Speaker1: [00:00:00] Hello, I'm Suhail Mirza and welcome to this episode in season three of Voices of Care. I'm joined today by James Tugendhat, Chief Executive Officer of HC-One.

Speaker3: [00:00:09] Voices of Care, the healthcare podcast.

Speaker1: [00:00:13] James, welcome back to Voice of Care. Thank you for coming back and seeing us.

Speaker2: [00:00:17] It's a pleasure to be back and I'm looking forward to our discussion.

Speaker1: [00:00:20] Likewise, I can't quite believe it was in 2022 that we last met.

Speaker2: [00:00:26] Where does it all go?

Speaker1: [00:00:28] It passed by and we're in season three now. It's been I mean, there's so much to cover, but since we last spoke, just be interested to have a little bit of update from HC-One, the kind, caring company, you've been busy. I think opening new frontiers and acquiring businesses.

Speaker2: [00:00:42] It's been a really exciting 12 months for us because it's been in lots of ways, the last 12 months have been the culmination of so much of what we've done, really, in trying to rebuild since Covid, and it's all been coming together. And, you know, in so many ways our care is complicated. But it's also straightforward the homes that do best are the ones with the best reputation in their local community, and they tend to be the ones who have really invested in their people and their environments. So, for us, so much of the last 12 months has been completing or moving forward with that journey around people. So, you know, our turnover rates and are now in the low 20s when they were over 40% when we met. We've raised pay 30 plus percent over the last three years. We've got 85% of colleagues now on a real living wage. And that then is around how we've introduced flexible working, how we've really grown our training and development. And with that, our quality has gone from being pretty average, I have to admit, to being one of the best in the sector. And with that, our homes are full. 

Speaker1: [00:01:56] And the awards have flowed.

Speaker2: [00:01:58] And the awards have flowed.

Speaker1: [00:02:00] Health Investor, and CareHome I'd like to highlight.

Speaker2: [00:02:02] But, you know, there's no way round building your reputation. It's always people delivering quality. And then the awards come and then you can be full and then you're able to, you know, grow investment. I mean, we I think 93 million we've been investing in refurbishing our local authority facing homes. We brought Ideal Care Homes into the group, we've opened up as HC-One in Scotland, you know, and that's before we even talk about the big digital investment. But I think digital will come to later. 

Speaker1: [00:02:37] Absolutely, now that's a really busy time. And you talk about quality and investment. I want to just pan out a little bit. Social care is in the news, perhaps even more than it was when we last spoke. We've had the British Social Attitudes Survey, unfortunately, showing really record levels, low levels of satisfaction amongst the public, the trade associations demanding better investment, etc. and politicians. Sir Ed Davey spoke very powerfully, and I think passionately personally about the importance of carers and social care. I just wanted to get your picture on the broad levels of the healthcare landscape. Funding remains an issue, but social care very much I think, remains at the top of people's lips, if not in policy terms. 

Speaker2: [00:03:23] So I think this is one of the core struggles of social care, which is I don't think there's a person who you meet, who doesn't believe it to be important and who doesn't believe that our front-line care practitioners make an incredible difference. And most people's individual experience of care is really positive, and they're really grateful for the support they had for their loved ones towards the end of their lives. And yet, we really struggle to organise ourselves as a system, to come together, to create the funding, to deliver the integrated care that we know we need. I think the challenges are well-rehearsed, so I don't think you need me to add to them. But, you know, I think what's making it so challenging as we look forward is between now and 2040, we're going to nearly double the number of people living with dementia. We're going to need not far off triple the number of beds. And while the number of beds has been fairly static in the last few years, most of the building, all the building has been in the higher end, privately funded care. So, we're getting social care deserts growing up, where those authorities with the least means, the highest level of social deprivation, often the most prevalence of dementia, are the ones least able to meet current needs, let alone the future needs of care. So, you know, if organising us, coming together to better organise our sector has been urgent for the last few years, it's going to be even more so.

Speaker1: [00:05:14] And I think in an election year, one hopes that those that are given the honour of leading the country, whoever they may be, will listen and begin to take on board some of these findings.

Speaker2: [00:05:27] I hope so, and, you know, we are going to need real funding. But funding aside, I think there's lots we can do to better integrate with the NHS, to better organize ourselves to have longer term pricing structures, not necessarily more, but longer term to bring more investment in. So, there's plenty we can talk about that can be done even if a government is short of the financial firepower.

Speaker2: [00:05:53] And I think that type of proactive thinking is really, really important. You touched upon dementia. I'd like to spend a bit of time focusing on that. I think people are well aware that dementia is ubiquitous, but not quite how ubiquitous. I think the numbers are startling. Between now and 2040, we're going to move from 900,000 people to 1.7 million. As you say, tripling of the bed capacity in social care. And I think from what I understand, 70% of care home residents currently have dementia. 1 in 4 NHS beds occupied by people with dementia. The scale is enormous. What has HC-One done? Because I think that's been one of the key things that you've developed since we've last met. Reimagining dementia Care, I think, is the title of your focus.

Speaker2: [00:06:40] Well, we've certainly been trying and, you know, to your point 80% of those in our care are managing dementia or they and their families are managing it. And 70% of our homes would be nursing registered. And therefore, we've got a great deal of frailty that overlaps with that. You know, terms like residential care don't really pay justice to the complexity of need that individuals towards the end of their life require from providers like us. And given that dementia is more often than not the underlying condition, it's where we've been starting. So where do we start? Well, we start with kindness because we've, as you know, have long believed that caring through kindness is the key in that it's about caring about you, not for you. And why is that so important with dementia? The key we believe to better dementia care is doing what wonderful care practitioners have always done, which is they're true detectives constantly trying to understand the need of the person in front of them. When that person is expressing their need in ways the rest of us can't hear or follow. And what's kindness? It's meeting you where you are. What's kindness in a dementia setting? It's understanding what it is that that person needs and wants. And so, for us, a lot of it is how we put some more substance behind what great practitioners have always done, which is apply curiosity and compassion. It's also around recognising that within dementia there are different ways it presents, including more complex, challenging behaviours that require a very different workforce model. So, we've been looking at how we can develop that as well.

Speaker1: [00:08:48] And you developed an enhanced strategy I think under your director.

Speaker2: [00:08:53] So, Graham Stokes who colleagues in the sector know well, Professor Stokes, who's one of our dementia experts, with his support and many others, we've opened the first of our units in our Meadowbank home, the Sabrina unit. So, Meadowbank's in Preston, where we're working very closely with the local authority around delivering complex care for individuals exhibiting what is often termed in the system sort of challenging behaviour where as well as a very deep care practice, we have enhanced nursing and then we have psychologists. And what we found is that for three out of four people in our care, we have seen a marked diminution of the behaviour that brought them to us. And therefore, having a unit in a bigger home, we're then able also to step down individuals. For the local authority, the win for them is well, the care we charge for, given the staffing we bring, is higher and it's much less than sending people out of county and it's much less than some of the environments that those people would have gone to, which probably weren't appropriate because they were probably young adult environments would otherwise have been. So, it's a good example of working together in an integrated fashion. 

Speaker1: [00:10:25] Outside the box, with what we have.

Speaker2: [00:10:25] Thinking outside the box, using the facilities that we have, people getting the right care, the system making a saving and investing in developing the workforce.

Speaker1: [00:10:38] It's very inspiring and I think it's the first of its kind.

Speaker2: [00:10:41] It's the first, we're looking at around 30. The one thing we're totally clear on is the need is nationwide.

Speaker1: [00:10:51] Oh, absolutely.

Speaker2: [00:10:52] Our next one is opening in Scotland.

Speaker1: [00:10:54] Fabulous. Now, that's a tremendous response. And as you say, it goes back to the principle, in an ideal world, we'd have much more funding in all of these things. But right now, this need has to be met and actually honoured. These individuals need to live their lives to the best of their abilities. 

Speaker2: [00:11:08] And so often the key to commissioning is being able to ensure the right need and the right place. And that can give you a saving to then invest in giving a sustainable rate to the providers to be able to invest in their people.

Speaker1: [00:11:23] And now the predicates of this, one of the predicates, or a couple of them will be adequate learning and development, specialist development and having the right workforce that we talked about now, I wanted to touch on nursing as a topic within social care. Even now, it's still not something that people have front of mind nursing, social care. They think of the NHS, uniform for nursing, but it is very powerful within social care, we have a chief nurse for social care of course appointed. 

Speaker2: [00:11:53] We do, I mean 70% of our registrations are for nursing care. We've long talked and spent some time, last time we met talking about the workforce crisis. I don't think recruiting care practitioners is going to get any easier, but the sort of single hardest to recruit group are nurses, and so often we're competing with the NHS rather than working in tandem. Having said that, we think there's an enormous amount we can do. So, for a start, we've been doing with working with our nurses, as we do all our care practitioners around different flexible working models around really thinking about the benefits that matter to them. But then the rest is education.

Speaker1: [00:12:46] And you've launched the Nurse Preceptorship.

Speaker2: [00:12:47] So we have a Nurse Preceptorship programme. We obviously have got a very developed programme about getting our international nurses through OSCE. We've got a nurse associate program in Scotland where the rules are different. We've got our pre-registered nursing degree program.

Speaker1: [00:13:07] With the Open University.

Speaker2: [00:13:08] With the Open University. And so all of that is key to offering different pathways, especially to colleagues who discovered the love they can give and get in care but want to grow professionally but can't leave work and don't want to become students. So, providing them with pathways where rather than just choosing management, which is a wonderful option, they can also grow as nurses. And that's another big part of the answer, which is how do we create more and how do we enhance the role of care practice. So much of our model is about focusing nurses on what only a nurse can do so that the nurse is always operating at the top of their license and then allowing care practitioners to enhance their skills. So, we pioneered a model a few years ago with nursing assistants, we called them. We're now thinking of it much more in terms of advanced and enhanced care practice, but around how carers can train and develop to do meds management, to take on a lot more of what traditionally nurses often did, but actually don't need to do. What the CQC wants is the competence level in the home, not necessarily the individual doing it. And then of course technology which we'll come to is a big aid here because of what it means you can do around care planning and really understanding the acuity of those we serve. 

Speaker1: [00:14:47] No, absolutely. Again, a very powerful initiative that hopefully others can see in the sector within the bounds of what's available now. Just briefly touching upon since we last met, I guess a big watershed has been, there's been a few, but the Long-Term Workforce Plan for the NHS, which was silent on social care. But we've had Skills for Care and other initiatives. The government announcing funding for, I mean, a relatively small amount, but at least announcing the funding for the level two. So, the idea of a career pathway and professionalisation of care, I think has moved a dial or two.

Speaker2: [00:15:25] It really is. I mean, I think, you know, going back to Covid and people clapping for care as well as for our NHS colleagues, you know, was a big step in people recognising that health and social care go together. You know, just renaming the department the Department for Health and Social Care as being key. And so, the idea that we need a social care workforce plan, I think is well understood and is key and it's not the same. You know, we want to be able to work in tandem with the NHS, but the role of social care is a different one. The level of management is much higher, much earlier. If you're a senior carer as a common term in our sector, you know you can be managing a whole home on a night shift, you know, which is a far greater set of responsibilities than some of the peer roles that are sometimes associated with care and from the NHS. And I don't think there's one of us who doesn't believe that lifelong learning is key. So, anything that helps build towards the recognition of the skill involved in and care we applaud. What I think is important is to complement formal registration and qualifications, which have their place with how we can support other means of lifelong learning and career development. Because as you and I know agree, so many carers have come into care from a place where traditional education didn't work for them and aren't necessarily as open or as willing for sort of traditional education yet want to grow individually. So how we square that circle will be. 

Speaker1: [00:17:24] It might be potentially there's a pathway for new modalities of learning, which perhaps are not the traditional book learning. Black and white paperwork that perhaps of a certain age I might be used to 

Speaker2: [00:17:36] Well, you know, and I mean, I'm sure you have to. I mean, I've sat through training sessions, you know, and I was a historian in university. I mean, the ultimate book reading degree. And I've sat through training on sort of especially safeguarding and things, and I've not been able to make head or tail of it. So, I think new modalities of learning are absolutely key. And training that grows with you because pay is always going to be key in our sector and one way that we can make pay possible is for people to grow their experience and their ability to work at a higher level of skill and for that registered skill to be rewarded.

Speaker1: [00:18:30] Absolutely. Now, you touched upon technology earlier, and I'd like to just tarry there for a while. Much work is being done about the possibility of technology and supporting in social care settings. The King's Fund produced an interesting round table discussion under Chatham House rules, Simon Bottery. Very interesting. They talked about a very wide potential for technology in social care but did highlight the fact that many of the research findings were talking of potential, not actual execution because of cultural and systemic system hurdles. I think you have decided to take the grass of the nettle in terms of a fully integrated digital care platform. I'd love to hear more about that.

Speaker2: [00:19:14] So we're still at the early stages. So, it's really in three big parts. It's an incident management system where we're partnering with radar. It's electronic care planning where we're partnering with Norwich, although we also have PCS, one of the other system providers in some of our homes. And there's also obviously, we've long rolled out digital rostering. And so, there's sort of that those three come together in a trinity. And I think what's so exciting is, you know, it's not often, I think, in our world where you are behind where colleagues are in terms of they're the ones clamouring for digital care because they can just see what it can do to admin time and for just giving them more time to care. And so that's a very clear win. But on top of that, I think what it opens is a real opportunity to understand how effectively we're deployed to current need, because you get a sense of what's taking the time in a home where everybody is. So just in the homes that we've been rolling out, we realised that we were getting the night shifts wrong in terms of when it was that residents, in this case, our Douglas View home in Scotland needed attention.

Speaker2: [00:20:55] And we've been working on a program with the Care Inspectorate about reducing psychoactive drug use. Just E-Care has helped us with that in terms of understanding and tracking people's needs, and we've understood a lot more around some of the underlying conditions that we think we could serve better, like diabetes. So, you know, what's the key to being a group like ours? It's learning once and being able to apply 300 times once. You can track incidents and not just count them but look at the underlying driver of what's causing a fall or a moment of distress, you can start changing practice. Once you understand where it is the carers are spending time and associate that back with the initial assessment, you can start understanding acuity and recognise what it is that the home is ready to do. What is it great home managers have always done? They've known what their team can do. They've understood the need in the community and the demand. They've matched the two. And we can extend what brilliant managers have always done with real learning, culture, with live data. And if you can marry data, culture and leadership, I think we can really change the face of care.

Speaker1: [00:22:25] That is a holy trinity indeed. And I'm talking about just staying on this briefly because we're talking about this potentially being rolled out across your 260 homes, etc., and focusing on digital care plans and medical management. But there's an even greater vista, isn't there? Perhaps down the line where the digital platform could extend into interfacing with primary care and other settings? 

Speaker2: [00:22:48] Yes. So, and of course, I didn't even mention eMeds, which we rolled out to all our homes, which is a core component of this. So, part of the reason, one of the key criterion in the partnerships we created and part of what our partners at Nourish are very focused on, although I'm sure others are too in the sector, is on how we then integrate with local authorities and local authority care being the core of what we do. That's a really important part. You know, great homes have great relationships with their local GP. Anything we can do around facilitating that? Facilitating meds management, facilitating working with pharmacy I mean the integration sort of boundaries just broaden and broaden.

Speaker1: [00:23:41] And it matches the zeitgeist of course, the statutory footing of integrated care systems. So again, working within the confines or parameters that we have now, it's just turning the dial even a few basis points on use of resources, can have a dramatic effect. 

Speaker2: [00:23:59] It really can. And in a world where we're all going to be working with constrained resources for some time, we have to become more effective. We have to be able to have more people operating at the top of their license. We have to be able to deploy our workforce ever more effectively. Partly because the need is growing and the acuity, as we say, is increasing. And partly because we need to create the room to invest in more time to care. And if we're not going to have more resources, we've got to find it from our own effectiveness. 

Speaker1: [00:24:40] Absolutely. In addition to that, looking at the resource question to end off with, if I may. You've written very eloquently on the idea that actually there's a need for a new generation of care homes, particularly those facing local authority funding. Care home deserts. Deborah Sturdy, the chief nurse, has talked about the idea of a new narrative for care. Just stepping back, what really would you recommend that needs to be done in terms of commissioning, in terms of to attract the investment that we need to grow capacity to meet dementia need, if nothing else.

Speaker2: [00:25:20] So going back to the need we both dwelt on and emphasised, I mean, there's just a straightforward need for more capacity and a need for that capacity in local authority funded care, which is still half of the care provision and has seen no building. So first and foremost, we just need to be able to attract capital. And we've had periods in the past in the UK where there's been extensive building within local authority and NHS funded care, as well as the ongoing investment we've seen in private care. So, if we're able to give investors and developers a long enough time frame and a funding certainty not necessarily generosity, but funding certainty. People want steady returns. There's always a market for those who want to invest in steady returns and long-term assets. We can provide that sustainable funding. And I've got no doubt we can bring private capital to bear in support of the state to build. So that's the first thing. The second thing, and people can talk far more eloquently than I can around this, is the importance of building homes that are fit for the dementia needs of today and of the future, and that so many of the environments in social care. I think I'm correct in saying it's still about half the sector are in converted homes, Victorian buildings, traditionally, it's the legacy that we've all got, and even those of us who have got mainly purpose-built settings, a lot of them are 30, 40 years old. So, there's so much that we can learn about the environment and design which just supports those living with dementia as opposed to creating an environment that makes the management of that condition for the individual and for the carer harder. And then the piece is put simply, we just want our buildings to reflect the quality and the commitment that our individual carers bring to what they do.

Speaker1: [00:27:41] Absolutely. And one other dynamic element on that, just to touch upon that, to track the investment. You've talked about it's happened in the past. So, they need a visibility of return, a steady return. And there will also be a place for collaborative and, dare I say, dynamic commissioning. 

Speaker2: [00:27:58] Yes. Well, I mean, 1 in 4 people in waiting to be discharged from hospital has dementia as their underlying condition. So, you know, the only way with funding in short supply, one of the key ways that we're going to make the system work is if we can get the right care and the right place at the right time. And a big part of that is how we manage hospital discharge, how we support people with dementia. You can create a truly value added, clinically enhanced care model in a care setting, a much lower cost than an acute provider setting. And I don't think there's an acute provider who doesn't want to see more people leave the hospital when they're medically fit to be discharged, so that they can in turn diminish the queues waiting to get into the hospital. So, integration is clearly the name of the game. And to your point, how do you bring more capital in? Well, the private capital will invest wherever there's a steady return to be made. And there's, I think, a great opportunity for us to organize the sector, to encourage responsible, long-term capital in a well-regulated fashion to build the homes we need.

Speaker1: [00:29:28] I'm hoping that those in policy circles will be listening. I don't think there can be anyone who can disagree with that peroration.

Speaker2: [00:29:36] Well, the key, I think, is how we do it together.

Speaker1: [00:29:39] Absolutely. All stakeholders.

Speaker2: [00:29:42] All stakeholders. On that collaborative note, James Tugendhat, thank you again for your time and your wisdom. 

Speaker2: [00:29:49] Suhail, always a pleasure. Thank you for yours.

Speaker1: [00:29:51] Likewise. If you enjoyed this episode of Voices of Care, please like, follow or subscribe wherever you receive your podcasts. And if you want to find out more about how we are re-envisioning health and social care, please visit newcrosshealthcare.com/voicesofcare. In the meantime, from me, Suhail Mirza. Thank you very much and look forward to seeing you on the new episode.

Speaker3: [00:30:12] Voices of Care, the healthcare podcast.