Mark O'Brien:
Hi, I'm Mark O'Brien and you're listening to Transformational Healthcare Leadership, a podcast series from Oxford University's Saïd Business School. A collection of interviews with leaders from across the globe exploring the five key themes of the school's healthcare leadership program, the personal leadership journey, understanding the involving environment, effective strategy formation, driving innovation, and improving performance. The COVID-19 pandemic precipitated massive disruption in business-as-usual healthcare. New models of care have been developed along with the discovery of novel technological and therapeutic regimes. Many have identified this as a turbocharging of healthcare innovation, but alongside that wave of innovation has been another story, one of burnout, resources stretched beyond capacity, workforce shortages, and unanswered questions as to the burden of disease from long COVID over the coming decades. So how are healthcare leaders addressing these challenges? What are they thinking? What personal journey are they on? How did they survey the changing landscape? What strategies have they tried, or intend to try to ensure their team, their organization, their country not only survives but thrives? In this episode, I interview Bruno Holthof and particularly explore the themes of personal transformation and improving performance.
Bruno recently stepped down as CEO of the Oxford University Hospital's NHS Foundation Trust in the UK after nearly seven years of service. Currently, he is a visiting professor of health innovation in the Nuffield Department of Medicine at Oxford University and an investment partner of the EQT Health Economics Fund. As well as his medical qualification, Bruno has a PhD in healthcare economics and an MBA. And has successfully straddled the scientific and management world throughout his illustrious career. After working for 15 years as a consultant at McKinsey's, he undertook a number of executive roles while also managing to accumulate significant board experience on both academic and industry boards. When he left McKinsey's, Bruno accepted the job of CEO of Hospital Network Antwerp or ZNA, a large hospital group in Belgium that was under considerable financial strain and in need of quite a turnaround.
I began by asking Bruno what insights and experience he drew on to reverse the fortunes of ZNA.

Bruno Holthof:
Thanks Mark, for this kind introduction. I mean, when you say the hospital group was under considerable financial strain, you could actually say it was bankrupt. And before taking on the CEO role, I was the partner leading a McKinsey team that developed the transformation plan for the hospital group. And as you may know, consultants have excellent analytical skills, and of course we developed a very strong fact-based plan for the network going forward. This included some drastic measures like closing one of the hospitals and the transformation of two other acute hospitals into longer term care facilities.
And you can understand putting a plan on paper and implementing that plan are two quite different things, and they require different skill sets. So certainly in McKinsey, I was able to really look at the problem, analyze it, and propose solutions to address the issues. But I had quite a steep learning curve on how to work with unions, politicians, and thousands of staff members once I became CEO. Because it's evident that when you take such drastic measures as closing hospitals and transforming others, it has a big impact on people's lives and you have to make sure that they go through that difficult change period.

Mark O'Brien:
Yeah, Bruno, I can only imagine the emotion around closing facilities and transforming acute hospitals into long-term care facilities. There's a huge tension there that you must have managed. So as you look back on your time at ZNA, perhaps I can ask you to reflect on the cultural change that you needed to bring about in the organization to increase its performance. And from what you're saying, salvage it from bankruptcy.

Bruno Holthof:
Yeah, I mean, ZNA was a public healthcare provider owned by the city of Antwerp. And as with many public healthcare providers around the world, the clinical and administrative staff in the hospital, they have no real interest in finance. They didn't really understand finance, and there were no financial incentives for staff to change their way of working. So for example, when the Belgian government changed the hospital reimbursement system to a DRG type payment for the inpatient admissions, that's when the hospital group went bankrupt because the doctors, the nurses, the social assistants had no understanding of how length of stay, or a shift to day admissions was impacting the revenues generated and the cost incurred. So the biggest cultural change was to introduce a financial understanding, first of all, and then financial discipline. And that is quite difficult, especially in a healthcare environment where people put quality above all and rightfully so.
So the best way to engage clinicians on this topic is by discussing how quality and operations and finance are interrelated. So for example, mobilizing patients quicker after an operation improves the outcomes. There's quite a lot of evidence for that, but it also reduces the length of stay. And then in a case of DRG payments, it increases the profitability of the hospital system as well. So it is a win-win-win for the patient and for the hospital in terms of its finances. So that's how you engage the doctors and the nurses, the physiotherapists changing the way they operate to improve patient outcomes, but also improve the finance of the hospital.

Mark O'Brien:
So Bruno, I imagine that we know from change management that people respond differently to a transformation like that. I'm sure you had leaders and clinicians who were on board, but could I ask you just to reflect, did you find any resistance, cultural resistance as you actually tried to drive that change?

Bruno Holthof:
Yeah, no, absolutely. I mean, every change when it's a significant change will elicit resistance and people have the different sort of phases of reaction to that. The most comfortable way of working is having no change at all. And in many healthcare organizations, people stay with the same organization throughout their career. They may do a few changes at the start of their career, but once they're sort of established as a doctor or nurse, they tend to stay with their institution often for 20 years or more. And so especially with doctors, nurses that have been doing their work in a certain way for more than 20 years, if you then come and say you have to change the way you practice to reduce length of stay, or to not even have an admission, but do it in a day setting. I mean, people are resisting often because they're a bit anxious, they're uncertain. So there's a lot of support that you need to give them to go through that change.

Mark O'Brien:
And as I know, you turned ZNA around and made it into a very profitable and sustainable organization. So as you reflect on the skills that you developed in driving performance as a leader, after moving from McKinsey's to ZNA, what did you take forward into your role at Oxford? What did you see of great value in that experience that prepared you for the very important role that you took on then at Oxford?

Bruno Holthof:
Yeah, Mark, I just mentioned the important skill of engaging clinicians because it's the clinicians that take decisions that drive the quality, the operational and financial performance of an organization. And I think one of the things I really learned in ZNA and I took with me to Oxford was that as a leader, you have to pick the right clinical leaders, and both in Antwerp and in Oxford, I had to change some of the clinical leadership because some would not believe in the fact that you can improve quality and lower cost at the same time. And some of these leaders would always ask for more budget without a commitment to increase productivity.
And then inevitably, you will have to make some changes in the leadership if that's the case. Maybe a second lesson that I took from Antwerp to Oxford is that you actually do need to make operational changes to improve quality and increased productivity. And I often ask people, "What have you changed in the way you operate or practice?" And it's things like, "Okay, we've changed this inpatient facility to a day case unit." Or, "We've changed the skill mix in a department." Or yeah, "We've done something differently." And then they usually can also point to improvements in patient outcomes. And in most cases, that also will lead to the team being able to treat more patients, either diagnose or treat more patients. So that's an increase in productivity.

Mark O'Brien:
Oh, that's fantastic. And my understanding too, Bruno, I mean, as you know, two of the five key themes of the Oxford Healthcare Leadership Program that I'm the program director of, are performance and innovation. And so there is a link between those two, isn't it? And my understanding is that when you moved to Oxford, one of the attractions in accepting the job was the opportunity for an interplay between the health service, research, and private enterprise. So what was it about this combination that excited you as you thought of making a very significant and substantial contribution as the CEO of the Oxford Trust?

Bruno Holthof:
My interest, Mark lies in bringing together academic researchers, clinical experts, private enterprise, and private funding to bring these innovations to as many patients as possible. And there are many ingrained biases against each other with every one of these stakeholders. And you'll probably know that some academics believe industry is taking unfair advantage from academic innovations. For example, the pharma sector often is blamed for pursuing value based pricing instead of a cost plus pricing. And some clinicians find that research in their clinic is a disruption to the efficient clinical operations, and they don't really see the value of the research. And I can go on with private enterprises sometimes find academic and healthcare institutions difficult and slow to work with. And to be honest, there are many biases and often they're based on past experience and therefore perceived to be real. So my interests is to build trust among these different stakeholders and find win-win situations for all of them involved.

Mark O'Brien:
So Bruno, just following up on that, do you believe that if you develop a strong innovation culture that it actually drives high performance?

Bruno Holthof:
Absolutely. I mean, there's lots of evidence that research-based institutions have better outcomes and a lot of the innovations actually increase productivity in healthcare. And it's certainly one of my passions is to improve outcome and lower the cost against the current golden standards of medicine. So my real interest lies in innovations that achieve that objective and then those innovations will increase performance.

Mark O'Brien:
Well, I know out of that combination of innovation and performance, one of the major successes during your time as the CEO at Oxford was the development of the Oxford-AstraZeneca COVID-19 vaccine. So what do you see as you look back as the performance enablers that existed at Oxford during that time that led to the incredible speed of its development and deployment?

Bruno Holthof:
Yeah, I mean, that was certainly one of the more interesting periods in my career, Mark. And I mean, all of the expertise to develop the vaccine was actually living in Oxford and were part of the quarantine measures. And it was a time when the world was put on hold, no travel was allowed. So having all of the expertise in one location was a major advantage. I think the second factor of success was that all the decision-makers in Oxford and the UK were very focused on solving the COVID crisis. I mean, in Oxford for example, we did a massive redeployment of our people and the resources that we have in research and in the clinic towards one single disease.
In normal times, we run more than 2000 clinical studies and all of these resources were now focused on a few key trials such as the vaccine trial and the also globally known recovery trial for COVID. So that was certainly a second factor for the success. And finally, I mean another key success factor was that the decision lines were also very short and fast. I recall receiving a call from the then Secretary of State of the Department of Health and Social Care on a Sunday afternoon when we were all in lockdown checking to make sure that I would deliver face masks to the volunteers and the researchers of the vaccine trial. I can tell you, Mark, in normal times that would be called micromanagement, wouldn't it?

Mark O'Brien:
So clearly there was a level of anxiety there, but could I follow up with that, Bruno? I think it's really interesting, isn't it, I've heard leaders that I've interviewed and spoken to across the globe who say, "How do we capture that sense of focus and urgency and those short decision lines." A crisis almost gives permission for that. How do we keep that rapid cycle of innovation and development going once things sort of get back to normal if we ever get back to normal? Do you have any thoughts on that?

Bruno Holthof:
Yeah, I mean, certainly the COVID crisis, it was easy to focus. It was the most important thing to do. And we put lots of other things on hold, both in the research as well as the clinic. And as a consequence, when you focus, you get things done quite rapidly and decisions are made fast, et cetera. Once you go back to a diverse set of research and clinical operations, it feels like you're having to hold many balls in the air at the same time. And that means things inevitably will be dropped or will be slowed down. So my advice is if you really have some important issues to solve, make sure you prioritize and be ruthless in your prioritization. We had to do it during COVID, but you also have to do it when you have your own issues to deal with. That's how you create that sort of sense of urgency by saying, "This is the most important thing we have to do, let's focus on it."

Mark O'Brien:
And Bruno, along those lines, would you go so far as sandboxing people and resources?

Bruno Holthof:
Yeah, I mean, I had an interesting discussion with the chief executive of the National Health Service who said, "Well, it's easy when you say you have to focus and limit your priorities, but I get different priorities every day." So in my view, Mark, you just have to, as a leader say, "Okay, this is what the organization can handle. This is what we are going to focus our resources on. These are our priorities." And if some projects or people don't fall within those priorities, either you have to redeploy them or say, "Yeah, we're going to have to slow down your initiative."

Mark O'Brien:
That's fascinating. So Bruno, as you look back now at your time at Oxford, what do you identify as the key lessons and insights on driving performance that you gained during your tenure there? That might help our audience as they're listening to this?

Bruno Holthof:
I mean, I would say Mark, putting the right leaders in charge of each of the clinical services is the most important thing that I've done in Antwerp, in Oxford. And that is easier said than done, especially in a world-class academic hospital. But then even though that's difficult, more important is that you have to make sure that these leaders are well-supported by removing barriers for them. In many hospital systems around the world, the corporate departments of these systems tend to work in silos. They often report to different executive officers. And as a clinical leader, you need the support of logistics and IT, human resources, and finance, procurement and the pharmacy, and so on to get any meaningful change implemented in your service. And it can be pretty frustrating because you need to align all of these departments. And so in my role as CEO, helping them to get coordinated support from all of the corporate departments was pretty essential.
And coming back to the priorities, I mean, if as an organization you have, let's say, five key priorities, it's easier for the corporate departments to align themselves along those priorities. And that's certainly what happened in COVID, yeah, everybody was really focused on that and aligned and things moved very fast. So that's what I would say is quite important, is that interface between clinical services and support services. Then, I mean, finally, I would give us a sort of advice that clinical, they're not really taught the management and leadership skills that you teach at business schools. So skills such as team building and change management or concepts such as P&L and balance sheets are very new to them as a leader. And you need to offer training programs for them so that they can get familiar with how to build a team, how to manage change, how to read financial statements. And so that's why we built our own in-house program in Oxford to exactly achieve that.

Mark O'Brien:
That's really interesting, Bruno. And as you say, many clinicians are not trained in the basics of P&Ls and balance sheets and cash flow. And I suppose that nicely segues into the fact that you are also a health economist. You've had the opportunity to study and analyze up close the advantages and disadvantages of private and public funding of healthcare service delivery. So what are your reflections as a health economist on the impact of funding models on performance?

Bruno Holthof:
Yeah, I strongly believe universal access to healthcare is essential to reduce inequity in health outcomes. And that's where the US has a problem, because if you're insured, you get access to excellent care, but a large part of the population is uninsured, and that has an impact on outcomes of the population. And I amazed on why universal access keeps being rejected in one of the most developed countries in the world. So in my view, publicly funded health systems and whether the funds come from taxes or social security contribution, that doesn't matter. But publicly funded systems with universal access provide the best opportunity for increasing health outcomes for everyone. Then moving on to what may be a bit more controversial is that I don't believe that the actual care provision needs to be public. And in Belgium, most of the care is delivered by private organizations.
And if the public funder sets tariffs or payments for the care needed, in my view, private institutions are a much better place to provide the health service. These institutions tend to be more entrepreneurial and service-oriented, and that's why I'm amazed why the NHS is still so well respected in the UK. Because the service orientation, the access is a lot poorer than in some other countries. So in my view, you need to keep the NHS as a public funder of care but allow private providers to offer the services. And then I know that a lot of the arguments will say, "Yeah, but we're concerned that then shareholders will be profiting from taxpayers' money." And therefore, if you're really concerned about that, then do as is the case in Belgium, only allow nonprofit institutions to contract with the NHS as a payer. But I believe that private initiative in the actual care delivery will drive innovation and increase performance.

Mark O'Brien:
Bruno, you've really tapped into something there because I was going to ask you about your view whether payment methods can drive innovation and performance, and you've actually touched on that. But can I put to you, as you know, I've spent a lot of my life in the Southern Hemisphere, and a big topic of discussion, when we start talking about payment methods in public versus private is a lot of people can see the value of payment methods that drive private performance in things like surgery or procedural work, but they struggle a little bit more with the idea of private providers of complex say multi-system disease in elderly people. So it's very easy with, it's an operation, here's a defined amount of money for a defined period, but it's more complex when it's an elderly person, say with heart failure and diabetes and perhaps some chronic arthritis. How do you see payment methods driving performance in that more complex type of multi-system long timeframe care delivery?

Bruno Holthof:
Yeah, I mean, we already talked about the DRG payments and certainly a payment for a hip implant or a cataract operation works well and drives innovation and increases performance, and people are getting used to private providers offering those services. Once you talk about sort of long-term care and chronic conditions, potentially multiple conditions at the same time with the patient, I think capitated payments could fulfill a similar role as DRG payments have done for the sort of surgical procedures. Because in a capitated payment, again, you get an incentive for innovation to improve patient outcomes and lower the cost of the care package that that patient needs over let's say a year's time or so that could be done. And certainly, we talked about the US not having universal access, but one of the things they do well is their help maintenance organizations like Kaiser Permanente when they have stable membership, they do have an incentive for managing those chronic conditions at lower costs and therefore adopt innovation in that area.

Mark O'Brien:
Oh, that's very interesting. So, Bruno we've spent much of our conversation so far discussing organizational performance, but can I ask you about your own personal performance? What are the strategies and techniques you use to maintain your own high performance as a leader?

Bruno Holthof:
Yeah, I mean, I need to take regular breaks for rest and reflection. I don't believe in leaders that can work continuously for months or years in a row. For me, that means being able to do a short walk or a bike ride every day, but also taking longer breaks a couple of times a year just to enjoy nature and culture in different parts of the world are key for me to just have that moment of rest and reflection.

Mark O'Brien:
Yeah, I think part of every CEO's role is to tap into that sort of wisdom that sort of only percolates to the surface when you've had a break. But look, it's interesting, Bruno, when we last met face-to-face in Oxford, the world hadn't heard of COVID-19. So three years on healthcare service leaders across the globe report and exhausted and burnt out frontline workforce. Many have said to me that even discussing increasing performance can elicit a rolling of eyes or a look of incredulity. So as you know, the buzzword at the moment is resilience. But in your opinion, what can leaders do to support and improve performance in times of strain and scarcity of resources, whether that's financial scarcity or even human scarcity.

Bruno Holthof:
Yeah, Mark, what I need, other people need as well. So my advice would be give people time for a break to rest and reflect. I mean, during and after the pandemic, I insisted on staff taking all their annual leave and I asked to monitor that staff performed a reasonable number of shifts just to make sure that they could take a break. And I mean, second, I think what we can do as leaders is to listen to what staff experience, and then I mean genuine listening to what would make their work experience better. And then quite importantly, asking what you can do as a leader to support them.

Mark O'Brien:
Bruno, I have the feeling that we could go on for hours talking about your insights into performance. It's been so enjoyable hearing them both at a personal and organizational level. Perhaps I could ask you, are there any final messages that you'd like to pass onto those listening to this podcast about how the lessons you've learned in your outstanding career can assist them as leaders?

Bruno Holthof:
Yeah, my advice always is make sure you have fun because if you don't enjoy your role, it probably means you're not in the right place. And I've had some of those coaching discussions at McKinsey, in Antwerp, in Oxford. You really need to enjoy what you're doing. You need to follow your passion. And if you're not happy, maybe look for something else.

Mark O'Brien:
Yeah. It often takes great courage to admit that, doesn't it if you're not happy in a role. But the problem is, as you almost implies that you can become an anchor on the organization if you're not enjoying the role and if you're not engaged. Well, Bruno, finally, we ask all the contributors to this podcast series, the same two questions at the end of each interview. So I'd like to ask you, what possibility in the healthcare ecosystem excites you most as you gaze into your crystal ball for the next 10 years?

Bruno Holthof:
And in the past seven years, Oxford has created many technology companies using genomics and artificial intelligence to better understand the genome and phenotype of individual patients. So I'm convinced that in the next 10 years, we will see these technologies translate into real benefits for individual patients and entire populations by just understanding what is the specific genomic composition of that patient, and what are the biomarkers that we find that give indication of disease that is brewing or high risk for certain disease. I mean, these are lots of buzzwords, the big data, artificial intelligence, the genomics revolution. But I believe in the next 10 years, we'll actually see new devices, new software being made available for clinicians that will improve the diagnosis, get to earlier diagnosis, and a lot more targeted treatments, which I think is great news for us all.

Mark O'Brien:
Yeah, it certainly is exciting. And secondly, as a leader yourself, what's the one piece of advice you would now give to your 20 years younger self about becoming a powerful leader?

Bruno Holthof:
Yeah. Over my career, I've found many of the healthcare leaders to be quite risk-adverse, and it's quite normal because we work in healthcare and mistakes can lead to serious complications or even unwarranted deaths. So safety in healthcare is absolutely essential. But with that, as a caveat, I would encourage leaders to push the boundaries of risk-taking because in my experience, the safety argument is often used for keeping the status quo and doing nothing.
I mean, I recall when I started in Oxford, transferring medically fit for discharge patients. So these are patients that are still in the hospital but actually don't need to be in the hospital. And I transferred them to empty nursing home beds in Oxfordshire. And some people thought I was crazy to take such a risk, but in my view, not being able to admit seriously ill patients in your hospital because you don't have any empty beds is a much higher risk. So we had no beds in the hospital and empty beds in the nursing home. So the transfer in my view, was reducing the risk as a system, but it haven't been done in the years before I became CEO and people hadn't done it because they thought it was too risky.

Mark O'Brien:
So taking risks is a huge part of being a great leader. And I'm so pleased that you highlighted that as we finished off our podcast today, Bruno. So Bruno, thanks very much for your time, and I look forward to seeing you around the Oxford campus for many years to come.

Bruno Holthof:
Great, Mark and I look forward to seeing you here in Oxford and welcome from Australia to the Oxford campus.

Mark O'Brien:
You have been listening to Transformational Healthcare Leadership, a podcast from Oxford University's Saïd Business School where we speak to outstanding healthcare leaders from across the globe who share their insights on healthcare leadership as we navigate the complexity of modern healthcare delivery. And for those interested in furthering their healthcare leadership journey by joining us at Oxford for the executive education offering that I and my colleague Eleanor Murray have the privilege of leading at Saïd Business School. You can find details about the Oxford Healthcare Leadership Program in our show notes. We'd love to see you at Oxford. Transformational Healthcare Leadership is produced by Chris Ashmore Media. And if you enjoyed listening, please subscribe to hear further episodes and tell your friends. Thanks for listening.