Welcome to Voices of Care, the podcast series from Newcross Healthcare that seeks to get to the very heart of the issues facing the health and social care system by truly understanding how we can enable the healthcare workforce of the future. I’m Suhail Mirza. And really, is the NHS out of the news? Waiting lists are growing, strike action, prime ministerial intervention and a cost of living crisis in amongst all of this. It’s therefore important to hear from leaders who have been at the forefront of innovation in terms of workforce, and I can think of few better qualified to speak about this than my guest today, Sir Julian Hartley, Chief Executive at NHS Providers and until recently, Chief Executive at Leeds Teaching Hospitals NHS Trust. Julian, I’m delighted to welcome you to the series and thank you so much for your time.

Thanks very much. Great to be here Suhail.

Thank you. I’d like to start off commentators, whether they are within the healthcare sector, whether in mainstream press, the public are calling this period now the worst workforce crisis in the NHS history. Some of the guests that we’ve had in the series are saying the similar things. What’s your view, given the depth and breadth of your experience in terms of the nature and breadth of this particular crisis?

Yeah, absolutely. Well, I think that’s true. I think we are at a pitch both in terms of workforce, as you say, but also operationally that certainly I’ve not seen before in 30 years of working in the NHS, just in terms of the crisis in urgent and emergency care particularly we handled the pandemic, I think in an extraordinary way. Our staff were magnificent but hot on the heels of that obviously the crisis we work through when we were finding beds for patients who needed intensive care and so on, the shock waves of COVID are now rippling right through the health and social care system, and our staff have just had no let-up in terms of the pressures that they have faced. So, we’re facing the challenge of and we’re still not fully out of the woods with COVID. Of course, we’ve got new variants and so on. We’ve had a flu challenge. And if you combine that with the pressures that we’re facing operationally in terms of both the backlog of care as far as elective activity that we need to get through together with the really difficult circumstances that we find ourselves in with the urgent care pathway for patients. It’s well documented the waits for ambulances, the challenges with hand over the crowding of EDs, the challenge of patients getting out of hospital because of issues in social care. You put all those things together and you get what you described the biggest crisis we faced in the NHS, arguably ever.

And it’s instructive to put that into context with strike action. Obviously before us, it’s an amazing time to become the chief executive of NHS providers and I guess it’s never been more important for the work of the trusts to be explained, advocated and engaged with.

Absolutely right. And that’s the reason I took on the job Suhail because I feel hugely motivated by what I’ve learned throughout my career. The NHS has given me so many opportunities and I owe the NHS an enormous debt of gratitude, both professionally and personally. And so, I feel. Both head and heart, hugely motivated to make a difference in terms of championing what the NHS is about and indeed helping to influence the securing of a positive and viable future for the NHS. Because we’re going through some turbulent times, as you say. And at the heart of the NHS are its people. We need to make sure we’re focused on them. We need to make sure we’re thinking about the needs of all of the staff that work across the service. And it’s a tough time right now. And therefore this is I think, a period where all of us who believe in the NHS, particularly those of us in leadership roles, need to step up and need to make our voices heard.

Absolutely. And I’d like to delve deeper into that question in a moment. But the broader landscape, despite it being, of course, turbulent, it’s also transforming. We’ve had legislation now giving statutory backing to integrated care systems. Collaboration is the theme. Now collaboration can’t be enforced, of course, but you spent a number of years as chair at the West Yorkshire Association of Acute Trusts and played a big role in terms of that collaboration. Do you see a lot of hope from a systems perspective, not just for delivery but for workforce as this landscape now becomes more familiar?

I do Suhail and I would go further in the sense to say that the solutions to the current challenges that we’re facing lie in some of those approaches that you refer to. Just to put this into a bit of historical context. The NHS has been through many different reorganisations, and I can remember early in my career seeing the separation of the purchaser and provider in healthcare. The working for patients reforms of the early 1990s and then in my first hospital chief executive role in Blackpool, I led Blackpool to become a foundation trust and the foundation trust movement at the time was a vehicle for the expression of self-governing NHS trusts with more freedom, more financial freedoms, independence from the direct line from government. All of that was a period where there was a release of energy and optimism. However, with it came some downsides, which were about the sometimes acrimonious relationships you’d find locally between commissioners and foundation trusts, and also some of the issues with a system very much based on a tariff payment by results, which meant that you’d find a more of a transactional relationship happening between organisations and also a very much a competitive environment between foundation trusts in any given locality. I think we’ve learned the lessons from that period and therefore the emphasis on partnership, I believe, is to be welcomed. Certainly, my experience of leading the West Yorkshire Association of Acute Trusts has been that we’ve broken down many barriers between different hospital organisations across West Yorkshire.

We’ve learned to work really well together, not just as chief executives where we started, we met together for dinner back in 2015. We agreed we needed to work differently. We agreed to enter a strong partnership and from that came a whole set of benefits that have deepened in terms of the engagement of executive teams, clinicians, managers within all trusts, to the point where during the pandemic, our levels of collaboration were like none I’ve ever seen in terms of how much we helped each other, depended on each other, worked together to support the safe, effective care of patients and indeed supporting staff. Now, that spirit of partnership is something that we’ve continued to build on to the point where we’ve been able to reconfigure key clinical services without having to go to sort of ask for the judgment of commissioners on this, which we often see in other parts of the NHS. So, I think we have seen some of the future, if you like, of how the NHS can work more effectively, particularly with those deep levels of provider collaboration in our case across hospitals. But of course, this counts for mental health, community primary care, social care and at the heart of that partnership. Is about building the relationships. It’s about trust and it’s about reciprocity.

Absolutely. And that bodes well as we move into this next phase in the new statutory framework and in particular with workforce collaboration. I’d like to delve a little deeper into that, because Leeds has been recognised as throughout the NHS for the great things that it’s achieved. You left a legacy of investment and two new hospitals regeneration. I’d like to focus a lot on what you’ve done with the workforce there. Yeah. The Leeds Way Leeds Improvement method. Drawing on the world-class experience, of course, with the Virginia Mason Institute. I’d like to begin with wellness and burnout. You’ve talked about that. You’ve alluded to the challenges that the workforce have had and continue to face today. The latest NHS data, of course, you know, shows some 42,000 people leaving voluntarily in quarter two, which is a tragedy in many ways with 7200 citing work-life balance, the highest ever. So, if you could perhaps elucidate a little bit. In terms of wellness and burnout, what you did at Leeds, because it’s been recognized that the Leeds way was transformative.

Absolutely. Well, that’s a big question, Suhail, so let’s break it down. So, if we start with, I think the fundamentals of certainly my philosophy of leadership and management and I think one that is particularly applicable in health care context, if you look at all of the evidence. And there’s a large body of evidence now. And academics like Professor Michael West, for example, have written extensively on this. The more engaged and empowered your teams are, your staff are, the more aligned they will be to the overall shared purpose of the organisation. Then the better the outcomes for patients. Operational delivery. Financial performance. That connection has been made numerous times. As an aside, when I went to do my secondment in 2019 on the National People Plan. The first thing I did was look at those trusts that had achieved outstanding in their use of resources and match that against those trusts with the highest engagement scores in their staff survey. Guess what? There was a direct match. So often there’s there are some voices that say, well, this is all the soft stuff we need to focus on the kind of bottom line, on the finances performance. You can’t separate them because one delivers the other. So, without a strongly engaged, empowered workforce, you will not get to a sustainable position either on financial performance or on quality or on operational delivery. So that was my starting point, really. And therefore, walking through the door in 2013 in Leeds teaching hospitals, priority one was about the culture and about engaging everyone in that organization, all 20,000 staff.

And to do that, we undertook a major piece of work using crowdsourcing. Everyone got the chance to say what was on their minds. We went through that moment. I describe it as the moment of catharsis where everyone talks about what’s wrong, is able to give vent to being truthful and honest about how it felt to work in the trust. That’s a very important moment because it’s important the leadership is there to hear the truth and feeds it back that the leadership gets it, and that then becomes the moment of, if you like, the baseline. This is where we’re at and it isn’t great, so what are we going to do about it and then build up from there in terms of engaging everyone in the creation of a better way, which was the Leeds way. And the key values of the Leeds way came from those 20,000 staff, not from the boardroom and to this day, ten years later, it is still our North Star. And the great thing about that is it wasn’t about me. It wasn’t about any individual. It was about a collective effort to identify and shape a culture where people felt valued and empowered, where there was significant recognition, continuous improvement, and an enlightened management style. Now, those are ingredients. I’m sure the vast majority of leaders in the NHS would recognize, but I would argue strongly those things are the prerequisite for attending to the challenges we face now, particularly in terms of staff, health and wellbeing.

So, from that point we embarked on a whole set of improvements which took the Leeds Way culture and fed it into everything that we did, including our approach to health and wellbeing. And certainly, the work that we’ve done with Virginia Mason on the Leeds improvement method as it has become, has also been central to this, because when you listen to colleagues at Virginia Mason, they talk about only those people doing the work can improve the work, which is a truism. But often we think the answers are top-down, don’t we? And we think we need to tell people what to do. And it’s also about leaders going onto the front line or the NBA as the Japanese term for where the work is done. With big eyes, big ears, small mouth. And that is a key part of the approach and why the solutions for the challenges need to come from those people working and I would argue again strongly that that sense of agency ownership, empowerment among frontline teams is vital for them to feel that they have agency to deal with the challenges, the stress, the difficulty. And it helps with that whole sense of health, wellbeing, support. And of course, we wrap around that many initiatives in HR. But I think at the core of this, at the heart of this are those features.

And it’s also an iterative process. It’s not cast in stone. I think in 2022 there was a refresh. Listening to the staff, I think the principles of compassion and kindness was brought into the forefront. And that empowerment piece, I think, is so important for retention. By the way, I love the idea of leaders having big eyes, big ears, small mouth. I think we could fit that large into a broader framework, but that’s a topic for another discussion. But going back to the empowerment point, I think one of the examples I’ve seen and perhaps you can briefly elaborate is I think some 8000 staff were given leadership roles in terms of improvement programs right across the board, clinical non-clinical different facets.

Absolutely. So, our journey in terms of continuous improvement has been genuinely it’s perhaps an overused word, but transformational. And what was vital in that was the learning and the curriculum that all of us did. So, we created a course called Lean for Leaders, which I did, and I did it with a cohort of colleagues, consultants, physios, nurses, accountants, and we ran these cohorts continuously and got through large number of staff and we had different kind of levels of qualification in the Leeds improvement method. And those were run by with support from Virginia Mason by our KPI, our Kaizen promotion office, another Japanese term. But these were the people who were, if you like, our experts in the method. And those programs enabled individuals and teams to learn some key skills and key tools, which included how to identify flow of people, products of medicines, patients within a given area, how to break that down, how to see where the blockages were, how to improve the lead time, how to understand the processes, how to understand tact time. All of these different components that make up any clinical process or non-clinical process for that matter, which have their roots in the work of Taishi, Ohno and Toyota back in the 1950s. The Lean principle, indeed. But they are absolutely applicable to health care. And I’ll tell you something Suhail, they came into their own during the pandemic, where we were able to apply them directly to our testing process, to our vaccination process. So, the lead time for a patient, well, for a member of staff or indeed anyone getting their vaccine. We got down from 30 minutes to 14 minutes to 10 minutes using the method. And of course, that is something which staff then feel energized and motivated by because they’ve come up with the improved process. It’s not been imposed on them. And I think that’s where you can apply this philosophy and approach to many of the challenges that we spoke about at the start of this conversation.

Absolutely. And Kaizen, of course, is continuous and never-ending improvement. And I guess that ties in because one of the modules I think staff were required to attend was to understand value and waste. And with the efficiency targets that have been set for the NSS over the next few years, I think I guess you’re tying in a non-silo approach to empowerment, engagement and efficiency in terms of financial outcomes.

Absolutely right. That’s been one of the most important features and benefits really of the approach in the sense that we moved away deliberately from the language of cost improvement programs. CIP If you go around as a manager and talk to staff, nurses, physios, doctors about CIP, they’ll glaze over. Whereas if you talk about what, what are the rocks in their shoes, what are the annoyances? Well, I can’t get hold of the bladder scanner when I need it. Well, there’s it takes ages to log on. Well, all of those things, that’s waste. And clinicians can identify and see waste every day in their place of work. Framing waste and going back to the literature and the method, there are seven types of waste and each of them can be addressed, but best addressed by the team in situ. So, what we did was create the opportunity for them to learn the skills of how to identify and tackle waste. And because that was happening in every kind of area at the front line, when you grow up, all of the benefits and savings because of course that meant an extra patient on a list. It meant a quicker process. It meant less waiting for patients, it meant more efficient use of resources, of medicines, of stock and so on. All of that added up to many millions, which of course supported our financial recovery program. So, if we go back to 2019, I think we recorded a £50 million surplus from a position a couple of years earlier of significant deficits. So, we wouldn’t have done that without this approach. And even to this day, under these huge financial challenges. The finance director, Simon Worthington, has the regular conference with all clinicians on clinical waste reduction and as you say, connecting. Quality, cost, workforce because we cannot see these things in isolation in hospitals, in any health care setting. They are inextricably linked.

Absolutely. It’s refreshing. It’s the Six Sigma approach, small changes that cumulatively make a profound difference. I’d like to touch upon learning and development because clearly part of the return from surveys are showing people have left because of pay and reward. You’ve made Leeds a centre for empowerment for people’s career paths, new roles, variegated roles. You’ve been recognised nationally for the use of apprenticeships and by health education England in terms of the talent for care, employer and board. Can we speak a little bit about that? Because retention is vitally important, but also attracting staff. There has to be a career pathway. There has to be a learning environment that is supported.

Yes, absolutely. Well, perhaps just to expand the frame on this one, Suhail, because we’ve done a lot of work with our partners in Leeds on this, and we have something called the Leeds Health and Care Academy, which we establish some years ago with the purpose of consciously bringing together a learning and development offer for the 57,000 staff that work in health and care across the city. And that’s about deliberately ensuring that, for example, nursing staff that work in hospitals understand and can learn with social workers out in the community and in hospital, with community staff, primary care and so on. The idea being that we all have a stake in the learning and development of all of our people in health and care, and we need to have an approach to that as a city. We as a trust hosted that and have been involved with our partners in taking that forward. A big part of it is about our role as an anchor institution with the City Council, university and other organizations, because getting into schools, getting into priority parts of the city of Leeds has been a key mission for us. So, part of the work of the Academy has been, for example, to target areas like Lincoln Green, which is an area on the doorstep of St James’s Hospital where we’ve worked very closely with the local community groups and we’ve been able to target employment opportunities for that community and consequently we’ve been able to recruit quite a lot of staff into high quality NHS jobs. Now, that wouldn’t have happened if we’d not as a city had that perspective and that attitude and created the infrastructure to do that. So, I think the NHS, together with its partners, can play a fundamental role in tackling not just health inequalities, because we know health inequalities come from wider determinants, particularly employment, housing and so on. But playing into those priority neighbourhoods, as we’ve done in Leeds to create jobs, to transform lives. Now that I think is a massively important role that the NHS can play. And then of course, we’ve done a lot with our own people who are already in work and with apprenticeships where we are the biggest recruiter of apprentices in the NHS. And we’ve seen a fantastic consequence of that in terms of young people taking up key roles in the trust, including an excellent scheme for young people with learning disabilities, autism, who have come in on a specific scheme and worked with us and have secured roles in the trust. And I think all of this is doable. All of this is possible for any NHS organization to take, but it requires some imagination, it requires some dedicated resource and partnership in the way that we’ve structured that in Leeds in terms of the Health and Care Academy. So those are some of the features and approaches we’ve taken to address some of those issues.

And collaboration being the golden thread, I think running through all of this now. You’ve obviously left Leeds great contribution made potentially, of course, with terms of the new hospitals that are coming there, the economic value add, the new jobs. There is a challenging situation now, but I guess from your perspective and your commitment to Leeds, you’re confident that the local population is well served?

Oh, absolutely. I am very fortunate to have worked in a great city. I’m in Yorkshireman. I’m from Bingley. It’s not far from Leeds. The last decade has been a wonderful experience. I mean, we’ve had lots of challenges. We’ve had our difficult times. However, what I’d say, Suhail, is that we’ve got the makings of a fantastic opportunity around innovation, economic growth, employment with the Leeds innovation arc. And as part of that, the innovation village that brings together what will be the new Leeds General Infirmary and new Children’s Hospital that will release five hectares of city centre land on which will create that innovation district that brings together university ourselves, city council, private sector investment start-ups and we’ve already started that with our innovation pop up, and we’re working with many companies already to give them the proximity to a major teaching hospital for their innovations in terms of medical devices and technology, which of course Leeds has a great history of. So, there’s a huge opportunity. And that’s the other thing about the answers to some of our current challenges. Investment in the NHS is not money into a black hole, it’s money that will have a return in many cases. And for us we see that in terms of the case we’ve put forward for the new hospitals program, the hospitals of the future, and that will be a major part of the city in terms of its future, its economic growth and development.

Well, you should be rightly proud of that legacy just to take the lens back out away from Leeds nationally, of course, now and very much a national role as chief executive of NHS Providers. One question I do have and this is based on the fact that obviously the NHS people plan was a watershed moment in terms of workforce engagement. You’ve played a foundational role in that with the interim people plan. We are promised a workforce strategy. Various health secretaries have now said that. It’s a big question. But of all anyone to speak to you was hugely well informed around this, given the work that you did or the NHS people plan. Talking to the government. Are they one or two absolutely essential key things from an NHS provider speaking on behalf of the whole of the trust environment that you would like to see front and centre of any workforce strategy?

Yeah, absolutely Suhail. So, I think in the short term we need to resolve the current turbulence in terms of industrial disputes and so on. It’s that at the heart of the NHS are its people and we must attend to the health, wellbeing, motivation of our people. And that’s the, I think, the most important job of any leader in the NHS. And while there is this discord, difficulty and industrial strife, we can’t maximize the effectiveness and the and the and the discretionary efforts, if you like of all of our people. Those are things that are happening at a national level and need to be resolved at a national level that hopefully will give us the opportunity then to think about how we really take forward the recovery and development of the NHS, because we’re in a place now where we talked earlier, we’ve never been more operationally stressed. We need to start to get into solution mode and many trusts are doing great work on this and we need to give local leaders a chance to really make progress on that. So, a workforce plan is really important in terms of giving us a sense of the medium term and the longer term. Amanda Prichard’s already been on record talking about the importance of expanding our recruitment and the development of staff for the NHS within the UK. We need to make sure that the culture of the NHS is one that people want to be part of and feel very positive about. We’ve talked a lot in this conversation about the importance of culture. We need to ensure that leaders are working in the right way and supported. A lot was written about this in the review done by Gordon Messenger and my chair, Dame Lynda Pollard. So, we have many of the answers in that. We’ve got, I think, an opportunity to really take the improvement approach which we’ve talked about across the NHS and that I think would send a powerful message that we’re interested in improving obviously first and foremost services for patients, but also the experience of staff and of course the workforce plan needs to attend to those areas that have the most critical shortages and have a clear plan and timelines for how we’re going to get to a point where we’re not as stressed in terms of the number of staff that we’ve got in areas where we know we need more staff for key specialties and key professional groups.

On that note, as we wait, I’d like to leave it there and thank you, Sir Julian Hartley, for your candour and your compassion, if I may say so. It’s always a pleasure to catch up with you.

Thanks very much, Suhail.

You’re welcome. If you’ve enjoyed this episode of Voices of Care, please like follow or subscribe wherever you receive your podcast from. And if you want to find out more about how we are truly enabling the healthcare workforce of the future, please visit NewcrossHealthcare.com/VoicesofCare. In the meantime, I’m Suhail Mirza. Thank you and goodbye.