Can better culture improve the results of an NHS Trust?

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TRANSCRIPT

Bruce Daisley (00:07)
Here’s a question. Can you fix the performance of an organization by changing the culture? Can you take that sort of culture first lead, fixing the culture first and then trying to see if everything else will ripple from it? And how about if there’s the added complication that you don’t have a lot of resources to do other things aside from that. So that’s the discussion today. We’re to go inside an NHS hospital in a sector that’s already beset with resource shortages, a government that’s refusing to settle a long running pay dispute.

We’re going to try and get our head around that culture first idea. Last year I was really flattered to go and do a talk at Barking, Havering and Redbridge University Hospitals Trust. It’s an NHS trust and it’s fair to say that the trust has had its share of problems in the past. High turnover at the top. It’s a reflection of the fact that the institution had challenges. It had a succession of interim leaders. Additionally,

The job was made harder by the fact that its catchment area covers suburbs that have some of the highest levels of deprivation in the country. It’s just a really poor area. When the job of Chief Operating Officer was advertised on the Health Service Journal, they described it as the hardest job in the NHS. Now, I went in and they gave a talk about resilience. was talking about my book, Fortitude, but I hung around afterwards because I loved these opportunities to…

hear what people say and how they describe what it’s like to work in a place like that. I spent an hour wandering around and chatting to people and I was so dazzled, I found myself going over to the Trust’s CEO, Matthew Treanor, to ask him an unusual question. Could I come back and record a podcast at the episode? So that’s where I found myself in September last year. I made my way into the King George Hospital in Ilford. I was a little early and I was helped navigating

myself by a welcoming man with a turban greeting people in reception. He wore a label indicating that he was a volunteer helper and it turned out he’d been volunteering at the King George for 14 years. Wow. If you want to know what the NHS and free healthcare mean to communities, then wow, what an endorsement, volunteering for 14 years. I was taken to meet the team. I wandered around, I was taken around the whole hospital.

When I’d previously visited, was struck by a sense that there was a real will to win, even though they’d had some bad performance results and there were no shortage of challenges. Everyone really felt a sense of optimism that they could make things better. Matthew Trainor said to me that he’d wanted to explore whether by creating a more engaged organization, it could be helped to improve. He was a real optimist. He really believed that there was a route to them improving their performance.

And at the heart of it, knew everyone wanted to feel proud of where they worked. Recently, things have been difficult. Waiting times in accident and emergency were some of the longest in the country, and the waiting lists were long. I found myself checking waiting times at 3 a.m. in the morning, he told me. He’d get up, go to the bathroom, and find himself just logging in to see how long people had been waiting. In the distant past, one of the things that really inspired me about the idea of leadership

was a TV show called Can Jerry Robinson Save the NHS? So in it, Jerry Robinson was this retired big hitter. He was the real life CEO of a major broadcaster who was tasked with the problem of going into NHS hospitals and seeing if he could solve some of the bottlenecks, solve some of the challenges they were having. Whenever I chat to someone on this podcast, I always ask the question, you know,

When Frances Frei, someone’s on here, I say, what did you go in and do? What did you say? And that was what was compelling about the Jerry Robinson show because he didn’t presume he had the answers. He just went in and start asking questions. And it really interestingly, it seemed that the staff had all of the answers. They knew how they could make things better. They chatted to Jerry Robinson. They knew what needed solving. And more than anything, the frontline staff.

actually were the people who revealed the solutions to him. I’ve put the link in the show notes to one of the episodes of the show. I loved it. It really made me recognize that, the idea of servant leadership, really this sort of egoless approach. Jerry Robinson had visited operating theaters and found that some of them were empty on a Friday. And why he asked? he was told it was because doctors didn’t want to do followups with patients on Saturday mornings. So.

That spirit of Jerry Robinson actually was what really I could see that lit up the eyes of the people inside the Barking, Havaring and Redbridge Trust. There was a sense that the ideas to improve things might come from anywhere inside the organisation. One consultant had told me that when he first came to London from India, he had gone to the London teaching hospitals, the likes of Guy’s or St. Thomas’s or UCLH. And he said to me,

This consultant told me that he said he felt the tradition of those places didn’t seem to welcome ideas and inputs from an outsider like how he considered himself. But when he’d moved to the hospital in Barking, Havringham, Redbridge, those barriers weren’t there. There was a willingness to give things a go. The Trust has a waiting list of 35,000 patients. In the past, the waiting list has struggled to be helped in the winter, basically unplanned operations.

surge in cold winter months and they’d take precedent over the planned procedures, what’s called elective work, that the waiting list patients represented. For the last six winters, they’d had to stop elective work because the urgent needs were just so high. So the trust had hatched an ingenious way to solve this, setting up what they call an elective surgical hub, meaning that emergencies no longer led to the cancellation of long-planned operations.

Surgeon 1 (06:20)
What has happened is we’ve had to stop elective work in terms of people who need elective cancers or even…

Bruce Daisley (06:29)
effectively they kept them separate. Now it’s worth remembering that every person on a waiting list isn’t just a number, it’s a person who’s often experiencing a lower quality of life or they’re possibly in pain. So getting that waiting list down actually just is a really important way to try and increase net happiness. I was delighted to be taken on a tour around the hospital to meet some of the people handling patients.

Nurse
that we try to adapt. Because you have a creative decision to run a creative decision goes between three.

Bruce Daisley (07:02)
Okay, right, so this is right into the detail of it. And so that would in comparison would be how much?

Doctor
Well, one videographer probably for six and (inaudible)

Bruce Daisley (07:11)
Okay, okay. It’s interesting when you break it down like that, isn’t it?

Included on my tour around the hospital were visits to a brand new ultrasound machine that was enabling medical staff to perform operations without a surgeon. So it’s really a concentrated bandwaves that just break up. It’s a bit like limescale in the kidneys. it just

Bruce Daisley (07:35)
Right. So it eliminates the need for patients. can come in here at 9 o’clock in the morning and you’re home.

Bruce Daisley (07:44)
Or going in and witnessing a gallbladder removal that used a robotic device effectively with 3D vision to enable a surgeon to perform far more effectively and really sort of get a better outcome.

What I really loved and I’d heard this when I’d gone in to have those initial discussions is the trust had just hatched radical ways to solve their problems. They’d not only this elective surgical hub, but they’d introduce one initiative, for example, called TonKids. And that was about trying to perform 100 tonsil operations in a week. The waiting list would be reduced by about 25 % in one week of focus. And they did that in a really

simple way. They’d call patients in, they’d be calling the next patient while a new patient was rolled onto the operating table. Really interesting, they were trying to systematise it to try and get better results. But now I sat down with Matthew, the CEO, and tried to get a perspective of him and his approach. He’s had quite an unorthodox career, taken in journalism along the way before he reached his present position. And he’s a incredibly likeable man who, as part of his own character, he’s very willing to describe his own mental health challenges, something that can’t be enhanced by getting up at three in the morning and checking on waiting times. But he seemed really optimistic, really committed in the discussion.

I mentioned the Jerry Robinson TV show that I’ve just given a shout out to and I mistakenly ascribe it to the TED Talk legend Ken Robinson. I don’t think they’re related but listen out for that.

Matthew Trainer (09:42)
I’m Matthew Traynor, Chief Executive of Barkinghaver and Redbridge University Hospitals Trust.

Bruce Daisley (09:48)
And so you’re, is it seen in the NHS as like suits and medics? there a separation between sort of…

Matthew Trainer (09:56)
think there is a sense, yeah, I’m very much a manager. I’m a non-clinical manager. I mean, the vast majority of managers in the NHS are clinical. And the figure that we use nationally is 19 out of every 20 managers are clinical. Management is direction and use of resources. So ward managers will be nurses, clinical directors and services could be surgeons or doctors. lots of the management is delivered from that medical context. But I’m a non-clinical manager and there’s a kind of element of operations management and senior management in the NHS that is not

Bruce Daisley (10:26)
I adored about 15 years ago a show that I suspect is a bit of like ancient history in the NHS, which is Jerry Robinson tackles the NHS, and you know, I was really struck in that, that there was sort of these immovable objects which were consultants and surgeons and they didn’t have a lot of respect with the leadership. Now I’ve just gone round the hospital here and that doesn’t remotely seem to be the case. One of the things Ken Robinson…

saw in his thing was that there were no operations on Friday, because the consultants didn’t want to do operations, but you have operations all day on Friday here. So I’m just interested, if you were surveying it, what’s the state of relations inside the NHS? What’s the insider’s guide to how the NHS works? And maybe with the caveat of how it might be different here.

Matthew Trainer (11:14)
The NHS has been through, I think, probably some of the hardest times in its history in the last couple of years because we had the Covid pandemic, which was a hugely disruptive event for the NHS. It hugely simplified for a period of time the delivery of healthcare because what the NHS was about for a period of time was we’ve got to stop people dying from Covid and then we’ve got to get vaccinations out to try to reduce it in the future. But what that did was it really disrupted the running of hospitals.

broke a sort sense of the flow within hospitals. And what’s always been in hospitals, you’ve had the clinicians who deliver the care, which is typically, you’ve got your medical professionals, nursing professionals, and other healthcare professionals. And then you’ve got operations management, which is the kind of glue that holds it all together. And the role of management is to enable the clinicians to do their job better. The only point in having someone like me in a hospital and I’m not clinical is if I can make it easier for the surgeons to operate.

if can make it easier for the nurses and frailty to provide good quality care for elderly people, if we can get the right resources there. So our job is look after the staff, give them the best environment to work in, get better outcomes for the patients and look after the money. I think COVID’s put a lot of strain on that. I think lots of services changed quickly in ways that tactically made sense in the context of the pandemic, but the effect it had here, I think, was of throwing everything up in the air and it kind of all landed, but not quite in the right order and right shape.

And I think this summer has probably been the first time since the pandemic here where we felt as though we’ve started to get some services back into the right place. And surgery in our trust and planned care has been forging ahead and doing some great work. And you’ve spoken to some of those guys today and we can talk a bit more about how they’re working. Medicines had a very different experience with social care in real trouble, primary care demand going through the roof. And as a result, the pressure on the front door for emergency medicine is really different. So it’s been interesting within the trust seeing the really positive.

can do culture in surgery where what they ask me for is more patients. You go to the surgical wards and talk to the matrons there, what can we give you more of? We want more patients because we can do more here. Medicine, they say we need more space to practice medicine and that means fewer patients and we need more support around that. So there’s some really interesting contrary dynamics playing out just now.

Bruce Daisley (13:25)
And tell me this, so one thing that I’ve been really struck by is that while COVID was this horrible disruptor that has sort of knocked you out of the natural rhythm and added hundreds of thousands of extra people to waiting lists, the thing that really strikes me, and maybe I’m getting this wrong, is that it’s been a provocation to think about how you can do things differently. And so I just walked around the elective board here, and that seemed like it was

response because previously you had emergency surgery and chosen planned surgery, elective surgery done in the same place and actually by separating it, it meant there were fewer disruptions from doing the day job by these emergencies that come along. Or another one, really struck a chat to one of your brilliant colleagues, Avinash it might have been, but he’d done this 100 tonsillectomies in a week. Was it Avinash?

Matthew Trainer (14:24)
Tankheads, that was the operative.

Bruce Daisley (14:26)
Okay,

so we’ve done a hundred tons of Tamsin’s in a week and it struck me that that came from both of those things came from

unusual circumstances have prompted inventive thinking. So I’m just interested in whether that actually has been, you know, not desirable in terms of the provocation, but whether it’s forced you to sort of reimagine and reinvent in a way that you maybe wouldn’t have done.

Matthew Trainer (14:54)
So first things first, I won’t take credit for a lot of this because I wasn’t at this trust during the real heart of the pandemic and lots of this has been driven by the surgeons and the surgical leaders you’ve spoken to today. What I’ve really seen though amongst them is when the pandemic hit, what lots of people in the NHS were asked to do, as the whole country was asked to do, was do something different that they’d never done before. And what that meant actually, if you were in a planned care surgical ward, was people suddenly turned around to you and said,

We need you to change the way they work because actually there’s not going to be any more tonsillectomies tomorrow. What we’ve got is intensive care patients who need help breathing. And what we’ve got is we’ve got to change our emergency pathways, we’ve got to change our surgical pathways. And overnight, lots of those wards had to very rapidly change the way they deliver care and their staff had to go and work in different environments at very short notice. And what I’ve seen particularly from the surgical side and particularly here at King George is that’s given them a real confidence to try things.

And we’ve talked a lot about quality improvement in the NHS and that kind of spirit of, most quality improvements are PDSA cycles when you come down to it, whatever you dress it up in. But you talk to the surgical folk here and in a previous job in the NHS, it took me the best part of two years to move a blood service out of an area to put it into a discharge lounge, a really small discharge lounge. And it took me two years, I banged my head up against the wall to make it happen. And suddenly in COVID, people were doing things overnight.

And what it’s done for the teams here is give them a huge confidence to try stuff. Let’s try something different. If it works, we’ll keep doing it. If it doesn’t, we revert and we think again and we go again. That confidence to try, to make mistakes and fail has given them these really enhanced processes, a really dynamic sense of all the different disciplines in the team pulling together around it, and a real sense of pride in what they can achieve. There was a couple of important elements of it. One is we’ve got this hub here, which is separated from the emergency pathway for surgery. you know, if you were…

run over by bus and you need emergency surgery. You’re coming through an ambulance, we have to get you into a theatre, get you operated on really quickly, your appendix burst, that kind of stuff. That’s unpredictable. You need space and capacity to deal with surgeries and that. The planned care here, we know who’s coming in, we’ve got them booked in and we build around that. And we’ve taken a very deliberate decision to separate that from the emergency. In the NHS pre-COVID, what happened every winter was you got into December, January, February, you would just fill up your surgical beds with emergency patients.

And I used to have an anaesthetist working for me when I was working for Kings in South London, and she used to send me an email sometimes on a Wednesday morning, off 10, say, I’m going home now, because you’ve cancelled my list for the rest of day, because you filled it with emergency patients. You’re paying me, know, best part of hundreds and hundreds of pounds to come and do this session. I’ve got no patients to care for, so I’m going home now. And she used to always send me these emails, and it used to drive me mad, you know, but then you’ve got the ambulances queuing, you’re balancing the risk off here.

they deal with the ambulance patient or they deal with the person that needs to come in for a procedure who’s been waiting six months in pain. Really difficult decisions. What we’ve got here now and where you’ve been today in that hub is protected and we don’t put emergency patients into there and we treat that as sacrosanct really. I think post-COVID that’s really important because we’ve got now 65,000 people on waiting lists and some of it’s not urgent but lots of it.

It’s people sat at home in pain, it’s people unable to work and we know from the ONS there’s more people out at work now because they’re waiting for operations than there has ever been before. We’ve got to these people treated. You speak to our local GPs, their clinics have got people coming in saying, I’m waiting for an operation at Queen’s or at King George. Do know where I am? I’m in pain. You’re trying to balance off all these different requirements for healthcare.

in a way that you can do within the resources you’ve got. Recognizing you do have to make trade-offs somewhere, and those trade-offs in healthcare create risk.

Bruce Daisley (18:42)
When we first spoke, you had an interesting comment that you said to me that was like, want to see if we can improve patient outcomes by changing the culture of the organization. That’s a really lofty goal, but a fabulous goal. we, as I see that, can we improve patient outcomes by making this a better place to work, or maybe a clearer focus on excellence, or clearer focus on innovation? How do you think about those things?

Matthew Trainer (19:09)
Yeah, so culture is, for me, there’s many different definitions of culture in an organization. It’s the way we do things around here. One of the ones I always think is really interesting is how do people behave when no one’s watching them. And I think that’s a good insight into the default culture of place. If no one’s watching you, do you tidy up, get things in order, make hay with that timer? you think, no one there? Do you walk past things that are wrong? Do you tolerate poor quality stuff? And in a safety conscious industry like the MHS, I think that’s really important.

So I think culture for me, the kind of how we do things around here thing is really important because if you get that right, what we’ve got here is thousands and thousands of clinically trained staff, some of them incredibly technically skilled, who I think, my premise around this is if you give them the right equipment, the right levels of staffing around them and good environments to work in, that their primary driver will be to do their job to the best of their ability. And if they do their job to the best of ability, our patient outcomes should be better. That includes

how we treat our patients and how we treat each other and how we make sure that civility in work. And there’s some good work by a guy called Chris Turner who’s going to speak to us next month about civility saves lives in hospitals actually and how good civil positive cultures create a psychological safety that allows people to speak up at faults. And I think it was an interesting stat from, this is from I think 2001, but it showed that something like more than 90 % of airline pilots were happy to be told they were making a mistake.

but was only about 55 % of surgeons at that time were happy to be told they were being made a mistake by a junior. And there’s lots we need to think about in terms of creating safety cultures where people can speak up confidently and where people can feel they’ll be listened to and things will change because of that. my premise is create the right culture and the right set of behaviours within the organisation. We’ll empower people to speak up when things are going wrong. We’ll encourage people to speak up openly about the things that could make things better and do things right.

And that happier workforce is workforce that will put more into the job. I know you talk a lot about joy at work. I think when you speak to some of the folk you’ve been with today, you will sense their joy in what they do. You’ll sense the real pride they get in what they do and that sense that what they’re doing is making a difference to the people that are coming into them for care. There are other parts of our trust where you won’t get that same sense of joy and pride. And what you’ll do is you’ll find people who feel as though they’re having to compromise left, right and center on the quality of care they deliver.

because they’re too busy, they don’t have enough staff, they’re working and cramped in appropriate conditions. And that for me is the stuff that me and the other leaders in the organisation need to try to fix. junior doctors are a big challenge for the NHS just now because lots of them are really unhappy. Some of them are counting out at university with huge debts and these are some of the best and brightest people in our schools. And they’re coming out with big debts and they’re being paid money that doesn’t allow a lot of to live in London. When I was at school.

I think one or two people in my school went off to be doctors and you thought, right, big house, nice cars, foreign holidays, made up. And now we’ve got junior doctors just saying, I can’t even live in a shared house in London, can’t afford that. And they’ve been told, you’ve got to accept this pay settlement. They’re looking at their mates on Twitter, off to Australia, et cetera. And if you see some of the threads on what would improve your lot as a junior doctor, some of them are really depressing because what they say is, I’d like to get my rotas in advance so I can do things like go to a family wedding.

They talk in amazement of trust they’ve gone to where their work pass has been ready on the first day. They talk about how impressive it is when they get paid the right amount after the first month in shift. These are real core elements that when you think about joy at work and pride in what you’re achieving, these are all things that stop people experiencing that joy.

Bruce Daisley (22:49)
It’s almost like a Maslovian hierarchy of, it’s like a hygiene factor, it? I’m always fascinated with discussions about knowing people’s shifts because it’s a big theme in retail. know, the biggest thing you can do in retail is give people their shifts a month ahead, two months ahead, or give them an app that allows them to switch their shifts without having to request permission.

And you wouldn’t have thought it, it’s such a hygiene factor, but it’s transformational. But the complexities of retail mean that it’s very hard to give someone their shift to month-end. And so it’s this interesting trade-off. So you’ve said a couple of really interesting things there. You’ve said that sort of hygiene factor plays a part in mitigating the misery of their lives. You’ve also said that thing which is, maybe these are distinctly separate, but that only 55 % of people in operating surgery are willing to speak up to the surgeon.

Now in airlines, the way they’ve done that is by creating a mandatory system called crew resource management and it’s stipulating the rules of engagement. So people know, they know when a sentence starts in a certain structure that this is going to be a deliberately constructed way to raise a concern. Exactly.

Matthew Trainer (24:04)
Excuse me, sorry, but I think…

Bruce Daisley (24:07)
And if we don’t recognize the consequences of this, I think the outcome could be this. But everyone recognizes this is the structured way to do it. It’s transformation for the airline industry.

So those two factors there, the hygiene of things actually creating storm clouds in people’s lives and systematizing psychological safety, they’re two very different things. But how would you set about solving them from a management perspective?

Matthew Trainer (24:32)
Yeah,

so I’m not sure they’re that different in some respects. So on the surgeon’s one, I think that study, so I say that was 2001, it may have improved considerably by then. And certainly you would, I mean, you’ve seen today, Dick Markerjee is one of our brilliant surgeons taking out someone’s gallbladder. Dick is our trust lead for patient safety, and he is one of the very first people who spends his time going around services, encouraging people to speak up when they see mistakes. And you know, we’ve got some folk here who’ve got really good culture of that, but.

A couple of things about the airline comparisons are interesting. The nuclear industry is another comparison we get. And I used to with a guy called James Titcombe, who’s done some fantastic work nationally about safety. And he said when you work for British Nuclear Fuel, there was a kind of award of the month for someone who’d called out a safety fault. He used an example of a guy who dropped a spanner off a scaffold and it burst the pipe. He immediately went and told management and he got a bonus for that. Because it’s a positive safety culture.

And the NHS has got quite a long way to go in that. And I think we are in a framework at the minute where there’s been problems in the NHS around quality, around safety. The Francis report into Stafford, which was my local hospital when I grew up. I’ve got stitches in my head there from Stafford Hospital and other things like that. But there was the Francis report there. Lots of that was about culture and psychological safety.

And we’ve just recently, of course, had the cases in Chester and the conviction of Lucy Letbe, where again, there’s been conversations about psychological safety to speak up. And it’s so important in a healthcare context that people can do that. Part of the, I think, the fear factor that comes into this is that sometimes, actually, people feel as though when they own up to mistakes, they’ll be blamed. And we have got into a situation where I think there is a worry about your liability when things go wrong, the outcomes from…

coroner’s cases, the outcomes from inquiries, where we’re always looking for someone to say, you made a mistake. And I think healthcare is people who are fallible, caring for people who are vulnerable. And I think there are different categories of mistake there. There’s just the things that go wrong. And I think that’s the old, what is it, coach, console, punish framework. You coach people when they make mistakes they could have avoided. You console people when something just happens and it wasn’t avoidable. But when someone willfully and maliciously does something wrong, then you punish him.

I think in healthcare we’ve sometimes not always got the balance from that. There’s always a hunt for a scapegoat and I think what that does is it disincentivizes people from saying, do you know what, I’ve got this wrong, I’ve made a mistake, I think I’ve caused harm. We have pockets of great practice around that. But I think the service as a whole at the minute, you do get feeling in places that people are treading around on tenterhooks hoping they can get through things without things going too wrong.

Bruce Daisley (27:08)
Right, that surgery I just watched there, a very accomplished surgeon doing it. But you know, the thing that really struck me, I’m looking at these 3D visualisers, extraordinary, I’m watching him sort of quarter eyes, the cuts as he goes, amazing. But if he made a mistake in that, all I was aware of is, my goodness, like the precision that’s required here, that there is, with a less accomplished surgeon or with anyone actually, someone could make a mistake. So in that instance,

That isn’t about punish.

Matthew Trainer (27:38)
No, that’s predominantly console. Consult. Consult, because when you are operating in those kinds of spaces within someone’s body with the equipment you’re using and that sort of magnification, you make a mistake, can, you know, well, there’s a mistake that could be addressed through training, and then you do something that you’ve done 100 times before and 101st time it goes wrong. Okay. You can’t eliminate that kind of error, you know? And I think-

Bruce Daisley (28:03)
instant the trust would have that surgeon’s back.

Matthew Trainer (28:07)
Yeah,

we absolutely should. And those guys would tell you, the guys and women that work here, they would tell you whether they felt as though we had their back for those kinds of things. hope they would say that we did. The thing is that they’re also regulated professionally. There’s always the risk of GMC referrals, which strike the fear of God in the doctors. You hear nurses talking about their PIN numbers and so on, when they feel as though they’ve been doing something that carries a degree of risk. And I think one of the critical differences between an airline, for example,

and a hospital it is, and I’ve had clinicians say this to my face, you talk about airline safety, but if you had a plane on the runway at Heathrow and you said, actually we’re missing half the staff and we’ve got twice as many passengers on, it wouldn’t take off, right, never take off. And yet we run emergency departments that will be about 50 % over capacity with staff off sick. And that creates a different safety culture and there is a different safety culture.

flying a plane, is predominantly mechanical, although it’s human factors that always cause plane crashes, isn’t it? As we know from reading this stuff. Here, there’s four more human factors and less mechanics around it. the reason I connect that to the other hygiene factors is these are all, I think, part of a continuum. If you come into a workplace and you get your shifts in advance and your pass is ready and you get paid properly and you can park your car and you’ve got a nice break room and then you go in to do something really difficult that you’ve been trying to do.

I think these are part of a continuum where people feel as though the organisation values them and feels as though it’s created the right environment for challenge. And I think a training doctor who’s had that positive experience of the organisation and they’ve joined us in a good way and heard that we value them and heard what our values are and what matters to us, I think that’s someone who in an environment might be more prepared to speak up about stuff. I think these are different elements of culture.

but I think they contribute and I think if you let down the side on some of the basic hygiene factors, you put a little bit more toxicity into the water around calling it the big things because I think there might be an inclination to say, do you know what, if I’m sitting in a dark room with broken chairs and the computer logon that doesn’t work, why should I expect them to care when I say in an operating theater that I’m concerned about the processes we’re following here?

Bruce Daisley (30:22)
Can I ask about the impact of pride on people’s own identity? Yeah. When you took over the trust, historically,

Matthew Trainer (30:30)
Like, no.

Bruce Daisley (30:32)
you told me I think the trust has had a bumpy time.

Matthew Trainer (30:35)
Yeah,

I first came to this trust in 2012 when I worked for the Care Quality Commission who inspect hospitals. And I came into the office, which is now my office, to talk to the Chief Exec at the time about warning notices that we were issuing. And those warning notices were about long waits in the emergency department and concerns about safety in the maternity department.

From that point onwards, I was kind of aware of BHRET. And the place has always had a reputation as being a tough place to work. And as we say, we advertise the chief operating officer job, the editor of the Health Services General, tweeted the same, probably the toughest job in the NHS, actually. An interest in the first two or

Bruce Daisley (31:13)
What did they say?

Matthew Trainer (31:15)
A couple of things, one, the context around here. We’ve got a population with some of the highest levels of deprivation in London.

We’ve got some of the lowest numbers of general practitioners in London. They work very hard, our GPs, but if you’re somewhere like Hackney, which has got a brilliant hospital, the Hallmerton, I think in Hackney there’s about 95, 96 over 65 per GP. In one of our local boroughs, it’s about 350 plus over 65 per GP. So lots of the demand falls into the acute hospital.

We’ve got lot of care homes around here as well, because it’s out of London, it’s cheaper, so get a lot more people in care homes being brought in through ambulances. So it’s in a tough environment. It’s historically probably not had the right level of investment as well, and out of London has tended sometimes to struggle for investment compared to the inner London, where you’ve got the bigger, you know, some brilliant teaching hospitals in London, but there’s always a sense that that’s created a bit of a pull towards inner London. If you’re a clinician living out here, you can jump on the train and go and work in a London teaching hospital if you want to.

There’s a kind of doughnut, because my other previous acute hospital role was in Bromley in South East London. And we had people who lived locally, and I’d see them head enough to get the train in to work at Guy’s and St Thomas’s and then Mark Hill and other places as well. So you’ve got to work hard to attract folk to work here, particularly when it’s a bars market for employees, which it is just now. And also we’re very busy. Queens can get north of 100 ambulances a day.

King George here gets very high numbers of patients with mental ill health coming in through the emergency department. know, they’re two really, really busy EEDs. So, creates a tough context and the measures you’re measured on. Money, it’s got deficit problems, had for years. A &E performance, really clear thing. And staff survey, we don’t do well on any of them. So, that’s the context you’re coming into. It’s basically, it’s a place that’s had a lot of interim chief execs as well over the years, just because it’s been…

sometimes difficult to get people into the permanent role for the right reason and all that creates a tough old gig.

Bruce Daisley (33:08)
What struck me though is that this a sense amongst a lot of the stuff I’ve met where they think like, okay, well we’re trying to do things differently. We’re trying to have an impact here. But the hundreds tonsillectomies in a weekend, I was really interested to hear like the genesis of that of someone who was, and I think he was a…

an employee who’d come from overseas and he’d gone to the London teaching hospitals, correct me if I’ve got anything this wrong, he’d to the London teaching hospitals and because they’re sort of establishment and they’re, you know, they’re sort of traditional, they weren’t necessarily open-minded to an outsider coming in with suggestions. Is that right? Tell me what really happened there.

Matthew Trainer (33:55)
So I don’t know the hard details of that one, so I’ll start separately. We have here one of the highest numbers of overseas doctors in London, I think probably in the UK actually. We’ve got a lot of people who’ve come from overseas to work here. I mean our Chief Medical Officer trained in India and came here and lots of people we’ve walked around with today are from overseas as well. And I think some of them have had different experiences of working in teaching hospitals. Some have had a great…

time there but some of them have also I think found it hard to become established because they have felt like they’ve got an outsider status and when you talk to quite a lot of our staff they’ll talk about feeling at home here in a way that they haven’t felt in other hospitals and I should say for all the tough performance challenges we’ve got here I love working here and the reason I love working here is the people that you work with.

The hospitals are not easy places to work. Queens in particular at times can be a really difficult environment to work in because it is so busy. But when you ask people why they stay, why they come back here after they’ve trained and gone anywhere else, they say it gets in your blood and it gets in your bloodstream. And some of that I think is, for some people it’s a kind of outsider sense and you know we’ve got for example more than 800 staff from the Philippines working here.

And when I talk to some of those people who’ve been here more than 25 years, they talk about the fact that if you come here from the Philippines, there’s a great community here. People will make you welcome, they’ll help you navigate life in England and in London. You know, there’s a really strong sense of belonging. We’ve got lots of stuff from India, you know, from other parts of the world, and that creates a sense of belonging. And along with all of our local staff, lots of whom live locally, work locally, they’ve had children here, their parents helped build the hospital, that kind of story. And that stuff ties people together.

And that’s really positive. The other thing though, and I talked to two consultants who joined us recently who’d come back here, having trained here, gone elsewhere, and then they heard good things about some of stuff we’re doing here, and they’d come back to work here, and they told us this in the last consultants induction. They said, if you really want to make a difference in clinical practice, you want to go where the need’s greatest. And one of the attractions of coming here is they felt as though actually if you really want to make a difference, you go where there’s more people with more problems than anywhere else actually.

I think we attract a certain type of person. It’s never going to be an easy gig. But if you don’t mind hard work, if you find teams where the team culture is something that you enjoy and where you really want to get stuck into making a difference, you can do it here.

Bruce Daisley (36:17)
What is the culture?

Matthew Trainer (36:18)
So that’s an interesting question, isn’t it? Because there’s no… And I don’t think there are single cultures within organizations like this. And I think there are very… I could take you around four or five different…

parts of this organization and you see very, very different cultures actually. So I think part of my job, and I’ve talked about trying to change the culture here, Chief Exec’s role, first set direction for the organization. Be really clear about the objectives that you want to achieve. Next thing then, and I spent a lot of time doing that, is build the right senior team around you. And they have to be really good at their job and part of my role is to give them really clear focus. And if you go on our intranet,

You’ll see me and each of the execs has got two objectives for the year. Mine is improve flow, make the place a better place to work. If you look at my chief nurse, it’s improve the patient experience outcomes and spend less money on high cost agency. Nurses, chief people officer, it’s complete our restructure and improve our recruitment and retention, but no more than two objectives each, because otherwise you can find 101 things to do in a hospital. So set direction, get a great team together and give them really clear objectives.

Then the next bit for me is to really focus on the expected behaviors. And I think culture and behaviors and all these things is a really interesting mix of stuff. I don’t think you can change people’s deep held values about what they think about the world and what matters to them, what’s important to them. I think some people have got prejudices that are quite difficult to deal with in the modern workplace.

I wrote a letter to all of our staff about sexism and how we deal with women in the organisation. We won’t tolerate sexist behaviour because I had a number of women approach me to talk about the way they’d been treated by male colleagues here. I think what you can do is set behaviours and set tones. So this is what we’re here to do. These are the things that matter. This is how we’re going to do it. And behaviours are something you can work against in a way that… If you say this is our culture and someone behaves slightly inappropriate, you can say, that’s not really in line with our culture. That’s quite a grey conversation to have.

If we say, this is how we expect our staff to behave and you haven’t behaved in that way, that’s a much easier way to try and create. What you’re trying to do is create a framework that encourages a certain culture rather than define, you you want to define a culture and we hear all this stuff these days and it gets mocked a bit these days. I when you talk about be kind and treat dignity and respect from everyone, but actually what are the behaviors that create that positive culture is really important, I think. So for me, set direction, get the right people.

establish the behaviors that will do that positive culture. And the last bit for me is to be able to lead with optimism. I think cynicism in leaders is the worst single trait. There’s a great psychiatrist, Dr. Derek Tracy, he used to work with me in an old trust and he sent me brilliant paper about cynicism once. And actually one of the ways to impress people you don’t know is to be cynical. Because people naturally flock to a cynic because they’re worried that the cynic knows something that they don’t know.

And so if you and I went into a room with 10 other folk and we didn’t know anything and we were talking about plan of action and we said, this will never gonna happen. What you don’t wanna do is challenge that and be exposed to be wrong in front of because we’re social creatures. You don’t wanna be exposed as wrong. So cynicism is a kind of cheap way to establish yourself as knowledgeable. But it’s also incredibly destructive because I found them cynical to my staff about what we can achieve. I give them permission to be cynical. So those things together for me.

the strong team, the behaviors, and a bit of optimism about what we can achieve and a reflection of the great stuff we do. I guess I’ve probably gone right in a journey with that, where if you’d asked me about this a few years ago, I’d have talked really strongly about defining the culture first. Now I think you do need to define the kind of culture you want to have, but you construct it through the behaviors that you expect of people around it.

Bruce Daisley (40:15)
And I’m interested to know how you think that you’re on track with that because you mentioned something to me which was almost like the toxicity of numbers is the way I took it to be like, you know, if you’ve got someone and all they’re focused on is getting waiting lists down or getting numbers, numbers, numbers,

Matthew Trainer (40:34)
numbers.

Bruce Daisley (40:35)
it probably has unintended consequences. You know, the old thing that I regularly quote is Goodwins, Goodheart’s Law.

which is that any measure that becomes a target ceases to be a good measure. There’s some truth in that, right? And I just wonder how you, the whole of the NHS is obsessed with numbers and waiting lists and waiting times and how do you pay respect to that, the external measure, and make sure that everyone feels that their work is respected, the quality of their work.

Matthew Trainer (41:09)
It’s interesting, there’s lots of different numbers in the NHS. One of is about money and that’s a huge driver at the minute of concern because we are running some really big deficits and that does influence your behaviour because it does guide how you’re able to make decisions about staff and resource and investing in new services and that’s part of the role of management is to try to work with clinicians to do that kind of stuff and that is a source sometimes of the us and them stuff.

where your management managers come into rooms and we’ve got to reduce the amount we spend on staff, and you’ve got clinical staff who working really hard in that context. That’s a point of tension, but more broadly, I think it’s a really strong challenge for the NHS to get better about using numbers in a way that reflect good quality clinical outcomes, rather than just the units of stuff we can count. So I could probably reel off for you quite a bit of chapter and verse on who’s on our waiting list, how many 52-week waiters we’ve got.

you know, how many of you had a really illness since the strike started this year? What I don’t have to hand is to talk to you about the quality outcomes that we get from certain types of procedures. And we used to these patient-reported outcome measures for knee and hip surgery, and I think that was stopped pre-pandemic and hasn’t started again. Some of the metrics we use, I think, are about have we done enough units of the thing rather than has the thing we’ve done.

produced a better outcome for the patient. And I think within specialties and services, you’ve got more of that nuance, but at trust level, sometimes that’s a bit hidden. And the other thing is, we’ve tried to introduce proxy measures for really quite messy and complicated systems. So, you know, the four-hour A &E target, it used to be 95%, now we’re trying to get 76%. You know, when I got here, we were the worst in the country, very much kneeled to the bottom for our majors A &E performance, and we’ve just moved out of the bottom 10 % in the last couple of months, and we’re trying to

claw way up that really, but still got lots of people waiting far too long in our emergency departments. But that four hour target is weirdly quite a good proxy for a lot of other things. Because if you do come in undifferent, chest pain or sore arms or whatever, fever, that four hours tells you broadly, have we been able to get the right resources to people who’ve come in sick and have been able to see, treat or discharge them within that time or transfer them into a ward.

And that’s quite good proxy for quality, I think, because a hospital that’s delivering well on the four-hour target usually has a relatively clear A &E. You can get people off ambulances, get them seen by the right specialties, either get them home or get them into the right beds. And that, think, has got a nice link with good quality patient experience and care without necessarily going down to that granular level. So I think at the NHS, we’re good on data. I think we’re not as good as we should be on analytics. And we’re sometimes so awash with information.

that I could probably pull out any kind of stats to prove an argument in some respects. you know, it’s interesting, know, so we’ve increased the number of people going to our Freedom to Speak Up Guardian. And when I was working at CEQC, I’d speak to trusts who said, we’ve got more people raising concerns and that’s a really good thing. Because it shows we’ve got more transparent culture. And I’d go somewhere else and say, we’ve got fewer people raising concerns, which is a really good thing because there’s less to be concerned about. You think, right, where do I go with that?

Bruce Daisley (44:14)
You can see the argument.

Matthew Trainer (44:16)
For

both, you can and they may both be true, but in different contexts, they tell you an entirely different story. And that’s part of the management job, is trying to cut through that stuff, isn’t it?

Bruce Daisley (44:25)
It’s

really striking how focused and motivated and professional everyone is. It’s really impressive for that. But you said one of your jobs is to make it a better place to work.

Matthew Trainer (44:35)
you

Bruce Daisley (44:36)
And obviously you’ve got some long-term strategic things about that. But are there any short-term things that you’ve thought, actually it’s just had an impact on morale to do this.

Matthew Trainer (44:47)
Yeah, we had a great staff thank you event in the summer and we got more than five and a half thousand of our staff over three or four days came to edit. I’ve worked in places before where we’ve had award ceremonies and I didn’t feel like the minute, especially with some of our performance being nowhere near you’d want it to be. I didn’t think a sort of black tie, team of the year kind of thing was right, although we may go back to that at some point, but what we did and our chief nurse, Catherine, and our team did a brilliant job putting this on.

We had a staff lunch, we had an evening do, I play keyboards in the band and we knocked out some songs and got people up on stage singing with us. On the Saturday we had a family fun day where people could bring their families along. That was really important because for some of our staff all the rides were free, the ice cream, it only cost us 12 quid a head across the whole thing because we had so many people at it and we got some really good deals from suppliers and so on. But talking to some of those parents they said this is…

this is the big thing we’re taking our kids to this summer because if you take two or three kids along with fear these days, you can spend 70, 80 quid on ice creams and rides and things like that. And the fact we were able to do something for some of our staff that they wouldn’t otherwise have been able to do just to say thank you, the buzz over those days was lovely. know, people were really happy, really positive about it. And that was a less tangible but great thing, I think, for organizational culture, which we’ll have to remind people of at the staff survey time because there’s lots of other things.

Bruce Daisley (46:07)
Patience thanking people is one thing.

Is there any way to sort of, I’d have thought patience thanking people is…

Matthew Trainer (46:13)
Yeah,

we get some lovely stuff from patients. I because I get the complaints and I get some terrible emails about people who’ve had awful experiences with us that just aren’t acceptable, you know, and I spend quite a lot of time saying sorry for those things and speaking to people about some really quite distressing things. And it does happen in healthcare where we get things wrong. I also get some lovely emails from people, you know, beautiful one I got a couple of months ago from someone whose mother had died in the hospital and just wanted to say what…

wonderful experience it had been in terms of how the palliative care team had dealt with the family, how their mum had been really frightened about coming in and she was frightened about the pain she’d experienced and so on, but the staff had been so thoughtful and attentive and it was a really beautiful reflection and a really sad moment at the end of this woman’s very long life and how well it had been handled. I think a lot of the thanks goes direct to the staff. I they get chocolates, they get flowers, they get thank you cards.

I think the vast majority of folk who go through the NHS, and think it’s something like 1.6 million people a day, I think most of them on the whole are probably pretty happy with what they get. But we do need to address the stuff that doesn’t go well. I think though really for me, going back to your point about the stuff that is work, and I think some of it is about seeing more staff with the kind of pride you’ve experienced today. I’d like the kind of pride that you’ve heard from some of the surgical teams today.

I’d like more people working in the really hard areas of medicine and emergency medicine to feel that about what they’re doing, because I don’t think they do at the minute. I’d like more of our junior doctors and our training doctors to feel as though they’re having a really good experience here and that they’re learning the right things when they come here and that they want to commit to the NHS. I’d like some of our non-white staff to feel that there’s more fairness and progression within the organisation. We had a moment yesterday, we had an exec team yesterday and I’ve…

made a lot of changes to the team and to our structures. We’ve got four more clinicians now working in leadership roles. Even a year ago, our exec team was largely the sort of senior execs talking to each other and everyone else, they were silent. Or they contribute things, one or two of them who were pretty confident about raising concerns. Yesterday, I’d say probably three quarters of the conversation was led by the clinicians and the ops people in the teams.

and that felt like a sea change. A few people commented yesterday, we’ve been building up to that. Part of it, I think, was getting people face to face. I know you’re really interested in hybrid. I think some of this has been about us being quite specific now that certain sessions should happen in the same room. You’re with people, you read their body language, you make the informal context around that, and we’re trying to get back to learning how to get that, but that felt to me like something that gives me optimism about the next 18 months to two years.

Bruce Daisley (48:52)
One of the things that I guess is the other side of that is that I chatted to one of your colleagues and they said, look, when you’ve got this number of practitioners in a high stress environment,

Matthew Trainer (49:02)
Yeah.

Bruce Daisley (49:03)
the one thing that you have to be aware of is that by the order of probability, there might be people who stuff were in a bad place and the very nature of that should extrapolate in the circumstances that stuff are contemplating.

sort of actions against themselves, you know, and I was really interested in the thoughtful way that your colleague was talking about that was like, okay, if you even mention suicide, everyone will come up, no one wants to attend suicide awareness. so his suggestion was, okay, all you need to do in that case is in a high stress environment to say to people,

What’s your next step? What’s your plan? Who do you phone when things get too much? I wonder if you could just talk through how you think about doing that and how that sort of thinking came about.

Matthew Trainer (49:59)
Yeah, it does worry me and I think last winter, particularly January, February, etc. I was really concerned about the state of mind of some of our staff who were coming into particularly really distressing emergency department environments day in, day out. So what you’ve got in surgery is people doing really technical, complicated, sometimes 12, 14 hour procedures, huge degree of concentration with very small margins for error.

Elsewhere you’ve got people working in really intense, crowded environments with angry, distressed patients. know, the amount of abuse and violence and aggression our staff are experiencing has gone through the roof. You know, we were talking this week about tests, was introducing body cameras for staff and saying, do we need to do the same in some of our areas now? Because we’re getting so much grief for that. And you do worry because people take it home with them. And last January I was having a couple, you know, I went through a couple of weeks where I felt unable to switch off.

and you’re getting up and checking your phone at three and four in the morning to see how many people are in the ED and that kind of thing and you feel that worry and you worry about the staff and the key thing for me is for people to not feel as though they shouldn’t talk about it but not to compel people to talk about it if they don’t want to. There’s a wonderful psychiatrist, Dr Alice Cole King who’s a leading expert in addressing risk of suicide in organisations and some of the work her and her team do is not about talking about suicide risks, it’s talking about safety plans.

And exactly as you said, what she looks at is not going into a room and saying, right, let’s have a conversation about whether you’re feeling suicidal. What she goes in and says, what are you like? What are the behaviors that you start to notice in yourself when you’re not well and not coping well with the structures, the stress and strains at work? And then what might you do in that circumstance to make things better? Who might you talk to? And just that fact of having a plan is sometimes what people need.

There’s some really good work, another, I’m sort of dropping names in this, there’s a guy called Neil Greenberg as well who’s a psychiatrist who’s done lot of work with the military and they looked a lot at debriefs and all this kind of thing and there’s actually some really interesting evidence around this that single debriefs after really distressing events are sometimes not that good. You know, sometimes need quite a structured approach or nothing at all to really help people get through it and actually most people will deal with traumatic circumstances through their own strength. For lots of people actually, all they want is bit of time and space.

They just want a quiet room to go and sit in. They don’t want someone to come in and talk to them. For others, they will need that structured approach. So I think it’s about a menu of options. We do a lot of work with our local mental health trust, Northeast London Foundation Trust. We’ve got a great occupational health team with a really good psychology offer. But it does worry me. I was diagnosed with a type of bipolar disorder about 15 years ago. And cyclothymia, which is I think type two bipolar or something, often described as mild, though it doesn’t feel it.

at times. so I had two long periods of cognitive behavioral therapy and that was all about dealing with catastrophization and thoughts. And I’ve given up drinking and I run a lot. I do a lot of stuff to try to look after my own mental health. And sometimes you just, you think about your staff and you think about what more can you do to create an environment where they can talk about this stuff. Yeah, it’s hard, but it’s great to help people talking about that stuff with a bit more awareness. There’s still a lot of stigma around it, isn’t there?

Bruce Daisley (53:19)
Yeah, absolutely.

Matthew Trainer (53:20)
especially in some of more natural environments and sometimes healthcare can be a little bit, know, one person once described management in the NHS as they go in in the morning looking for a fire and if they can’t find one they’ll start running the bin. So they’ve got something to deal with and I think that’s the problem sometimes is we get very focused on crisis management and we don’t spend enough time thinking about the longer term changes we can make to make these more satisfying jobs. You know, what a great…

sense of purpose, you know, are you coming into work to do today? You’re coming in to do a job where if you get it right, someone’s life will be better and they might be in distress, they might be in pain, they might be in fear and it might be about putting that right, it might be about a woman who’s going to have a baby and all the incredible things that happen around that time, it might be someone who’s at the end of their life.

and where actually a good end to their life can be such a profound thing for a family. There’s all these amazing things our staff do day in, day out. And actually the NHS, whether you’re someone like me who’s in a support role to help these clinicians do these things or whether you’re one of the clinicians doing these things, it should be the best place in the world to work. And sometimes it is, but quite often it isn’t. And often the reasons it isn’t aren’t to do with the clinical care, they’re to do with culture, they’re to do with resources. And actually that is the challenge for

Mike in the job.

Bruce Daisley (54:47)
Thank you to Matthew. In the show notes I’ve included a link to Matthew’s latest CEO report which highlighted the Trust ended 2023 as the most improved emergency care department in England. Now, as with everywhere in the NHS, the performance has still got some way to go and the results certainly aren’t as strong as the whole hospital Trust would want. Effectively, the whole organisation and the whole institution is woefully underfunded by the Conservative government.

But I’m massively inspired by what this group of people are set out to try to do. They’re filled with optimism to believe that they can make things better for patients by thinking about things in different way. It’s inspired me to think about things and I’d love to hear from you actually. So if you’ve made it this far, I’d love to give you the opportunity to get in touch. I want to think about other organizations and how they’re tackling questions like this.

One of questions I get asked all the time if I’m speaking somewhere is people say, what company cultures do you admire? What have you been impressed with? And what I want to do is give a platform to great company cultures. In the show notes is a form. If you think your company culture is special and you can articulate why and the actions you take, I want to see if this scope to highlight your firm. I’m expecting a lot of incoming PR on this. So I do want to hold a high bar of proof.

But if you’re interested, go and check out the form and think about whether you could make an interesting example of this too. Thank you to everyone I met from the volunteers to the surgeons to the consultants to the nurses at BHRUT. I was really inspired by the whole organization and it was great to give a platform to what you’re trying to do there. I’ve been Bruce Daisley. If you like this, do check out previous episodes. I’ll see you next time.