A conversation with Dame Jackie Daniel, Chief Executive of Newcastle-upon-Tyne Hospitals NHS Foundation Trust

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Roddy Millar
Roddy Millar
Roddy Millar is Founder and Publisher of Developing Leaders Quarterly and Editor-in-Chief.

Dame Jackie Daniel is a purpose-led leader. This is evident not just from the intentional focus she brings to fostering and strengthening the role of purpose in her organization, but from the values she has identified in building her leadership style and approach.

Today Dame Jackie is the Chief Executive of Newcastle-upon-Tyne Hospitals NHS Foundation Trust, one of the largest semi-autonomous organizations in Britain’s National Health Service. Here she heads-up over 18,000 employees and runs a budget of £1.4billion (approx. $1.7bn). She received her Damehood in the Queen’s New Year’s Honours list in 2018 having turned around the failing University Hospitals of Morecambe Bay NHS Foundation Trust.

The ‘purpose’ of ‘caring for people when they’re at their most vulnerable’ is a hugely powerful motivator, it is not a sufficient condition to just enable the smooth running of a complex healthcare organization

None of this was inevitable for her. As Jackie describes it “I crashed out of school and didn’t attain the qualifications I needed, to do what I wanted to do. So, I didn’t go on to university at that stage, and kind of fell into the NHS, into nursing…” and then she notes about arriving in nursing “I knew, as soon as I got there that I’d found my place and my purpose in terms of caring. Caring for patients when they’re at their most vulnerable, I suppose was where it started.”

Dame Jackie Daniel
Dame Jackie Daniel

The NHS remains a totemic institution in the British psyche, offering free treatment to all, at a total cost far below that spent on healthcare in many other countries , notably the US. That it sustains great care for the vast majority in spite of this underfunding is founded on the dedication and resilience of its staff at all levels, from hospital porters, through nurses to doctors and consultants. While the ‘purpose’ of ‘caring for people when they’re at their most vulnerable’ is a hugely powerful motivator, it is not a sufficient condition to enable the smooth running of a complex healthcare organization such as the Newcastle-upon-Tyne hospitals that Jackie Daniel heads-up.

Wings to Fly

As she quickly rose through the nursing ranks, she observed that providing the best care, also required good leadership. And that that leadership needed to include a large amount of care too. “As soon as you get to ward manager, ward leader level, you begin to appreciate the impact that you’re able to have on a ward of 30 patients… I appreciated that was largely down to leadership. And you could see the direct correlation. I’ve seen that at every career transition I’ve had, and that’s driven me. I thought ‘I can create an environment where people flourish, people get the best care, feel really satisfied and highly motivated about what they’re doing. But what about the rest of the hospital?’ And that’s what led me to first become a director.”

The key parts are the wings which, she explains, are the culture, the values and the behaviours of the organization, “these are the things that amplify and accelerate progress. They get you the altitude and traction through really good, aligned leadership”

Dame Jackie uses an interesting metaphor for how she sees the organization from her CEO’s perspective: that of an ‘airplane’. The fuselage is the part that most chief executives focus on—the strategy, the finances, the annual objectives. The cockpit also has a range of dials and meters that allow the leader to monitor the governance and risk of those operations—something that she feels is too often under-monitored by NHS leaders with occasionally dire consequences. The key parts are the wings though, which she explains are the culture, the values and the behaviours of the organization, “these are the things that amplify and accelerate progress. They get you the altitude and traction through really good, aligned leadership” she says.

Dame Jackie received her Damehood for her work at Morecambe Bay NHS Trust. When she went there it was an organization that was catching nationwide media attention for its failures in care quality, with particular focus on deaths of mothers and babies at one particular hospital. But the care issues were widespread across the trust. It was here that Dame Jackie was confronted with the real need to mix the art and science of leadership. She has been designing her own model of leadership over the years “my kind of central operating framework, which is all the classic stuff around strategy, breakthrough objectives, clear values…”. At Morecambe Bay not only was none of this kind of structure in place as “their strategy [had been] all about acquisition and building the business financially; and nothing actually about quality.” But also “there wasn’t a sense of organization, there wasn’t a sense of ‘team Morecambe Bay’.” Without this sense of ‘Morecambe Bay as an organization’ there was a responsibility gap, everyone was operating as individuals and few had any clear sight of their purpose within the wider structure.

Enabling Purpose

Purpose at work may be an intangible element, but people can feel when it is present. It is part of a leader’s role to foster that feeling of purpose in their staff. In Morecambe Bay the purpose that drew people to work in the caring environment of the NHS was not being nurtured, but rather a disconnected commercial one was leading the organization, which neither resonated with the staff nor enhanced the care being provided by the organization.

One of Dame Jackie’s first actions was to clarify people’s responsibilities and ensure everyone knew what other people were responsible for. Morecambe Bay operates over a large rural geography of the southern part of the English Lake District, so this was not as simple as it might seem. In focusing on the people, she was able to bring the art side of her leadership into play. Setting the technical, science side was simpler—writing the strategy and setting the objectives, but Jackie was aware of this. “I observed some chief executives at some Trusts doing that in a very technical way. It’s not difficult really to write a strategy; it’s whether that resonates and has any meaning with anybody other than the senior leadership team and the board which is really, really important. [If it doesn’t] I mean, it will just fail.” This is where the ‘wings’ of the airplane come in. In order to ensure that that the strategy flies, it is necessary to have everyone lifting it and propelling it forward. And that, as she stresses is the real leadership challenge, that requires alignment and purpose to be held with clarity across the organization.

“[The strategy] is likely to be set in the wrong direction without that broader engagement. For me, the purpose is a deeper sense of reason and direction. And it’s that collective sense of connectivity and understanding—why we’re here and what we’re here to do—that is so important. And that is why the two wings of the jet are so critical because you can’t get enough height, you can’t get enough amplification in a Trust like mine without that.”

So how does someone manage such an organization, keeping the strategy and objectives at the fore, while also ensuring that the culture and values are continually attended to and fostered? Pre-pandemic in 2019 Dame Jackie set out her core approach around this, in a five-page document called #FlourishAtWork Framework (read it here: It centres around three dimensions: Leadership; Strategy and Governance; and Networks of Activity. As she writes in the document of the third dimension: “This structure is dynamic, initiatives and sub initiatives coalesce and disband as needed…. this type of network activity typically morphs all the time and with ease. Since it contains no bureaucratic layers or command and control prohibitions, the network permits a level of individualism, creativity and innovation.” It is easy to see how this approach enables the growth of purpose, as it creates the space and conditions for all employees to have some agency to build on the areas they see as most important to them, within the overall strategic framework.

This more fluid approach to culture and values also allows things to surface that would not do so in a more strictly controlled process. “I think that’s where the central operating framework is so important, because things come into view. I operate on a 12-week cycle within the year. So of course, you’ve got your strategy, and then what we typically do in health, as most organizations do, is set your annual objectives so that you can try and break this down into bite-sized chunks that are meaningful for ward staff nurses or your head porter. And that’s really tricky because you’ve got to disaggregate it at every level and create meaning at every level. And of course, stuff happens….”

It’s not difficult to write a strategy; it’s whether that has any meaning with anybody other than the senior leadership team which is really, really important.

At the time of speaking, UK nurses had just voted, for the first time in five decades, to go on strike, which definitely falls into the ‘stuff happens’ category. In such a high risk and purpose-led environment it is important to note that the strike is not just about pay, but also the low number of nurses employed, so that they are over-worked and fear for patient safety.

The prism through which Dame Jackie views this is wider than just the immediate boundaries of her organization. She sees that as her experience has grown, her understanding of the eco-system in which the Trust works has broadened too. “As you get more and more experienced in your job, you build a deeper sense of purpose in the broader sphere. I am very, very connected with the health and wealth of the Northeast, as a region. And I do a lot of work to focus on driving up economic development and creating jobs.” Specifically, she sees that social deprivation in the areas that the Trust serves, inevitably stokes the flow of poor health outcomes which then come into the hospitals. “I see part of my role as a big employer chief exec is about creating opportunities. People who wouldn’t otherwise get it in those pockets of deprivation and inequality in our community. So, it’s broader than just running the Trust. It’s a broader sense of responsibility about the economic ecosystem.”

While the particular issue of the strikes will require a careful balancing act of understanding and appreciating the nurses’ issues, she still needs to keep the service running. This plays to what she sees as a major role for the CEO of being the voice of the organization both internally and externally. Externally is simpler to understand, but the real energy is in the internal communications. Dame Jackie uses a lot of different channels to keep not just messages flowing through the Trust, but reinforcing and re-invigorating initiatives and essential values, to ensure that core purpose is kept alive and vibrant. These occur as blogs, social media, visits and being seen. “I think my job is to curate and narrate what’s happening and try and make sense of it at the moment. It’s how you how you make sense of empathizing with the cause.”

Two Systems – One Culture

Dame Jackie keeps returning to the two distinct levels of leadership she provides, which are encapsulated in her Flourish framework. This is the two-system approach, one technical and highly structured, the other much less definable, but probably more impactful, that supports the ‘human magic’ element that people with purpose bring to organizations in their collective momentum, energy and drive.

The formal leadership work around managing the governance and strategic objectives, takes place at the top of the organization and is System 1. Dame Jackie notes “I am doing formal business hierarchically, some of the bureaucratic, but important governance stuff, with a very small minority of my staff”, this is necessary and works, but then leaves a disconnect with the rest of the organization. This potential divide is crossed with her System 2 approach of Networks of Activity. This work amplifies and provides reach of the core objectives but allows everyone in the organization from ward secretaries and ancillary staff onwards to take initiative and play their parts.

Dame Jackie admits that the informality and looseness of System 2 would have concerned her when she was starting out as a CEO. But she has seen that by giving people the space and agency to initiate projects around things they are passionate about, is entirely positive. “Some of this stuff in System 2 you can’t control, it’s just happening. And it’s like a thousand flowers blooming.” She goes on to point out that people will do the things they are passionate about to an extent anyway, so it is better to create a supportive space for it.

“Some of this stuff in System 2 you can’t control, it’s just happening. And it’s like a thousand flowers blooming.”

The NHS is a force for good, but its impact on climate, for instance, is large, whether from the high heating costs, waste output or use of toxic substances; people in the organization at all levels are passionate about healthcare and many also passionate about climate change, so allowing room for them to take initiatives and push forward projects that alleviate some of the impact leverages energy and purpose that is already in the organization. “People want to talk about the climate emergency; and people want to understand how in health, we play our part. And so, they’ll go at it, whether I’m overseeing it or caring about it or not.”

It is important to understand that the model only works because of both systems though. System 2 can only operate if System 1 is in place. Healthcare is a high-risk sector and appalling outcomes can develop if the governance and risk management is not in place. However, she is clear that if you only have System 1 in place, then the operating culture can turn negative quickly too. “The risk management keeps us safe; it alerts us to the potential for harm, … the formal mechanism highlights or triggers a flag and so it’s so important. But actually, if used badly, it creates an environment of fear, of defence, rather than of curiosity.”

Enabling and developing the culture and mindsets to achieve this environment is neither quick nor simple, and her NHS Trust is focused on strengthening and evolving those capacities. “We are investing a lot in the leadership development of our top 250 leaders around mindset and behaviour; and how you create the environment where people can flourish and not feel inhibited and not feel fearful. And that takes a lot of work. It is part of the science as well as the art.”

For Dame Jackie herself, she is aware that she has to attend to her own mindset and thinking on a regular basis too. She acknowledges that she is a conceptual thinker and an introvert, so her first responses to problems and emerging issues is to mindmap and reflect to make greater sense of them, before she actively brings in close colleagues to share issues with, to get that broader perspective and reflection. In addition, she has regular coaching, something she has engaged with for many years, and seeks out peers in other sectors beyond the NHS to get input, alternative views and to be challenged on her thinking.

The NHS is a massive, complex institution. The whole nation is hugely vested in it, both as patients or relatives of patients and as seeing it as a reflection of who we are. Ultimately it is guided by the current political administration–and as such becomes a punchbag for opposition politicians to attack the government. Beyond all that, it is an institution that needs to work well for everyone’s health and well-being, one that employs many devoted and purposeful people passionate about making it do that.

Dame Jackie Daniel long ago mastered the technical side, but sees the difference in outcomes now, as she did when she started out as a nurse, as resting heavily on how healthy the culture within the organization is and how it is nurtured and strengthened. That is a job that can never be completed, it needs constant attention and effort – and experience. All of which she brings with clear purpose.

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