well, obviously, as chair of the NHS Confederation which represents the waterfront for NHS colleagues and NHS trusts, acute trusts, mental health trusts, primary care, secondary care, integrated care systems, primary care networks, the lot. I know that the majority of my members, well, want to take complaints seriously. I think there’s a number of things going on here.

First of all, over a very long period of time, I think the NHS hasn’t developed a true learning culture.

Rob Behrens: You’re saying that there’s commitment?

Victor Adebowale: I think there is.

Rob Behrens: It doesn’t always translate, Victor.

Victor Adebowale: It doesn’t. So, let me tell you what I think about that. I think there is a difference between individual commitment and the system bureaucracy and culture. So, I’ve yet to meet the leader in the NHS who isn’t committed to doing the best for their patients. That’s the honest truth. Don’t matter where they are.

But what I think happens is, is the culture that surrounds them which, it tends to be risk averse in a negative way. So, and what I mean by that is it’s risk averse in favour of the bureaucracy rather than the patients. And at the end of day, it’s the patient that enters any health institution that is taking more risk than the institution. So, that’s the problem.

And then you find there is a… We still haven’t although I think there are efforts to move this, we still don’t have a comprehensive and sustained learning culture in which, you know, mistakes could be made in complex systems. The question is, can we learn from them so we don’t repeat them? And there have been several attempts to create the no wrong door, the airline approach where, you know, you take human factors into account, I think. And then you’ve got things like the speak out guardian and these, given the length of time that the NHS has been running, are still fairly early interventions. And they’re surrounding by a political context which is incredibly blaming. I mean, it is. And so that drives into the system. And the same culture and it’s a kind of phrase, a fish does rot from the head.

So, it is not just the NHS on its own as a set of institutions. It’s the NHS, as a set of institutions, within the context of a policy framework in the context of a political framework. And they all interact to create quite a complex set of relationships. And the patient isn’t always seen or isn’t always recognised and isn’t always heard.

But I think there have been moves in the last few years to start putting the patient and the citizen at the centre of the NHS. But there is still a way to go. And I think the Confed and your organisation could do more to highlight the best practice. I hate the term best practice but highlight where things are going well, where there are [lessons that] can be learned, where leadership is aligned and systemic. And I think that’s the way to go rather than beating people over the head. I don’t think that works. It has the opposite effect, I think. People hide things.

Rob Behrens: There are two things that came out of that that I want to ask you about. One, in a minute, is about health inequalities and the challenge that that brings with it. But the other is actually about the defensiveness of the NHS culture. And one of the things that concerns me is that we’ve been talking about a need to have a more sensitive environment for whistleblowers for the last 10 years.

Victor Adebowale: Yes.

Rob Behrens: And yet, I get lots of doctors who are very critical of the NHS, quite rightly, because when they’ve drawn safety matters to the attention of the management in the NHS, the tables have been turned on them and they’ve been hounded out of work and sometimes out of their careers.

To me, there is no sign that that has improved in the last five years. And that’s not to say that the Speak Up Guardian isn’t doing very good things in trying to move things on. But when you actually blow the whistle, they’re very much on their own and they have been taken to the cleaners by management boards in the NHS.

Victor Adebowale: Well, you have a very difficult job. I was thinking that while you were putting the question to me, in a way, because the thing that only ever comes across your desk is bad news. I mean, that’s the problem. You only ever see the failure. And I agree with you. We have a long way to go to move the needle in favour of learning. And there is a risk averse culture in some places and there are cultures where the bureaucracy is seen the same as accountability. Bureaucracy is not the same as accountability.

So, you know, to my previous point, I do think that the sustained effort to bring to bear accountability as opposed to bureaucracy, to build relationships as opposed to just objectives and to show what can be done to improve patient care when the relationship and accountability are aligned with vision and values. I think that’s the work that has got to be done and I’m not going to sit here and tell you that we’re there or that the NHS has learnt all its lessons. It hasn’t.

And it’s only recently, in my experience, that the attention that has been given to this has been taken seriously. I mean, throughout the system. And I would argue that it takes a while for people to understand that a) we’re serious; b) the change needs to be made which is systemic and not just, sort of, words, you know. And that people who blow the whistle will be protected and will be looked after and that will be the expectation. So, you know, this is an ongoing story. It is not easy and it’s certainly not going to be quick.

Rob Behrens: If I could suggest politely that you’re not quite right in saying that I only deal with bad news. I mean, the challenge for an Ombudsman is actually to use the good news as an incitement to good practice across both the health service and the public service. And if we don’t do that, then we risk alienating the very leaders that we need to be on side with in order to make the reforms that you’re not talking about.

Victor Adebowale: What, so-

Rob Behrens: A balanced approach.

Victor Adebowale: No, well, forgive me. I certainly agree with everything that you’ve just said. I mean, the Ombudsman, it’s not an English word, is it?

Rob Behrens: No.

Victor Adebowale: And it refers to quite an ancient notion of fairness and accountability. I guess you could tell me, you know, my sense is that people go to the Ombudsman to complain rather than to…

Rob Behrens: They do.

Victor Adebowale: So that was what I meant. It wasn’t…

Rob Behrens: No, you’re right. Absolutely. Okay, so let’s move on then to health inequalities and then I want to talk about social inclusiveness as well. So, the challenge for the NHS in addressing health inequalities is really very complex, isn’t it?

Victor Adebowale: Yes.

Rob Behrens: Because the people who most need the service are often the ones who are least likely to want to use it.

Victor Adebowale: Yes.

Rob Behrens: In your experience of drawing people in which is as good as anybody’s, what are the key issues in trying to get to the bottom of that?

Victor Adebowale: Yes. Well, I’m quite struck, you know, the Julian Tudor Hart statement for the inverse care law, you know, that those people who need the health and social care the most tend to get it to the least, seems to me has always been a driving force for me for my work in health and social care because it’s basically a crime. It’s outrageous.

Because the NHS wasn’t started by the likes of you and me. It wasn’t started in Westminster. The people who got it up and running, they didn’t go to Oxbridge. It was started in a village in Tredegar for poor people actually or at least the working poor. And the middle classes have benefited by default, by its expansion and its inclusion. And therefore, we should be really concerned about the possibility that we end up with a system that was designed for the poor that benefits the middle class at their expense. One, it’s immoral and secondly, it’s expensive. It is not cheap.

The fact that a woman in Barking and Dagenham has an active life expectancy of 55 and a woman in Richmond upon Thames has an active life expectancy of over 70. That is an expensive way to run a health system.

So, if you want to reverse it, then I think we have to do the following things. First of all, we have to look at population health as a whole across the place. Secondly, we have to create the incentives that actually mean that people get rewarded for reducing that gap rather than ignoring it or even increasing it. And thirdly, we have to look at our care pathways and our design of care pathways. Things like cancer and mental health and diabetes as inclusive of those people rather than exclusive of them.

And then finally, we have to look at the commissioning of services. We have to define it in such a way that commissioners are held to account for a definition of commissioning which is basically about understanding the needs of an individual and/or a community such that you can build a credible platform for procurement and contracting rather than just procuring the cheapest. That doesn’t work.

So, I think there is an accountability and a focus question. Certainly, 91% of my members of the Confed think that inequality and inequity are number one. That they’re really concerned about it. And COVID has drawn, you know, double, triple red lines across and round that issue now. We have to fix it. It is not going to go away.

Rob Behrens: Is it necessary to have a leadership in the health service that is representative of the community that it serves in order to deliver the things that you’re talking about?

Victor Adebowale: I think it helps. This is a tricky one because it would be easy for me to say, yes. But it is self-evident that we don’t. So, therefore, it is beholden on those people who do lead to understand the people that they lead. And to put it bluntly, they get paid for leading all the people all the time everywhere. They don’t get paid for leading some of the people some of the time somewhere. Right?

And that means that they have to put in place the mechanisms that ensure that they understand they have line of sight as to what is going on at community level. That that drives what happens in systems, integrated care systems.

So, the leadership, in a sense, what I’ve just said about what needs to happen is that leaders need to get a line of sight as to what is happening on the ground. They need to ensure that the mechanisms by which they understand commission services are those that understand individual community need. They must ensure that the accountability structures mitigate towards those people at the sharp end of the inverse care law rather than the other way round. And they must ensure that the levers, the financial levers and other levers do the same.

If they do that, then that would be a major shift forward. I would argue, and this is just a matter of organisational health, that decision making is best made when in diverse groups. And there is a lot of research to back that up. So, if you have a 
monoculture you’re likely to make monocultural decisions which aren’t going to favour leading everyone everywhere.

So, I suppose what I’m saying is two things. Leaders should lead everyone everywhere all the time. And you’re better off if you have a diverse team. And you’re even more better off if that team has people who understand what it means to be at the bottom. But just coming from a poor background or being black alone isn’t a qualification.

Rob Behrens: Two things, please. One is training and education in the health service need to be aligned to the strategic ambitions of the sector otherwise it is never going to deliver what you’re talking about.

I mean, my experience of looking for example at anorexia education is that it is horribly fragmented, that you can’t pull a lever and change things because there are so many different regulatory bodies that have responsibility for the curriculum and education and so on and different levels of clinicians. Do you ever get frustrated at the fragmented nature of the health service and its regulation?

Victor Adebowale: I do, actually. And I don’t think I would be the only one. There are lots of processes in the NHS. Lots of them. And one of the problems about processes is that they don’t always match the intentions. (Laughter) So, what you’ve described is a laudable intention, the intention being that anorexia services and anorexia education should be designed to provide the best possible treatments and care pathways for anorexics regardless. It should be consistent, right?

Rob Behrens: Yes.

Victor Adebowale: But over time, what happens is, processes get put in place that bear no relation to the intention and the process becomes more important than the intention. And so, I always take the view whenever I see complexity in care pathways, services, whatever, I always ask myself, what is the intention here? And then I match that intention with the processes in place. And if there is a mismatch and there usually are, one can be safe in deleting the intention of the processes that don’t meet that intention. And if you do that, not only do you save money, but you provide more efficient services.

But I’m afraid the health and care system is riddled. It’s nobody’s fault in that sense. It’s partly a product of having a complex system which has been going for a long time. But I think that focus on what is the intention here does tend to, sort of, focus the mind and clean out the process cobwebs as it were.

Rob Behrens: This is perhaps a bit fatuous, but how serious is COVID to the ambitions that you’re talking about? Because the NHS is under huge pressure of stress and resource in order to deal with this. It is setting back strategic movement forward considerably, isn’t it?

Victor Adebowale: Well, it is and it isn’t. I mean, the Confederation has been really focused on what we call ‘Reset’ because, you know, nearly 50,000 people, well over 50,000 people probably will have died as a result of COVID and we’ve got to learn from that. And it will be a crime and a travesty if we didn’t.

So, there are a number of things that we, with our members, have really focused on. And I suppose they might be summarised in three things. First of all, we have to be honest with the public about what the NHS can and will do over time. We have to be honest with them. Politicians have to be honest. We have to be honest with them.

Secondly, we have to focus, really focus on inequality and inequity. Because not only is it wasteful, it undermines the purpose and the trust that people rightly have in the NHS.

And I think the third thing we need to do is make sure that we resource it properly and stop debating, arguing at the edges of what the NHS needs. We need to fund it properly. It is still, as I speak, one of the, if not the most, efficient health system in the world. The alternatives do not bear thinking about in terms of personal financing.

In the US, 50% of all bankruptcies are caused by health costs. So, we have a good system here. And I think we should just remind ourselves how valued and valuable it is. I mean this in personal economic terms as much as I do moral and political terms.

And COVID has been a real wake-up call. And what I mean by that is, it has been noted that we have had five years of digital innovation take place since 31 March. Now that is tremendous change which is changing the way in which we deliver the health service, by and large, for the good. We need to be careful that it doesn’t leave people behind. But, by and large, it’s for the good.

And the second thing I’ve noticed that COVID has done is that it has forced people to work together. You know, it has really forced local government to work with health in a way that they just wouldn’t have done before. You know, 10 years to build the sort of trust that we’ve now been developing across boundaries. But not just at the political level for want of a better word.

You know, teams are working together better in hospitals across the health and social care settings. So, you know, the truth is revealed sometimes in a crisis. And what is being revealed is that actually, we can learn. We can change. We can develop. We could come out of this better and we have done. Crisis before in this country has resulted in better services and I do believe that that could happen with the NHS.

Rob Behrens: Okay. Well, we’re coming to the end. So, I don’t want to keep you. Incidentally, my great grandfather was a rabbi in Tredegar so I claim some historical relation to the foundation of the NHS in a way. But leaving that aside, we want to know what you are most proud of in terms of your career to date.

Victor Adebowale: I mean, the short answer is still being here. You know, my career isn’t over yet. (Laughter) So, I’m proud I’ve gathered some big learning about systems and organisations and people in leadership. I’m proud of what I’ve absorbed. And I’m proud of the people that I’ve worked with actually. I have to say that. I am really proud of the people that I work with and got to know as colleagues and then as friends.

I’m not one for ticking off. I just know that it is never just you, right? And it’s probably going to fail (Laughter) so I’m not one for ticking off like that. I don’t think life works like that. You know…

Rob Behrens: Okay, that’s fair enough. But the last question, I won’t allow you to deflect in that way.

Victor Adebowale: (Laughter)

Rob Behrens: So, there are a lot of young graduates who work for PHSO in Manchester and in London. We must have 250 to 300 people in their twenties working for the organisation at the beginning of their career. What message would you give to them? What advice would you give to them about sustaining their careers and sticking to their principles which you’ve managed to do?

Victor Adebowale: Well, that’s a fairly easy one. Because I’ll tell them what I told myself or what somebody told me that stuck in my mind actually for a long time. I can’t remember who told me now, it’s so long. The answer is retain a he althy level of self-doubt alongside ambition basically. (Laughter) That’s it. And always work with people who have self-doubt and ambition. If they don’t have self-doubt, they’re probably sociopaths. And if they don’t have ambition... That’s fairly straightforward.

I’ll tell you what is encouraging, the very fact that you’ve got graduates wanting to work for you. That is an indication to me that we are on to something. You know, if you’ve got people who want to work with you on this. The future is in the young. It’s an obvious statement. But I do think that the very fact that that is happening is a culture shift in itself.

Rob Behrens: That’s great. Thank you so much. Thank you for being our guest. Thank you for being so frank. It has been wonderful talking to you. This is Rob Behrens from Radio Ombudsman saying goodbye and stay safe. Cheers.

Victor Adebowale: Thank you, Rob.