Speaker1: [00:00:00] I've got this wrong. I've made a mistake. It sometimes drives perverse behaviours. Investment in robotics, I think, has been really, really important for us. People are really, really worried. Great to see some of those long waiters coming down, not just about health. They don't see the structure and the organisation. They see themselves as being the NHS and actually hearing that message is difficult. I think people really want to be able to plan their life well in advance.

Speaker3: [00:00:28] Voices of Care, the healthcare podcast. 

Speaker2: [00:00:32] Louise, welcome back to Voices of Care. It's good to see you. I can't believe it's been about two years.

Speaker1: [00:00:37] I know it's lovely to be back here.

Speaker2: [00:00:38] Well, it's great all change since we last met. New government, all sorts of reviews. I guess we'll start with the question I asked you last time, which was the performance of the NHS. We've had some statistics in November, some improvement, I think significant improvement in terms of waiting times, people waiting for more than 52 weeks, but urgent and emergency care still under pressure, as perhaps you'd expect at this time of year? 

Speaker1: [00:01:02] Yeah, absolutely. And I think that much as you try and really address some of those issues around urgent and emergency care, you still have a perception of people who are worried they won't get a GP appointment. I think they turn up at ED because they know it is an absolutely safe place. They're going to get care, 24/7. But it's great to see some of those long waits coming down. I think that's a real testament to the effort that's been put into that.

Speaker2: [00:01:29] No, absolutely. Now, we've also had the Darzi review, of course, and we're not going to spend a huge amount of time on it now, but just wanted to get your opinion. The vital signs are strong, I think is the phrase that I remember, even though it may be in critical condition. Looking at the broad system, you've been such an experienced leader. I guess the balance was right. He praised the workforce, specifically in that report.

Speaker1: [00:01:52] Yes. And I think that was really, really welcome. What's interesting, really, is how little had changed from the previous Darzi report. Of course, the big thing in between that was the Covid pandemic. So I think it's great that workforce has really shown how strong it can be. I think he highlighted all the things that people are worried about. The issue around capital and our buildings, and I think that that is really coming to the forefront now. So lots of, you know, if you look at not just the patients that weren't treated during Covid, but the work that wasn't done on actually the infrastructure of the NHS and its buildings during Covid, I think has been a real problem for people as we come out of that. It was great. He highlighted mental health. That's been a massive change, I think, in the last few years. And the demand for that, particularly within acute sector as well as mental health trusts. And I think the fact that there was a big focus on the fact that it's not just about health, but we have got to really address issues around housing and education and how much more contributes to the health and wellness of the nation?

Speaker2: [00:02:58] No, absolutely. Now I'm going to talk a bit about the ten-year plan in the offing in a second. But before I wanted to go on that, I wanted to talk a little bit around the importance of language and its effect, because there's been some discussion around that from think tanks. Mr. Streeting, of course, called the NHS broken but not beaten. He added that caveat. How important is that language for the workforce, for your colleagues? Because sometimes it can have a debilitating effect if you have language which is quite blanket in that manner.

Speaker1: [00:03:28] I think that has been a really, really difficult message to hear, actually, because if you speak to people who work in the NHS, they think they are the NHS. They don't see the structure and the organisation. They see themselves as being the NHS. So when you say the NHS is broken, they take that as a personal reflection on the way they are working. And, you know, I hear what you're saying about broken but not beaten, but people haven't heard that. And I think that particularly around the workforce morale piece, during Covid, you had two types of members of staff. You had some that really took a massive step forward and some that took a massive step back. The ones that took the massive step forward and we're here to do whatever are the ones, I think, that have stayed in the NHS. And actually hearing that message is difficult. And I think the public have heard that as well. And that sort of construct between the patient and the NHS is so important to what people do. And more and more you're seeing that lack of kindness, I suppose, between clients and professional. And I think that makes it really hard to work in the NHS.

Speaker2: [00:04:36] No, no, thank you for saying that so candidly. And I think that's hopefully going to be heard as we're approaching this new ten-year plan. I guess part of that is the change. NHS, the biggest engagement since the birth of the NHS and deliberative listening, so I think that will be important.

Speaker1: [00:04:56] I think it will. I think it will be really important. And I mean lots and lots of hits on the website where you can put your opinions in. So I think that shows people do want to be engaged. I think there's been lots of conversations with senior leaders. So I think that's really important. I hope that they get enough people who are going to come to those events to really be able to show what's important to them because not everybody will want to log on to the website and put in their opinions. 

Speaker2: [00:05:23] No, absolutely. Now we'll have to wait and see what the content is. There's been NHS plans before ten-year plans, as we're aware. Whatever the plan suggests, what will be important, and I bring it up because it's been really important in 2024 for good and bad reasons, is that the role of regulators is going to be fundamental. Now, I wanted to get your view because you've worked with the CQC, plenty of experience. Penny Dash, Professor Mike Richards asking for pauses to inspections. I guess that's going to be a really important task for Sir Julian Hartley.

Speaker1: [00:05:57] I think it will. I think Julian has the respect of NHS leaders, so I think that will really help. We had a CQC inspection in May this year in two areas when we're still waiting for our report. So I think that was highlighted really clearly in Penny Dash's report, that wait from inspection to result. I think that the regulator has got to be seen as someone who is going to help you improve. And I think that's where we've maybe not done so well with a healthcare regulation. So I know the CQC now published reports on things that have made organisations outstanding, but that really should be the absolute sort of bedrock of how inspection is done and, and how you can learn from the very best. And I think that, you know, the ability to reflect back and learn from others will be what makes the absolute difference to this.

Speaker2: [00:06:54] I think. Well, let's wait and see, because I think it's been a tough year for regulators, I think. So it'll be interesting to see that point. Just one final point feeding into the ten-year plan. Health Secretary Wes Streeting, I think it was the Labour conference at an Institute of Government discussion. He said that the long-term workforce plan, which was published back in July 23, might need a fresh pair of eyes. That was really welcomed at the time. So I don't know what your comments are on that because I didn't expect him to say that. 

Speaker1: [00:07:28] No, I'm not sure anybody did because I think people were quite impressed with the workforce plan. I think we've just got to change the way we look at some of these issues around workforce, and I think apprenticeships probably need to have a much stronger element in there. I think we need to look at growing our local workforce for the local hospital, and I think maybe that will be some of the issues around it. I mean, we'll probably touch on things like regulation of managers and all of those, I assume, will be the sort of topics you want to bring out in the workforce plan.

Speaker2: [00:08:01] It'll be interesting. Now going on to workforce. I wanted to talk about nursing in particular. Now the long-term workforce plan from memory. I think its projections are by 2031, 92% increase in the nursing workforce. Now, we've had stats from UCAS this year showing, unfortunately, over 20% fall in the number of people enrolling in nursing degrees at university. How worried are you about that reduction?

Speaker1: [00:08:30] Yes, I think it's a really big worry because we know we need to try and grow our own. We've had a long reliance on overseas nurses, and I think the outcome of that really now is I think lots of places have stopped doing overseas recruitment. So we absolutely need to have a plan that is going to make nursing and healthcare professions attractive to the UK school leaver, and I think a lot of that will be about apprenticeships. We've seen people not wanting to get into the same sort of debt they have by going to university, and I think that if we can manage to make it attractive and go into schools, really promote careers in healthcare in a way that I think we haven't done for quite a few years. In fact, if you look at a hospital, there's practically every job within that, whether you go from working in hospitality, working in catering, accountancy, you know, all of those. It's not just nursing. We need to really promote our hospitals as the place you want to work, a real anchor institution within a place.

Speaker2: [00:09:33] And I'll come back to that debt point, if I may, because the other stat, which I think is the Royal College of Nursing, it's drawing on wider statistics. And you're a nurse leader. You've been in so many of these roles. The other thing that struck me was the fact that there's been a tremendous increase in the number of nurses leaving within ten years of qualifying. I think it's something like a 43% increase in the last three, two years and 67% increase of those leaving within five years. So I guess that's another part of the perfect storm, which the long-term workforce plan, it needs to address that.

Speaker1: [00:10:13] No, absolutely. And I think actually we've seen a real decrease in our nurse turnover at the Royal Surrey from 13% to 8%. And I think some of that...

Speaker2: [00:10:24] That's a big move.

Speaker1: [00:10:24] It is. Yes. Some of that is due to the way we are addressing how people want to work these days. So the flexibility of rostering, I think people really want to be able to plan their life well in advance. I think there's something really important about how people see that relationship with their manager. We've put a lot of effort into that. Health and wellbeing is a big offering, and I think people really, really want to see that and that development of advanced nursing skills. People do want to progress their careers, and they want to see how they can do that in one organisation. So I think looking after your staff and putting those other pieces around it, like flexible, good, flexible working policies actually does make a difference. The other thing I think that's made a difference for us is having spent years and we were a really early adopter of overseas recruitment, is how we focus on making those nurses our leaders of tomorrow. We've really focused on bringing staff in, but not necessarily on the next part of their journey. And I think that that's going to be one of the key areas that we are going to need to address as a country in order to keep those nurses. 

Speaker2: [00:11:35] Absolutely. And I think you've said earlier that the point around people not enrolling and leaving and around the debt issue. And I just wanted to get your view on this. I've got I've got a slightly vested interest here. And the RCN, amongst others, have called for discussion of whether the debt... They've asked for increase in pay, obviously, and we don't need to talk about that. But real pay for nurses has fallen dramatically over the last 14 years. But in terms of the funding and the debt that a student carries, they've said that there should be an investigation into the mechanism of perhaps extinguishing that debt over a period of time, provided the nurse stays within the NHS. I'm an executive director at FuturU and our mission, we've been offering free education for anyone who wants to be a social care professional and 90,000 people on our platform, and we have a vision of free nursing in due course. What's your view around that? Because that would make a big difference if we were able to not carry that debt for nursing.

Speaker1: [00:12:35] I think it would make a huge difference. And I think that's why we're seeing fewer numbers of people going into nursing at an early age. We're seeing actually an increase in people enrolling for nursing, you know, in their sort of 30s, 40s when maybe they've got a bit more, you know, a bit more money behind them. I think people are really, really worried if you're not going to earn the sort of level of pay at the end of it that you might if you went into another discipline.

Speaker2: [00:13:03] Let's see if some people are going to listen to that in the current budgetary environment. I'm not sure, but I just wanted to get your view on that, because I think there needs to be a radical rethink, because these numbers, as you say, if we're going to hit the figures, we can't carry on doing what we're doing right now. You talked earlier around the idea of outstanding being a key benchmark for regulators. Now, you presided over a trust which has gone from good, I think in 2018 when you took over CEO. I think earlier this year, outstanding ratings. So congratulations for that. I want us to go into a bit more detail, because that's what we all as patients would like to expect. It's not an easy thing to achieve. Can you tell us a bit of around that? What's required to make that happen? And I think you also got that recognition for your maternity services.

Speaker1: [00:13:54] Yes, yes we did, which was fantastic for the staff. I think the key to it mainly is probably around culture. I think that we try and instil a culture that allows people to take control of their department, to innovate and try out new things and not be sort of told off is the wrong word, but, you know, be allowed to fail. I think that's really, really important. I think that there's a feeling at the Royal Surrey and we talk about the Royal Surrey family and that sounds really trite and I don't mean it to be, but there is something about people wanting to stay because they are heard. And as I said before, we invest in health and wellbeing. I think that if you can devolve some management down to people who are actually doing the doing, then that is really, really important. And that bit around transformation and trying to make it better, I do think is key. I think listening to the patient's voice is powerful. Making sure that we are responding.

Speaker2: [00:15:03] Have you done that through this particular engagement?

Speaker1: [00:15:05] I think particularly in maternity, they've had a real focus on maternity voices as a partnership that isn't nationwide, but really embracing that and trying to listen to what women say and adapt your services to that. I think you then get a real feeling that you're making a difference and you're adapting as things change. So I think really it's down to culture, down to local leadership. And we do know that there is something about if you've been in a place for some time, that continuity of leadership is important not just as an executive level, but at levels below that, because you are, you know, you know your service, and I think you're confident in being able to make some of those decisions and take brave decisions that other people might not do that might be innovative.

Speaker2: [00:15:57] And I guess that's the point. With the earlier comment you made around the international nurses that you haven't just recruited them, you've thought about actually, where's the career path for these people can stay here for longevity. A couple of other things that struck me. Looking at your 23/24 report was the role of innovation. I'm talking about, I think the robotics that's come up, that's come on a long way, I think in urology, but not just there. 

Speaker1: [00:16:19] Yes, a huge role for robots now. And I think one of the other things actually, is we have always invested in technology. And I think that makes clinicians want to come and work in a place where they feel innovation is driven. We have quite a big transformation team, and I think that they also really drive the way we work. We have a scheme which is a bit like a Dragon's Den thing. It's called Bid for Better. We run it in conjunction with the University of Surrey, and so people can bid for small amounts of money to make changes in their area.

Speaker2: [00:16:53] So, clinicians.

Speaker1: [00:16:54] Yeah, clinicians, anybody. If you've got an idea you think will make this better, you can bid for some of this money. Obviously, you have to do a bit of analysis at the end because it's with the university. And but people really like that. They feel that that gives them the power to make some changes in their area. But you're right, that investment in robotics, I think has been really, really important for us. 

Speaker2: [00:17:13] And also I think you're pushing the boundaries in terms of research. The report talked around the funding from the National Institute for Health and Social Care Research. 

Speaker1: [00:17:24] Yes, we're really trying to take research forward, and it was fantastic to get that. Research is a really interesting piece actually, post-Covid because of course, you stopped all research really, other than Covid related.

Speaker2: [00:17:36] It's not discussed very often.

Speaker1: [00:17:37] So people are trying to build that back up now. And actually it takes quite a lot of effort to go back from a standing start. But I think actually the greater collaboration you're seeing across ICBs around research will really help, because you do need that, that body of numbers in order to really drive those things forward. We're lucky because we're a cancer centre. So a lot of our research is cancer based. But I think not just with us, but nationally, there needs to be that drive to embed research into every speciality, because there are trials out there that definitely need the numbers. And it's just a case of saying, right, could we contribute to this and make sure that those opportunities are really out there for people to review.

Speaker2: [00:18:23] And I think you're one of 12 leaders nationally in this particular area.

Speaker1: [00:18:30] That's right, yes.

Speaker2: [00:18:31] And in terms of making this transformation, we've talked a lot about the idea of, you know, good to outstanding, the ten-year plan, all of these type of things. It's going to require leadership at all levels. And I really wanted to delve down into that a little bit more. I hate to remind you that your journey as an RN started when Wes Streeting was five.

Speaker1: [00:18:57] Thank you for that.

Speaker2: [00:18:57] If it makes you feel better. I started as a lawyer exactly the same year, so I'm in the same boat. But I think it was 1988. And we've seen quite a lot of change. Huge change. Mr. Streeting has been on record, for example, very recently talking, I think it was at a conference talking around naming and shaming poor leaders. League tables. So there's a push for highlighting poor management. But Penny Dash spoke earlier about the need for powerful operational managers. So put that into context. Just how important having leadership at the right level is to make these transformations.

Speaker1: [00:19:36] So I think it's absolutely vital having really strong leadership. And I think that league tables are an interesting one aren't they.

Speaker2: [00:19:45] We have been here before.

Speaker1: [00:19:47] We have been there before. And I suppose you focus on some of the difficulties with league tables, don't you? So if you're a trust at the bottom of a league table, are you going to find it harder to recruit? It sometimes drives perverse behaviours. I think there is little in previous league tables, there's been little ability to change between specialisms. So for example, I run a DGH with a cancer centre. So every day there is that sort of juggling between doing cancer cases or doing benign cases. How do you measure that within league tables? And I think that is that's quite difficult. Also, how do you measure for deprivation in league tables? 

Speaker2: [00:20:40] Absolutely. Socioeconomic drivers, which account for most of the outcomes.

Speaker1: [00:20:44] Yeah, I think that's really, really difficult. So I think that it's good to have something that people are aspiring to. It's great to have some real metrics, but we haven't met any of the metrics really. The constitutional standards, you know, for nearly ten years in some cases. So how would the league tables be able to drive excellence without making it, you know, really difficult for people that aren't at the top of those? And we know that if you've got specialist hospitals, they tend to always surface to the top because, you know, they haven't got that real breadth of what they do. And I think one of the things that's coming out of the ten-year plan will be as we look at some of those shifts, that specialisation of services. So if you're really going to drive efficiencies, you are going to have to maybe not offer everything in every place. And I think that's something that hasn't really, I hope that will come out of the ten-year plan very clearly.

Speaker2: [00:21:46] But lots to consider there because I think I was really keen to get your view on that. Staying with leadership. You've talked about culture earlier. Roger Kline wrote an article in September for HSJ saying that the culture was the elephant in the room. Looking at the Darzi review, many changes we've had. Dalton Review years ago. It's such a big word, culture. It's actually quite a short word, but it's profoundly difficult. How do you go about doing that? Because actually transparency, accountability, bullying these things are many, many-faceted to change.

Speaker1: [00:22:25] Yes. And I think we need to be really clear that elements of those exist in every organisation. Nobody can sit there and say they've absolutely got culture nailed. I think the key elements for me are really about trying to listen. Trying to be connected to your workforce. And I think that's one of the ways that things are very difficult. During Covid, people were not connected to the front line in the same way. I think the closer the decision is made to the patient, the more people feel empowered. And actually empowerment is the key piece to that culture piece. And actually not being frightened to come forward and say, I've got this wrong, I've made a mistake. That's how you learn. I think that's the important piece around culture. So the Secretary of State has talked, hasn't he, about driving out, you know, bad apples in leadership and I think that's a really interesting concept because lots of people have made mistakes. That doesn't mean if you've gone on and learnt from that, that you are a bad apple. And how do we encourage people to be brave and take some of the decisions that people did during Covid? For example, if they are worried about making a mistake.

Speaker2: [00:23:50] Some of the things, the remote working, the digital consultations had been in the offing for a number of years. But because necessity being the mother of invention, people went off and did them. So that's quite a difficult balance risk. If I get this wrong, I'm going to get criticised. 

Speaker1: [00:24:05] Yes, I think it's very difficult. And I think we need to support our leaders. So it feels like a lot of this is... I'm referring back to Covid and I don't mean to, but we had a lot of people who stayed on who were leaders during Covid because they felt they ought to see their organisations through that period. They then retired or went on to do something else. And I think we've got a real dearth of that at the moment. And I suppose that may be one of our levers into sort of regulation, of managers. 

Speaker2: [00:24:41] It's just a final point on this cultural point. It's fascinating. Obviously had the Letby case, Thirlwell, the reviews. But I wanted to hone in on what you said about having the bravery and the ability to speak out, call out things, make mistakes, transparency and giving people a voice where they feel safe enough to call out things. I guess is part and parcel of that. 

Speaker1: [00:25:04] Yes, absolutely. And I really think it is about being out there, being accessible, you know, open door policies, all those sorts of things are, are really important that people feel they can go to a leader, you know, if there is something that happens. If you have a never event in theatre, you know, I would expect the first thing to happen would be someone would be beetling down to the medical director's office to say, goodness, you know, this is what happens. I need to let you know. That's the sort of culture I want to make sure we have in an organisation.

Speaker2: [00:25:36] Final question, if I may. I mentioned your longevity in the sector earlier, but also, if I may mention that you're one of the most celebrated leaders, HHA's preeminent 50 out of 219, 213 somewhere, 19. So you're brilliantly placed to answer this question. We're going to have a new generation of leaders over the next ten years, their call is going to potentially be quite challenging because there is nothing conventional in the NHS, but people move up the ladder, take on new roles. One of the great transformations in the last decade has been this grouping of trusts. Larger and larger trusts. Shared leadership. We're seeing that a lot in the Black Country, in London, some people reversing it. What are your thoughts on that? Because I think you're about to take on another trust as part of your leadership as well.

Speaker1: [00:26:28] Yes. I mean, I think that there is absolutely a potential to work across a wider footprint. And actually, I think that really helps in how you manage work around, you know, integrated care boards as well. I think there has been, you know, going back to what I said, there is now a new generation of leaders coming through. I think that the trouble is, as the more we group trust together that natural progression from an executive to a small trust and then maybe moving on to a larger trust won't be there, because those small trusts will have been amalgamated to form group models. I think there is a real benefit in trying to standardise and allow maybe subspecialisation across two organisations. I do think you're going to have to really focus on the leaders in both those organisations to make sure they can step up, to move into those larger trust CEO roles. But I think the most important thing for me is when you look as you've said, some of them are disbanding now. It's about how you put how you put them together. I think if you have, so the situation I'm in, two trusts, both really good trusts, both about equal size.

Speaker2: [00:27:49] This is Royal Surrey and Ashford.

Speaker1: [00:27:50] And Ashford, Saint Peter's. So you're not having one that is perceived as better than the other. You're not having one that is much, much larger and is seen to be subsuming the other. And I think it's got to be about mutual respect, mutual understanding between the two organisations. Obviously, there are going to be concerns. I come from one of those two organisations. There is a worry that I'm going to be more invested in one than the other. The only way you can try and dispel that is, you know, walking the walk and trying to be absolutely engaged in both of them. So I think it's probably the right way to go. I worry about how you're going to develop the chief execs of the future in this model, but I think there is a real opportunity about working across a wider footprint, the economies of scale and actually the ability for those two organisations to subspecialise in a way they might not have been able to if they were one organisation.

Speaker2: [00:28:51] And just very final question. Darzi applauds some great management within the NHS. We've had the Messenger review, I think, just as a tangent. The really critical importance given the rich and celebrated diversity of the NHS workforce. Hopefully see more and more leaders representative of that group, that diversity?

Speaker1: [00:29:13] Absolutely. And I think we need to have a positive process of trying to get those leaders to the top. I think it's very difficult sometimes to advertise or promote in a way that you are attracting candidates from a very, very wide pool. And I think we need to do a lot more work on that at board level and at the immediate sub-board level, although I do think that is getting much better. 

Speaker2: [00:29:44] Absolutely. And crystal ball time. Last question. Looking not pre-empting the ten-year plan, but if there were 1 or 2 absolute priorities for you that you'd like to see come out of that, what would they be? It's a really tough question, but just be intriguing to see what you'd place. 

Speaker1: [00:29:59] Okay, so I think with the sort of analogue to digital piece, it's got to be about how we capitalise on AI, how we make that a real decision-making support tool, not just a sort of another bit of kit, and I think we need to centrally manage that. Otherwise, I think we will miss some of the opportunities. 

Speaker2: [00:30:22] What do you mean by centrally managed? Make sure that its consistency and standards.

Speaker1: [00:30:25] Across the NHS. I think we need to, if you look at the hospital to community shift, one of the problems we've got there is community contracts change every 7 to 10 years. So the acute trust is the stable piece there. So how do you change that and how do you make community services once again equitable across the whole country. So that in the same way you know an A&E department is going to be open 24/7, how do you know that your community services are the same? So people have real faith in it. And I think that would make a really big difference to and I think the prevention piece, and I know the Secretary of State has said there can be no double running, but we are going to have to put a lot of money into prevention whilst we deal with the changing treatments we've got in acute hospitals. We are going to have to double-run that to get the benefits in the next generation. So those would be my three.

Speaker2: [00:31:28] Well, on that last one, I think with the spending review coming up next year, I hope someone's listening to that. Louise, thank you as always for your time and your candour.

Speaker1: [00:31:37] Thank you. 

Speaker2: [00:31:37] My pleasure. If you've 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're really turning the dial on the health and social care debate, please visit newcrosshealthcare.com/voicesofcare. In the meantime, I'm Suhail Mirza. Thank you very much for joining us and look forward to seeing you on the next episode.

Speaker3: [00:31:56] Voices of Care. The healthcare podcast.