Interview: Scotland’s national clinical director Jason Leitch on changing culture in healthcare

Professor Jason Leitch - Image credit: David Anderson/Holyrood

Jason Leitch has not followed a conventional healthcare career path.

The Scottish Government’s national clinical director began his working life as a dentist, followed by a move into oral surgery, handling cancer, wisdom teeth, tooth extractions in children and trauma from road traffic accidents and sporting injuries – “lots of broken jaws and faces” – and he was also in academia.

Then a complete change of direction in 2005 saw him move to the US for a year.

There he learned transformation techniques through a fellowship at the Institute for Healthcare Improvement, the leading organisation globally for change and improvement of health and social care systems, and at the same time, he took a degree in public health at the Harvard School of Public Health.

It is a “weird combination of stuff”, he admits, but it was what he learned about change that really got him excited, which was how he ended up running what has now become the Scottish Patient Safety Programme on his return to Scotland.

This was right after Vale of Leven, where an outbreak of C. difficile at the hospital led to the tragic deaths of a number of patients.

A couple of jobs later, and Leitch became the national clinical director of healthcare quality and strategy.

The theory behind the role, which split off from that of the chief medical officer (CMO), was to have a third clinical voice inside the government, alongside the CMO and chief nursing officer.

“When Sir Harry [Burns] was the CMO, the idea was that I would do a slightly more operational version of the clinical leadership, so I would do quality, safety, person-centred care, compassion, those sort of things,” he explains.

“So, I was brought in initially part time and now I find myself as the National Clinical Director of the whole system. I honestly don’t quite know how it happened!”

He describes the job as threefold, the first being to lead part of the civil service, with his responsibilities including safety, quality, regional planning and cancer, working across policy and practice.

Key discussions recently have been about open visiting times and stopping inappropriate use of antibiotics.

The second area of responsibility is leading a team of improvement advisers who facilitate change and transformation, not just in health, but across the public sector.

This includes at the moment a project in the further education sector about making sure those who come into college go on to graduate, the Children’s and Young People’s Improvement Collaborative, which is about fixing the early years of life, and working with Cairngorm National Park on their agenda for change.

“It’s almost like consultancy,” Leitch says.

“We bring a set of expertise, which we leave behind. So it’s about empowering the staff, measuring what you want to fix.

“There’s a toolkit about change and improvement that will allow you to do that.”

The third area of work is, he says, “slightly more difficult to explain”. It centres on trying to maintain the image and the morale of the NHS.

This is both internal and external and involves working with staff, employees and the public and, along with the CMO, speaking to the media and at conferences more often than is normal for a civil servant.

“It’s a little bit of a sales job, partly,” he says.

And as if that wasn’t enough, outside of the day job, Leitch also does voluntary work in India, leading a team of healthcare workers to deliver treatment in an orphanage he has been visiting for 24 years.

Leitch says it’s the hardest he ever works but it “puts things in perspective a little”.

“You tend not to buy too many expensive cappuccinos when you come back because you’ve seen how the other world lives a little bit,” he says.

On top of that, Leitch has also recently become a board member of the Nazareth Hospital in Israel, an English-speaking hospital for the Arab-Israeli population, founded by a Scot, which does outreach in the West Bank.

Up until three years ago, he was still operating on a Friday but he found it was difficult to be a surgeon one day a week.

However, he tries to make it out to the frontline as often as possible, whether that’s a hospital or a care home.

After a trip to Oban planned for later in the week of the interview, Leitch thinks he will have visited every hospital in the country.

The Scottish Patient Safety Programme is 10 years old this year and while there are measurable improvements in safety – Leitch lists infections at an all-time low, surgical safety the best it’s ever been, the mortality rate after surgery at an unprecedented low level, C. difficile, as well as infection in intensive care, almost gone – a more difficult question is whether there has been a culture change around safety.

Leitch says independent evidence from the likes of the King’s Fund does suggest that Scotland’s safety culture has been transformed over those ten years and an example he gives is the introduction of morning huddles.

“Every day now in Scotland’s hospitals, at half past seven or eight o’clock in the morning, you can go to the morning safety huddle where the staff meet.

“Fife is the most recent example I went to.

“In the Kirkcaldy hospital, they meet at eight o’clock every morning, every senior nurse and doctor in the hospital, they meet and they have a safety huddle, they decide what the safety challenges are that day.

“So, it might be they’ve got somebody who is having cardiac surgery and they’ve got an infection risk and they’re very young or whatever and they deal with it together.

“And that’s new, that’s never happened before and it feels tangible, it feels different”.

Some of the improvements in safety are about improved knowledge, but the other part is giving staff a method to implement changes, Leitch says.

He explains: “It’s a bit dull, but people don’t know how to do change.

“They think change comes about because you send a letter or you write guidance. It’s not how change happens. That’s not how humans change.

“Humans change because you empower them, you give them the data, you allow them to put the data on the wall, that’s how change happens. It doesn’t happen because you write them a letter.”

Leitch says change theory is “a bit geeky” and “doesn’t lend itself to soundbites” but explains how it works.

“We talk about the change theory being in three parts,” he says, “will to change – does the system want to change, does that primary one teacher want to make that kid more physically active” – then the ideas – “the Daily Mile is an idea. It’s not magic. It’s an idea” – and then the “third and most difficult”, the execution of the change.

“Execution theory is about allowing the frontline teams to make the changes themselves, to monitor those changes very quickly.

“So don’t make a change measure in three months, make a change, measure it today. Do it thirty seconds later,” Leitch says.

But while improvement in safety can be measured, what about culture change in more intangible areas of his brief that you can’t benchmark, such as compassion and person-centred care?

Leitch mentions three examples of improvement.

The first is ‘What matters to you?’ which is now a global movement led by Scotland and Norway.

Leitch says that if you go into the Queen Elizabeth Hospital in Glasgow, you will see charts where patients have filled out what is important to them personally.

“It’s all about the individual,” he says. “And therefore, the ward rounds and the interaction with the staff are different.

“So they start to say, ‘Oh, I see you’re a Celtic fan,’ or, ‘Tell me about Mary, your niece, has she been to see you?’ So the conversation is just much more personal.”

The second change is ‘Care Opinion’, which is online feedback for patients and families to write about their experience in the health and social care system, with the difference being that it is not a senior executive in the NHS who replies, but someone involved in the patient’s care, such as a ward nurse.

Constituency MSPs also get alerts about any feedback from their constituency, so they can see what is happening and get to hear the positive stories as well as the negative ones.

The third area of change is around hospital visiting times, referred to as ‘person-centred visiting’, which Leitch says is “a bit of a new obsession” for him.

He points out that it has been happening in maternity and children’s wards for years, and it’s just a question of bringing that in for other patients in hospital.

He explains: “People are a little nervous when we call it open visiting, as if we want a free for all and fifteen people to sit at the bottom of every bed with a tartan wrap and a flask of coffee.

“That’s not really in the park. That’s not really what we’re after.

“We want it managed, but we want it to be about the individual, not about how convenient it is for the health service.”

All this is very much a focus on the individual, their needs and priorities, which is perhaps the next big culture change after safety which is, if not finished, at least improved.

Leitch continues: “I think those three things, along with a host of other things, begins to change the way we think about the person-centred nature of our system, the compassion, the family involvement, a bit like we did for safety.

“But it’s a bit less tangible than safety.”