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Case Study: Siobhan Clarke: Managing Director of Your Healthcare
“It was a really challenging process, but we would do it all again because it was the right thing to do.”
Your Healthcare, formerly part of NHS Kingston, was created as a mutual co-operative social enterprise on 1st August 2010 to deliver healthcare services to the local community as part of the NHS family. It is a not-for profit organisation staffed with former NHS personnel, delivering the same services as it did before. In fact, since the transition, it has been ‘business as usual’ for both patients and staff, who have continued to deliver the same high quality services. As it is not-for-profit, any financial surplus is re-invested into those services and the community. It was awarded a contract with NHS Kingston worth over £24m a year for five years, plus a contract to deliver learning disability services in Richmond. It also delivers additional business services to other clients. Just like GPs and dentists, it continues to be part of the NHS family and deliver care under the same ethos.
Siobhan Clarke interview:
Why did you choose to spin out and go down the route of social enterprise?
The social enterprise model provided us with a new vehicle to offer great healthcare services with a community focus. With all options considered, in 2006, the PCT took a decision to support the development of a social enterprise. I joined the organisation in September 2007 and we started the process by internally separating out the business of service provision from NHS Kingston. We then carried out an objective Options Appraisal; and following this the Board reinforced the original intention to establish a social enterprise. This was because it was the only option that focused on the community (community involvement and ownership), keeping our resources in the same place, for the same use. So from decision to launch the process took three and a half years.
Did you portray a “vision” for the spin out model, or for what Your Healthcare would look like?
It is difficult because you are asking people to transfer to an organisation that doesn’t exist yet and they can’t visualise it and know the culture of it. The issue is that you don’t have all of the answers, so you just have to talk about how things are going to feel once the process is finished. When you ask people why they came into healthcare, they really weren’t interested in doing data returns, they wanted to get out and care. So when you remind them that their aspirations and the care of service users can be achieved, explain that their terms and conditions are safe and show that they will be able to have a say in how the organisation is run, they love the idea.
How demanding did you find the spinning-out process?
We made it part of the day job, we weren’t fazed by it because it’s easy to keep going when you know what you are doing is the right thing. All we wanted to do was deliver fantastic services that meet people’s needs, in the place they want to receive them and at a price the commissioners are happy with. What’s difficult about that? It’s not difficult but it can just be tiresome; so if you are the sort of person who prefers a 9-5 work schedule then it’s probably not for you. You need to be able to manage chaos.
How did you involve your staff in the transition?
It would be fair to say that at first the staff were a bit confused. There were worries over what it meant for their terms and conditions and how the service might change. So we made sure that we went through everything with the staff. We had one-to-one staff surgeries, regular staff newsletters and updates, an open-door policy at all levels of the organisation and a lot of HR involvement. We just absolutely immersed everybody in the story to make sure it was understood by all. We didn’t keep any information back from anybody; we were completely honest and transparent about the situation and willing to receive feedback. In the end, it was actually the staff saying that we needed to do this and get very senior officials to understand that this would be something positive for the service users.
Did you feel that the transition needed to have a top-down approach?
You definitely need to have strong leadership, a lot of commitment and resolve. However, I don’t think it necessarily has to be a top-down approach. You need to really believe in it, and actually the reason you keep going is because you do believe it. If you believe in the idea; and you explain it to the staff and they see that it is best for the organisation then everyone has input. Leadership is important but it doesn’t need to be top-down all the way through the process.
Have any of your service users sensed any difference?
One of our strap lines is: Same services, same people, same place, and that’s exactly what we wanted. What we needed to do was cut down on bureaucracy, change the system and better our partnerships; it wasn’t the health services that needed altering. So, in answer to your question, if I say no they haven’t noticed any difference: then that is a positive response. We haven’t lost sight of what we are here to deliver; but we have had some amazing transformations around how we use our money and how we engage with our community.. We also have some people from the local area who are just interested in playing a role in the organisation as volunteers, wanting to be a part of it because they love what Your Healthcare is about. We have got some interim governors at the moment, until we build our membership, and then we will elect from this membership.
Were you unable to do this within the NHS?
There was no need to do it because we had a representative board appointed by the Appointments Commission. We are now building a membership of our service users. So that is what’s different. I think organisations think that they are being aspirational for their services users; but actually they don’t have a system that allows them to really input. They have a say about how public resources get spent. What you have in the health service is a rich system around accountability of resource use but the people in receipt of services rarely have a say in how money is spent and resources are deployed; a quite different emphasis.
What do you think was the most challenging aspect of spinning out?
I think there was a worry that policy changes with the new government could have a negative impact on our progress; but I used to say to our staff and service users, that regardless of the government in power our service users’ needs won’t change: they are our focus. We were trying to keep the NHS’s most senior managers happy; these were the people that would support our journey to independence and we had to convince them through rounds and rounds of interviews and assessments that we had got this right and trying to make sure they didn’t waiver, which took some doing.
I think it is important just to stay resilient and strong; both organisational resilience and personal resilience. Not taking your eye off the ball is quite essential. It is about never missing an opportunity to get across what it is you are trying to do, that in itself is quite exhausting. It was a challenging process, but we would do it all again because it was the right thing to do.
What were your reasons for keeping the NHS branding?
The NHS brand is a unique identifier of great public services. Our services are still delivered by NHS trained staff, the services meet NHS quality standards and they have been commissioned and paid for by the NHS; so it seemed quite logical to keep the brand. Our staff also recognise it; they love being part of the NHS and they still are, they are still providers of NHS services so they wanted to stay true to the NHS constitution and keep the brand. The only difference is that now we have the “Your Healthcare” logo sitting alongside it; so people realise that the changes are about the focus of the organisation rather than the provider.
Were you able to transfer all of the staff terms and conditions?
Yes, quite unusual, too, for 600 staff.
How did you negotiate that?
We used TUPE, so all of the staff were able to keep their terms and conditions. In addition, our relationship with the unions is brilliant; we have stood side by side all along. We have some fantastic provisions as a result of that collaboration. For example, we have a memorandum of understanding around things like pay: there isn’t anybody in the organisation who can earn ten times more than the person on the lowest salary. We have quite a narrow band in that regard.
The other thing about standing independent of the NHS is that we can keep our management costs down. We put as much resource in the frontline as we can, that’s where the taxpayers want it to be and that where they can see it and feel it. It only costs us 2% of our overall budget to run the management of the organisation, whereas your average NHS organisation can apply as much as 20% in overheads. If you are a commissioner and you have money to spend on services – 20% versus 2% is a bit of a difference.
Do you outsource any of your infrastructure support services?
What’s amazing is that we actually also have an infrastructure business, consisting of HR, Facilities and IT, which the GPs and our commissioners already purchase from us. So, we don’t need to outsource.
Where did you get your entrepreneurial skills from? Mentoring?
Not mentoring, I haven’t had any whatsoever. However, I have had lots of support and I have met inspirational people. I am just so passionate about the services that we provide; but I am not a fan of bureaucracy and I think that probably drives me. The more I was told it wouldn’t happen the more I was determined that it would.
Have the staff been entrepreneurial?
We have a democratically elected staff group called Potential, which is our staff mobilising to come up with business ideas. For example, they have already come up with a marketing idea to get the brand out there. They ran their own Race for Life and managed to raise over £900 for charity. They have also just mentored a group of sixth formers at Chessington Community College; considering an organisational issue of ours surrounding the use of greener transport for staff. We originally thought bikes may be the answer to our problem but actually their research showed electric cars to be preferable, because our community staff can’t carry essential medical equipment on bikes. This type of mutually beneficial association is simply unusual within standard public services.
And the Potential group will continue to run?
Potential run themselves, they are elected by staff and have a facility whereby they go back to their electorate and report straight to the Board. It’s not about Terms and Conditions and stuff like that, it’s about how can we generate great business ideas and prospects. It doesn’t matter where you are in the organisation, male or female, senior or not, everybody has the option to stand if they wish. As a result, we are very flat organisation without a hierarchy. Everybody has ideas, so this is how you can generate a medium where these ideas can be encouraged to come to fruition.
Do staff have to be involved with the business side of the organisation?
They don’t; we try to deploy clinical skills where they are needed, and we spend all our resources on clinical skills as that’s what our business is. It does mean that the Board and top team look a bit ragged because they may not have all the resources that they require, but we are fine; it’s the right thing to do. We are all members of the same organisation and we all have a role to contribute to its success, but we all have different levels of responsibility in this regard.
Does this different model of public service help you to carry forward innovative ideas?
Yes, because we are a social enterprise and are trading for public benefit. People are seeing our community ethos and the way that we do business as being just as attractive as the services we provide; that carries a lot of weight.
Do you think you have sufficient resources to cover the work you do?
Well this year we have managed to save 60k; it’s not a lot of money but it has been reinvested. Many organisations are struggling with insolvency in this economic climate so we are doing phenomenally well. We also have lots of supportive partners. For example, we currently have the most fantastic opportunity to work with the Local Authority around new forms of local residential care. If you put money into looking after people in their own home, where they incidentally want to be, it could make a tremendous difference to their health and psychological wellbeing; so it is a promising project. Your Healthcare receives just 8% of NHS Kingston’s resources. We are punching way above our weight and that’s because of our local relationships. We don’t have a lot of resources; it feels like we do, because we do a lot with what we get.
Say another Local Authority approaches you and wants you to take on their services, is that an option now?
Yes absolutely, we are trading in the market now. Some of our best successes have been our partnerships, often partnerships outside of the NHS. For example, we have been asked to support the running of a new school, which was not originally our type of business, except that it is in that we can help to support the health aspect of the education curriculum. So not only are you developing socially able and academically resilient children, but actually they are healthy and have confidence and high self esteem. This opportunity might not have been made available to us in the regime we left.
Where do you see Your Healthcare in a few years?
We are really focused on Kingston and Richmond where we have services too, but I would love there to be lots of Your Healthcare’s around that are focused on their own communities. Maybe a bit of a franchise model, but I don’t believe there is going to be a large central operation and we just have lots of branches; that misses the importance of localism although some would argue that you could control quality in a larger operation. But you don’t build ever developing relationships in large organisations – size is the enemy of this. You have got to have the engagement of your service users. So there’s no reason why you can’t have a Your Healthcare in any borough or county; but you would have to have the same energy and the same involvement locally.
What would your advice be to those spin outs in the same situation you were in?
Find someone like me; someone who has been there, done it and got the T-shirt. When we were spinning out there was nobody really that had done it under the Right to Request policy regime; there were lots of advisers but no one who had actually done it. We were the first social enterprise in London to establish out of the Transforming Community Services raft of policy. So once we had done it we became advisers to others using Right to Request. The spinning out process is absolutely hands on. We told those organisations where to focus their efforts; what not to worry about and just to stay strong and resilient. What’s great about having a year of trading under your belt is that you can start to talk about all of the benefits. What you can focus on now is development and you are able to talk about the first successes, and that gives you hope.