Matthew Trainer: Leadership in testing times

Matthew Taylor

Hello and welcome to Health on the Line. From here on, this podcast is going to try to combine some slightly more topical content with our regular leader or expert interviews. So with that in mind, what better to focus on this week than the fact that we've just had a set of local elections. Voters went to the polls last week in England and Wales and a set of local and also mayoral elections, including ten metro mayors for England.

I'm delighted to be joined for this brief conversation by Michael Wood, who is the NHS Confederation’s head of health economic partnerships. Michael, in a second I'm going to ask you about metro mayors and devolution, but before we do that, why don't you ask me what the implications of the local elections might be for NHS leaders? 

Michael Wood

That's a very good question, Matthew. What do you think, Matthew, with all your experience and wisdom, the big implications of last week's elections will be for the NHS? 

Matthew Taylor

What a great question, Michael. So I think, first of all, it makes it a little bit more likely, doesn't it, that there will be a Labour government elected at the next election? Perhaps not that much more likely, but maybe a little bit more likely. For the NHS? Well, you know, it's not easy, is it, when there's an election looming, the kind of short-termism that we're always subject to in the NHS, which results from the kind of highly political and centralised nature of the NHS, will continue, it'll be even more intense when there's an election in mind. 

I've thought for some time that maybe the Conservative government would go to the absolute final moment, which of course is January of next year. But as somebody said to me, the problem about waiting to January is you could be fighting election against the backdrop of a difficult NHS winter. And given the financial situation that many trusts and systems find themselves in, it's a big risk. It's a big risk to wait to go through winter. 

So, I think there probably will be an election in October or November, but I also think if the Conservatives were to decide to wait until January in the hope that something turns up, it's quite likely they'd have to find some more money for the NHS to avoid the danger of that election being overshadowed by a winter crisis. So those are my thoughts on the kind of general political consequences of the local election. 

Now, Michael, for those people who are not familiar with metro mayors, can you just say a bit about what they are and what they do? 

Michael Wood

Yes, Matthew, thank you. And unlike the general election, we knew when the metro mayor elections this year were, there were last week, last Thursday. 

Metro mayors now cover a vast majority of England, actually increasingly cover a majority of England. They are directly elected by populations up to about two million people and they have huge convening power, they reach across a huge range of different individual subjects of which they have control, they work with a range of combined authorities, bringing together local authorities. 

They are what we are seeing as place leaders and I think what's really interesting Matthew, I think the elections last week for me reflected a country becoming more accustomed to devolution. This is still new to us. I mean, the first mayoral combined authority in Greater Manchester deal was only a decade ago and the first mayoral election in Greater Manchester was 2017. 

So in seven years, we are seeing the emergence of a new form of place leader. And I think we saw that in terms of how almost chief delivery officers, I would say Matthew is what a metro mayor is. They're talking about place, what they're doing for place and that matters more than their colour of their rosette. 

Matthew Taylor

You know it's a really interesting point Michael because although something we used to say, we used to bemoan really which was that local elections didn't really reflect the performance of councils but just reflected the kind of national mood. What we're seeing with these mayors is that they do make a difference. They do lead to people sometimes voting differently on local issues and on national issues which I guess is a good thing. 

Now tell me, Michael, what are the direct implications of metro mayors? How do they matter to the NHS? 

Michael Wood

I think I would say two things Matthew, I would say that health in all policies and health policy. Now, devolution in England as we know it has been heavily linked with an understanding of the regional inequalities our economy faces. So many of the early powers of our combined authorities on metro mayors were focused on what would stimulate local economic development. 

So that could be skills related, that could be business support, that could be investment hubs, transport, housing, planning, etc. Now of course health is implicit in all of those and health has suddenly become a much more spoken about understanding of the economy. And what's interesting therefore is not only the role that those determinants of health and the powers metro mayors and combined authorities have over them, how important they are for an integrated care system, some of the more recent devolution deals actually have a health duty, a public health duty in them. 

So you can see a direct read across. ICSs will be a key part of the success of a local devolution deal but devolution will be a key part of the success of the role of an ICS. There's a real mutuality here, Matthew. And I think for me, we're now looking at parallel train tracks and where the intersections in those train tracks are, and they are coming fast ahead of us, and we need to understand the opportunities that exist to us. 

Matthew Taylor

Yes, absolutely. And kind of weaving bits of this conversation together, if the bookies are right and Labour does win the next election, there's quite a lot of conversation about how an incoming Labour government might pick up some of the threads that were left by the last Labour government in terms of ideas of devolution, like total place budgets, local area agreements. 

These are ways of trying to devolve more power to local government. Of course, that conversation takes place in a very different context. The first is the one that you've described, which is the existence now of mayors of higher legitimacy, higher profile. But the second is the existence of integrated care systems and particularly integrated care partnerships, which are also bodies that are supposed to look very broadly at health. So it is a fast changing and very interesting landscape. 

Now, Michael, this, podcast is going out, I think the day before the publication of a report that you've co-written on all of this. So just give us a little plug for your new publication on health and devolution. 

Michael Wood

Yes, Matthew, absolutely. So a report coming out which will describe why health and devolution are, the reforms we've seen, face the same way. Why health is intrinsically vital for what devolution is trying to achieve, why devolution is absolutely a part of the vision and success of an ICS, how we can work together. 

That's the key. I've had lots of ICS leaders come to me and say, I vaguely know about the combined authorities. I vaguely know what my mayor can do. How can we really work together? And I think, Matthew, it's a bit about the what is devolution, the why it matters, and how can we get together in the driving seat and really help make a difference for our shared populations. 

I want people to read the report, I want them to look at it and use it locally and try and understand how they can work best together. And what I'm really interested in is the future of this issue because this is an iterative issue, Matthew. You know, there's been a succession of devolution deals within areas, not just in new areas. Devolution is an iterative process of greater local autonomy.

And that's given us all excitement, I think, for what we can achieve together. 

Matthew Taylor

Great. Well, everyone look out for that report, which will be on the NHS Confed website. And Michael, one other thing before you go, you lead on health and economy for us at the Confed. We're very proud of that work. It's expanding all the time. We're talking on Tuesday, May the 7th. There's another big announcement today in relation to health and economy, and that's around the Work Well programme. Tell us more about that.

Michael Wood

Yes Matthew, I can say the government will announce 15 different ICSs to receive between £3 and £4 million to embed a local vanguard programme of working well, of aligning work and health. Work and health is one of the key areas in which we're seeing how important the value of health is to the economy and vice versa. It's now on the Prime Minister and the Chancellor's agenda, it's high up their list of things to tackle. We've got 2.8 million people out of labour market due to ill health.

This is something ICS leaders know they have a stake in addressing and along with local partners I think we can see some real focus and traction on trying to support people to be healthy and to be in work and Matthew you wrote the report on good work we just know the duality of this issue and how important it is. 

Matthew Taylor

That was the Confed’s Michael Wood talking to us about the relationship between local government and health. As I say - as we both I guess - think this is going to be a very important and exciting space for policy and action going forward. 

But now on Health on the Line, we turn to our main interview, which is a fascinating conversation I had just recently with Matthew Trainer, who's chief executive of Barking, Havering and Redbridge University Hospitals NHS Foundation Trust. 

Today we're exploring the topic of leadership in testing times. And ever since we had a chat, I think a few months ago, I've been really keen to have a conversation with you about this, but also to kind of do it face to face. And I've been here at Queen's Hospital in Romford this afternoon, just been to visit your emergency department, something we'll perhaps talk about. So great to see the ED, to understand the journey the department and trust have been on for a few years, but also actually to understand the kind of challenges that you face. 

So this trust, Barking, Hayring and Redbridge University Hospitals Trust, you made the most improvement on waiting lists for emergency care in 2023. The single most improved A&E in the country. Now things like that don't just happen. And having been just here in the emergency department, I've also seen that you've done this in really quite challenging circumstances in a building that was created without apparently any kind of awareness of what it had to do. So you've not even had to do this in really difficult circumstances. So I want to find out a lot more about how you've done that. 

But just before we get into that conversation, Matthew, tell us a little bit more about your trust, your local population. What's it like working in a place like this? 

Matthew Trainer

Okay, thanks, Matthew. So this trust is, I think it's a great place to work, actually. It's a really exciting place to work. And if you come into the NHS because you want to make a difference to the lives of people that need help and support from the health service, then it's one of the places where you can make the biggest impact because we have a population that really does need our help. 

We've got three boroughs here. We've got Barking and Dagenham, which is notable in London for having no one registered in the top two quintiles for wealth and for income. Barking and Dagenham has got the highest number of children as a proportion of the overall residents in London and huge influx of new residents as well. 

We've then got Havering. a large, traditionally more wealthy borough which has got a very low proportion of working age adults. A lot of people from inner London retire out here, so we've got a lot of care homes, a lot of older folk, and then we've got Redbridge where there's been a huge amount of population change over the course of the last couple of decades, huge amounts of immigration and population movement. So we've got a population that's changed dramatically, we've got high levels of poverty, and we've got the impact of that on people's health.

The public health of people around here isn't great, the rates of diabetes. Redbridge has got some of the highest levels of amputation related to diabetes in the country. Very high levels of childhood obesity come through the tracks. So it's a population that needs healthcare and it's also a population that's got low levels of access to primary care. And although the primary care around here are seeing more people than they did pre-pandemic, you know, they've hugely increased their appointment slots and we've still got people turning up in droves at the hospitals for healthcare because that's where they go.

There's not enough resilience in the community or in mental health services or in primary care to meet demand so lots of people turn up here in the front door. And we know ‘ where we are today is a real outlier actually in Northeast London for treating people in hospital for conditions that elsewhere you wouldn't find treated in a secondary care environment. 

So - busy, challenging, diverse, exciting.You have to have a high tolerance for hard work to come here but you also, if you're motivated by the right stuff, it's a great place to be. 

Matthew Taylor

So Matthew, you arrived here what, two or three years ago? 

Matthew Trainer

Two and a half years ago, yeah. 

Matthew Taylor

You arrived at an institution that had quite a lot of churn in terms of its leadership and had big challenges. When you walk into the organisation, what are the instincts that you bring to a challenge like this? You're coming in, you're already a successful chief executive but you're coming to an organisation that's got quite a lot of challenges where maybe there's quite a lot of scepticism because of that leadership turnover. 

As you walk through the door on the first day what are the assumptions that you bring about how is it going to achieve change? 

Matthew Trainer

Yeah so there's a couple of things about it. One is to try not to make too many assumptions about what you'll find and I think this is an organisation where actually there's some fantastic people working here and they've had to be very good at what they do because they've had a relatively low resource base to work in in some really tough circumstances. So there's quite a lot of innovation and quite a lot of good practice here.

You used the example of the emergency department down there dreadfully badly designed probably I think one of the worst A&E layouts you'd find anywhere…

Matthew Taylor

Great for hide-and-seek 

Matthew Trainer

Great for hide-and-seek.

So we've had teams that have figured out how to make suboptimal things work for them. So there's a kind of attitude here getting things done and getting things fixed and looking after the sickest folks. 

So when I came in, and I know there's all you always see this kind of first 100 days kind of thing, I've never really gone for that because I think one of the important things to do in an organisation is to spend a bit of time listening, absorbing what people tell you about the place and trying to figure out what the dynamic is in terms of the relationship between the leadership of the organisation and the people that deliver the services. 

Because of the very high degree of leadership churn, a number of interim chief execs, lots of interims in the executive team, there was a disconnect between the executive and the leaderships of the divisions. And what happened was the divisions had understandably because of that turn decided let's look after our own people but they'd become quite self-contained units and there was quite a lot of silo working.

And so there's some great people but they were working in kind of quite closed cultures. So I did quite a lot of work with the exec team and a few people who had just spent a long time here but they were worn out, they were exhausted. It was good to bring in some fresh blood and some fresh oversight there.

Then went through the structures of the organisation where there was a real lack of accountability or clarity about who was doing what, you know, who's responsible for flowing A &E today. The answer as well is about six or seven different people you could talk about. So slippery accountability. There was a lot of people who had been promoted within the organisation because there was a lack of an external field for roles and so people had said, look, I'll have a go. But we ended up with a lot of accidental managers who'd gone into the job because they were there and they were willing to try it, but they hadn't been supported or trained or developed in that way.

So there's quite a lot of people in jobs who really weren't competent to do the scale of the management challenge they had. And then reputationally, the place was solidly the worst performer in the country for type one A&E. And for London terms, had always been a sort of byword for being at the bottom of the A&E pile. And that creates a kind of self-perception. And it means that you don't attract investment. It means you don't attract good people for jobs. And quite a few of the team had a similar reaction to me when they say, where are you going to work in a BHRT? “ Ooh, you know. you sure about that? Have you thought about that? Have you thought about what that's going to do to you?” 

So part of it was come in, figure out what's going on, get the right team in place, get the right structures in place, and get in some really good delivery-focused people. And we've kind of managed to build a reputation for trying things and getting better at things. And once you start to make some inroads on success, you start to attract good people, better people, and you start to attract investment. 

Now, when I came here, we had some fantastic stuff going on in surgery and in planned care. And actually it felt like two very different organisations. 

Surgery and planned care - their experience of the pandemic was we'd had to redeploy, we'd had to change all the time. That had turned for them into a kind of engine for innovation. And they'd really started to run with this concept of rapid change and innovation, constant continuous improvement. 

Medicine felt very different, felt really beaten up, battered by the experience of the pandemic. Lots of tactical decisions in the pandemic about the organisation had created some really quite poor configurations within services, some gross inefficiencies in terms of the way that certain pathways worked as well. So it was kind of trying to build on the positive progress in some areas to attract other people.

My QNO Fiona, she came in to help us with elective recovery. Brilliant at that job. She's now expanded her remit into urgent emergency care. We got a new chief medical officer working alongside a really experienced chief nurse. We brought through some new talent from outside into some of the divisional leadership along with some really good people who'd been here a long time but never really wanted to step into leadership roles.You kind of just bit by bit build a kind of feeling of a different kind of organisation. 

Matthew Taylor

But it sounds like you started with the credibility of the chief executive role to a certain extent. You needed people to feel that you were going to be around… because accountability has to start at the top. 

Matthew Trainer

Yeah. So I was asked a lot when I got here: “How long are you going to stay?” And that was really interesting. And you go into a ward and say, hello, I'm the new chief exec. And people would say, “Well, how long are you going to be with us for?”

And when you find that the majority of staff have that kind of attitude towards the chief executive, I think, why are they going to listen to what you say about improvement or culture change? So some of it was being here. 

I was interviewed by the Health Services Journal relatively early on. And one of the things I said there was that if we didn't get our A &E performance to improve by August last year, that I'd look at my own position. The sort of implication was I'll leave if I don't get things sorted out. And interestingly, quite a few people said when they read that, I mean, I got lots of texts from my NHS colleagues taking the micky out of me for it as well. 

But quite a few of the people who work here said they realised I was serious about the place when they read that and they realised I was committed to the place. And I think actually what's now happened is that people recognise that they've got a leadership team who care about the organisation. 

Matthew Taylor

So I'm really interested to break this down with you. So you start with establishing kind of basic credibility in your role as chief executive. You then move to establish a culture of accountability which has a kind of entwined with that is a change of personnel because there are people who understandably don't want to be held to account in that way because they're exhausted, they're tired, it's just time for them to move on. 

You're then concerned with the gap between the executive and everybody else. So that's the next thing you've got to focus on. 

So it's almost like you're working down, starting with yourself, then moving to the executive, and then moving to the gap between the executive and everyone else. 

So tell us how you've gone about that.

Matthew Trainer

So in this organisation, we've got about 8,000 staff. Seventy-seven per cent of them are at band seven or below. And so if you don't work in the hospital, band seven's a sort of ward manager, you know, sort of manager of a service or of a clinical unit or whatever. So the vast majority of people's experience of culture in the organisation and leadership comes through someone who's possibly three or four reporting lines below where the executive team are. 

So in order to have the influence on an executive team, I can say something. I can say from tomorrow, we will do this. And I suspect in a hospital like this, about a quarter of people will do it from tomorrow. Probably about 50 per cent of them will think about doing it at some point fairly soon, and the quarter won't even be aware if you've ever said it, or if they have, they won't bother listening to me. So the only way you can do it is by building strength into the organisation. So that was get the executive in the right shape, which we did.

Then get the next structures down in the right shape, then really start to push down into the organisation. Talking to our unions here, lots of the problems they talk about here is the quality of local management. And we're now ruling out a manager's licence for all managers that includes the basics of how do you handle a difficult conversation between two members of your team? How do you support flexible working? How do you deal with conflict in the team? How do you do a good personal appraisal and development plan? 

And actually, because of… the organisation was interesting, lots of people had been promoted just because they'd been here quite a long time, but the organisation hadn't then said, you've gone from being a member of staff in this service to running the service, this is what you need to do differently. 

And so we're trying to build the principles of good management into the organisation. The place is grossly under-managed, it's not got enough managers. 

We've added a lot of staff over the last few years, as has the whole NHS. But what we've often done is we've put in a lot more clinical staff who are working with patients who are stuck in pathways rather than looking at people with the management skills and the operational skills to move people through those blocks. 

And the majority of our managers, when we talk about our clinical managers, but they've not necessarily had the management skill sets or the operational management support to get things right. 

The really effective surgical teams here have really valued the support of their admin staff, their business staff, of the multidisciplinary team and making sure that the whole patient pathway works smoothly. You know, so you get your appointment on time. You know, if someone doesn't attend, we've got someone on a standby list so you can pull them in. 

Someone from the bookings team calls the patient the day before. “You coming in tomorrow?”, you know, “Mr. so-and-so is ready to operate on you”. You have that flow through the whole service that gets people in. In large parts of medicine, emergency medicine and acute medicine, we didn't have that kind of attention to management detail and we've still got a long way to go on that.

Matthew Taylor

But you've done some quite innovative things in terms of closing that and we're sitting here in the boardroom for example, you've done some quite innovative things to close that gap between the executive and everybody else. Tell us about that. 

Matthew Trainer

So we've got shadow exec team and we're about to start our third cohort of that. This is 12 members of staff from across the organisation. It's open to anyone to apply and they get the full access to the executive papers at the same time as the main executive team. They meet as a group, discuss them. They then meet me the day before the executive and feed in their thoughts and input onto it. 

And I tell you, you get a very different perspective on an exec paper from a group of predominantly clinical younger staff at lower grades than you do from asking a group of people in their 50s who are on good healthy salaries and have been in the NHS for a couple of decades. 

And you get some really different insights and thoughts into how the organisation works through that. What's also interesting is the people who have been in the shadow exec, and this happened in my previous trust - Oxley's - where we did it as well, have started to look on leadership and management jobs differently. You know, so the clinicians have said, I never wanted to be a manager before, but now actually I think I do because I've seen that you can change stuff.

And we often hear, we didn't expect the stuff you talk about to be so relevant to us. We've now started from a couple of months ago, and we now open up our trust exec committee to everyone in the organisation to watch. So we run it as a Teams broadcast. So people can't take part, otherwise I'd just be dealing with 100 hands going up all the time and, you know, switch your microphone off, please. But what it means now is anyone who works for the organisation can now watch the exec committee, and they can hear what we're talking about, they can see how we make decisions, and so on.

And that's a kind of massive trust exercise basically to say we're going to open up the way the organisation works and let you see what's here. And there's nothing secret particularly about that. And what people love is we're worried about nursing ratios in the emergency department. We're worried about the number of midwives we’ve got compared to mothers. We're worried about our cancer 62-day treatment times. They see us talking about this stuff, balancing it off with the money, balancing it off with the quality. 

And some people only do that once. They'll never want to watch it again. But it lets them see what's under the bonnet of the organisation and it builds trust and so much of this is about trust. It runs right through everything we're doing here. 

Matthew Taylor

Well yeah, and I really noticed that Matthew when we were just in ED and I want to hear more about that transformation that you've achieved. 

But one of the points you were making to me is that there's quite a lot of scope for you and indeed it's true in many, many hospitals for a bit of gaming around targets, like the 76 per cent target. One of the things that you said to me that I thought was really interesting was, how important it was for to be seen not to be gaming the system in terms of your credibility, even if people might have understood why you lived on it, because if you game it successfully, you get more money, but it was really important for you not to do that. 

Now, I do see at all levels of the health service a certain amount of, we know this is stupid, but you just have to go out to play the game, and I think we underestimate how corrosive that is. 

Matthew Trainer

I agree. And I'd be naive to sit here and say, we're purists and everything, because the service does involve that. It's a political environment. And I thought the Messenger review was really good on this. We work in a political environment, and the priorities of the organisation as a service as a whole are politically set, and they're political in that context.

But there is something about the credibility. If I'd come here as an interim chief exec and I'd been told you've got six months to sort out the A&E performance, the majors A area here, it's about 28 cubicles, it's almost entirely full of admitted patients all the time, it has been since I got here. If we'd reclassified that as an acute pre-assessment ward, our number of 12-hour breaches would have dropped like a stone and our performance would have improved and all the staff would have seen exactly the same number of sick elderly people waiting as long. We'd have heard me say, our performance has got better by 10 per cent and they'd have thought, he's a fraud and they wouldn't have trusted me off the back of it. 

When I spoke to HSJ about the performance improvement, I was quite clear about the time scale. 

So one of the things when I came here was, because I used to do a lot of bed management in a previous role working for the Princess Royal Hospital in Bromley, it was a great place to work, some smashing people there, but a similar set of problems in some respect. When I got here, you could kind of see all the things you needed to do and in what order to get things into a better place. So when I said the performance will get better, I wasn't going to cross my fingers.

I could see the five or six steps we needed to take to get the performance better. Some of it was external. The urgent treatment centres performance was very poor. They were underfunded, so I was very loud about the fact that they needed extra support and investment. The ICB put more money in, they've got better doctors, they've got better workforce fill. They see and treat people more quickly. 

We've still got a big problem with mental health. We've raised awareness of that. We've had more investment to try to support with that. 

But then we also worked through a number of the internal pathways to really tighten up some of the breaches we were getting in children's majors, in type two, which we've got quite a lot for a hospital, which is eyes and urgent gynae, and then also to introduce an SDEC pathway. So rather than admitting people to an acute bed after a long stay and then discharging them after 40 hours, we could see them through a genuine same-day emergency care pathway. 

So the performance improvement 76 per cent has been done through an aggregation of two or three or four per cent improvements in a number of different places. The problem we've got to, though, is that 76 per cent still means 24 per cent of the patients who come through here can wait longer than four hours and in quite a lot of cases longer than 12 hours and we can still deliver. 

And so I know that in Queen's if you are an elderly person waiting for a frailty bed you will certainly wait 12 to 18 hours in our emergency department as a matter of course. If you're an adult working for admission to a general medical bed, similar sort of waits. Within 76 per cent there's enough tolerance for specific groups of our sickest patients to still wait a very long time for admission. 

So, you know, of the thousand or so people a day we get through our front door, 76 per cent still allows you well north of 200 folk a day to have quite a long wait in the emergency department. I come in on a Monday morning, every weekend without fail, I will have a couple of emails from people who've had a really pretty awful wait in the emergency department over the last few days. 

And I think that's the difference between 76 or 77 and 95. To do 95 per cent, the whole hospital had to be working well. You had to have capacity in your bed base to pull people out of acute medicine. Acute medicine had to be able to pull people through the emergency department, leaving ED to deal with the genuine emergency medicine patients. Ninety-five per cent showed that whole thing working well. And for that to work well, you had to have primary care and community capacity and social care capacity at the back of the hospital working properly. 

I think 76 per cent recognises the compromises we've had to make because of the overall state of the health and care system as well. So I think 76 per cent is, I understand the political context for it, but I think predominantly it's a political access target rather than a patient-focused one. 

Matthew Taylor

So I want to turn to some of the implications of that in a minute which is about how you work with other parts of the system and place. 

How concerned are you that the conversation we're having about the health service and the kind of process that took place behind the planning guidance? You know, the leaders that I speak to describe to me growing demand, very stretching performance targets, unprecedented productivity expectations and very often a structural deficit on top of all of that and we're not really talking about it openly? 

Matthew Trainer

So the planning guidance I think reflects some of that but not all of it and I think it's more implicit in parts of the planning guidance than explicit. Productivity is talked about a huge amount and we've certainly got a productivity problem.

You know, we have added thousands of staff to this organisation over the last couple of years and actually the experience of a lot of patients is that some of the pathways are worse, they're waiting longer for care. 

As I said, that's because sometimes we've had to put people in to look after people who are stuck in the wrong bit of the pathway. You've seen patients today in corridors on beds. We've got plus one, plus two, plus three patients on wards. We've got a virtual ward for 30 that's got 50 plus patients. 

Matthew Taylor

This is exactly what I hear from other colleagues, other leaders, which is, very often the number of staff has grown as a kind of coping mechanism because you've had to fill things in. You've not had the staff you've needed or you've not got the buildings you need or whatever it is. So you have to kind of make do. 

Now it's much easier to add people than to take people away. And so often it's a bit like the old joke, which is, well, how do I get to my productivity target? Well, I wouldn't start from here. You're not starting from a greenfield site, are you? You're starting from a set of adaptations. 

Matthew Trainer

Yeah. So we've kind of maladapted to a pretty poor set of circumstances in trying to manage the pressures around the front door. I mean, if I, my sort of physical bed base, you know, the declared number of general and acute beds I've got now is the same I had 12 months ago. Well, that doesn't include, is there probably 30 or so extra patients on the wards. 

At the minute, 18 to 20 patients in the corridors, or 50 patients in the virtual ward. And all those plus extra patients are more expensive in terms of human resources and in financial costs because they're bank staff than actually if we'd added another ward or two to the bed base as well. So you lose all kinds of productivity gains there as well. 

I guess where we are with the planning guidance is: A&E-wise, slight improvements being targeted. We can do that here. The problem is we could do 78 per cent still without tackling the really long, frail and elderly waits. The elective care side, we're pretty good on the way that the theatre's run, good on the theatre productivity. Ninety per cent of our waiting list is for outpatients. And physically, we haven't got enough space to see all the people we need to see. So we're trying to find extra space and capacity to get that into. 

The community diagnostic centres are really exciting. If you said to me you've got extra money to invest in healthcare services, I could easily spend here 20 per cent more than I currently spend if I could find the staff. And I think actually for the health of the population around here it wouldn't really have too much of an impact. Because we're already sucking more and more people. 

Matthew Taylor

You've got twice as many people going into A&E as... 

Matthew Trainer

…as it was designed for, you know. So I could keep spending money on that. And what we'd be doing is looking after people who've already reached the point of acute need and who passed the point where we could have intervened and kept them well. 

Actually, we really need to look carefully at what we're doing in terms of primary care access, particularly access to same day primary care. And the GPs around here will tell you a couple of things. They'll say, we're seeing or offering more appointments than we did pre-pandemic. They'll tell you that the hospital dumps too much work on them that we should do ourselves. That takes up capacity for them.

We're trying to do some work at the minute to understand the impact to people on waiting lists. The GPs they see a lot of. And we know in A&E we see people on waiting lists coming in through the front door. So the kind of inefficiencies we see in our corridor, you can see in the primary care pathways of people who are waiting for secondary care things. So I think we need to get really serious about a hospital investment, but recognise the probable double running context we're working in. So it's a hard thing. And I think the national team, we did a lot of work with Sarah J Marsh and the national team on UEC here and actually through the tier one process it was really helpful. 

You know, there were good folk who wanted to come out and help us learn from good models elsewhere and we've stolen shamelessly, we've adapted things from elsewhere, we've brought in great people from elsewhere and encouraged that. 

So I don't think there's any easy answers to this and I think it's easy to sit here and chuck rocks at the national team and say, you know, this is very, very hard. I think though it's kind of incumbent to think, well, what would we do differently? And I think at the minute, you know, God, it's hard... 

Matthew Taylor

But this is what we were chatting about, Matthew, with members of your team, which is that doing things better is very different doing better things… Yes …It's a different set of disciplines and doing better things means collaboration. It means working at place system, a local government with different providers. And my sense is that some way you can almost get trapped in doing things better, better and better and better, which actually means more people come to A&E. 

But then that can almost get in the way of saying, but yeah, but in the end, this is unsustainable. You know, if it was a thousand people coming to A&E or 1,500 people coming to A&E, that's not where we want to get to. 

So how do you as a leader balance the organisational leadership that you've shown, which you've done brilliantly, but in a sense you're in control of those things that you've changed. 

But then to really make a difference, it's going to mean working with other people. And I think this comes back to that trust word that you used earlier? 

Matthew Trainer

So, it's interesting. In December/January time we had about 28,000 attendances across both of our sites including the urgent treatment centres. Compared to the year before we treated 5,000 more people within four hours. So that's a big number of folk who have come in and been seen and treated. We also though, in January, went up from 1,400 ambulance attendances at Queen's here to 2,100 ambulance attendances which was the biggest jump of any site in London. 

And because we can hand over quicker and there's more capacity, more people are piling in. And March just gone, we had 30 ,000 attendances here across both sites over the month. That's never happened before. Any of the records we can find. Every Monday in March was in the 15 busiest days the trust has ever recorded. 

So for four Mondays in a row, we had the top two busiest days ever recorded and two the other 15 busiest. And this is in a relatively mild spring. So there is that risk. It's like building an extra lane on the motorway. You'll fill it up. 

So that's where we need to push out into the system. That's where we need to do things differently with community hospitals, we need to look at district nursing capacity around here, which is some of the teams are running at really high vacancy rates. 

There's a lot of factors around here that encourage activity to come into the acute. I think at an ICB level, we need to start thinking about multi-year financial settlements that allow providers like us to say, do you know what? We're going to take a risk on a percentage of our income, and we're going to put it into a pot. You don't necessarily need to use a Section 75 structure for this. I'm going to try and start investing through the place -based partnerships in some out-of-hospital activity that's going to try and defray demand. 

And we've got a new frailty off-site opening at a community hospital here in the autumn. We're taking renal outpatients out of here to give us a bit more space. We're doing some quite innovative stuff with primary care. And some of our primary care partners are brilliant. Dr. Jagen John in Barkinside, he's been running no-appointment-necessary clinics. And I think he had 7,500 people turn up in the sports hall in December.

What was interesting to talk to Jagan about this is the first one of these he ran, he had 500 people turn up. He said 250 of them were seen by him and his GP partners. The other 250 were seen by partners they had in from social care, mental health, local authority, charities. They needed other kinds of support but had come to health for that. Interestingly, Jagan said of the 250 he saw, he reckoned if they'd gone through 111, somewhere between half and three quarters would have been referred to the urgent treatment centre. They sent not a single person here. 

And so, lots of what we need to do is to push the expertise out into the community, make it accessible. Hospitals need to stop being a building. A secondary care hospital needs to be a repository of some fantastic expertise. Consultants are, they're the premier league footballers aren't they, or they're the most highly skilled, highly trained and rightly well paid members of the workforce. And yet we're often a bit too precious about holding that expertise here. 

And what we saw during the strikes interestingly is when we pile the resource of the really senior decision-makers around the front door in a way we can't do normally and run clinics and run outpatients, et cetera. But they can really help people get access to the care in the quickest way. 

The point of an NHS trust is to reduce by as much as possible the distance between the need of the patient and the clinical expertise that allows that need to be resolved. And at the minute, we've built up an accretion of basically rationing pathways and demand management pathways that have massively increased that distance and by the time the patient finally gets what they need, it's late, it's expensive and the recovery is delayed. 

And so we've got a system at the minute where we need to go through some kind of seismic shift of reinvestment to get care to people when they need it rather than trying to stop them coming through. I mean, what other business says, we've got a really well-known respected brand, in our case A&E, and let's spend huge amounts of time and energy trying to send people anywhere else.

And actually people know what that offers them. If you live around here and you're on a zero hours contract, and we know this because we did an Ipsos-Moray survey with CQC, the people who came to our A&E who were most likely to have tried other things first were people who either got paid sick leave from work or who were retired.

People who worked and who were dependent on that income. It makes more economic sense for them to come here at six in the evening and spend five or six or seven hours here and then get back to work the next day having had a scan, having seen the clinician they need to, with the medicine they need, than it is to see someone on Thursday, get referred here for a scan the week after, go back for a follow-up. Economically, rationally, and from a customer service model, the front door A&E is the most attractive part of the NHS at the minute. 

Matthew Taylor

So Matthew, we're coming to an end, but this is going to come together nicely in terms of the last question I'll ask you, which is, it feels like in the NHS the fundamental problem is demand management, when actually, really the fundamental problem is public engagement. So the problem is not the public want too much from us. It's that we're not engaging with the public more fully, empowering and enabling them to have a greater sense of agency in relation to their own health and getting the services that they need. 

So what you described, that kind of open access, it's a completely different model because you're actually inviting people in. But when you do invite people in, you find that by engaging with them, you can use the resources much more effectively. 

But I guess what that takes me to is that we're going to have a general election. Whatever happens at a general election, there'll probably be a new Secretary of State with a new mandate. What is the kind of reset that you would like to see if there's going to be a greater sense of hope and possibility? 

Matthew Trainer

So first place, hope is really important, actually. And one of the things I think in this organisation, I haven't said enough about that actually, is hope and optimism. And when I came in I was optimistic about the place and I thought what has happened would happen. I thought we'd improve on the key metrics, I thought we'd get better people in here. 

Lots of it was about unlocking the fantastic potential within the place, letting people recognise that we've got confidence in them, that we love being here and we love being part of BHRUT and that's really allowed a lot of untapped potential I think to come through and a lot of it just to be recognised that was already really good about the place. 

So optimism is really important in leadership and I think, I saw my job when I came in as build a great team, set the direction for the organisation and be optimistic about its future. I am optimistic. We've gone from being the worst performer in the country to being now top, I think, top 25 per cent. That's great. We're very good on the surgical side. We've made north of £20 million worth of savings in terms of our financial position. We've got some fantastic people here. Still got a lot to do. But optimism is important. 

Now, your point about the listening to people and empowering them. We run patient panels here. I read Terry Leahy’s book about when he ran Tesco's and the one thing Tesco's do, anything they do, they talk to customers all the time. 

They're going to open a new store, they go to the place where they're going to open a new store, they get a customer panel together, what do you look for in a shop? When they open the store, they let all these people walk through it, they say, what do you need to do with the tills? Where should the bread be? Where should the milk be? What does this local population want? They're really good on it. 

At the NHS we’re really bad on that. We talk about patient experience, but we largely mean complaints, compliments, friends and family tests. And so we've done a couple of patient panels based on this. Four or five patients talk for 20 minutes or so each about their whole experience. And we had one last week with stroke patients, four stroke patients in. 

What was really clear from all of them, and this comes through consistently, the hard end really important clinical interventions we’re brilliant at. You know, the thrombectomy, the experience in recess and A&E. You know, the care that they get when you really, really need the NHS is still really brilliant actually in most cases. And once you've got into the specialist ward and the staff have got time and space to care, really, really good. 

What we get wrong is the really busy demand management bit around the front door where you just can't get to where you need to, and the communication where we offer in pure customer service terms these days is a really poor experience for the public. And in a world where you can get Amazon Prime delivery, you can have a chat with your bank through a chat bot. You can rearrange them. You can do everything in really intuitive, sensible, digital ways. We're still a paper -based hospital without an APR. 

We run in the way that this place did in the 80s in a lot of respects as well. And so very long-winded way around this. The Secretary of State, what do they need to do? They need to really focus on making sure that the NHS is fit for modern expectations. And that's around digitisation, effective digital pathways, thinking about access in modern terms, not in ones that are based still in the 90s. 

They need to sort out the workforce. The junior doctors need resolution, really, really important. They need to be optimistic about the future and the NHS and want to commit to it. And so they need to sort out what's going on with the strikes and get the juniors confident that they should stay with the NHS and they want students to train and not come out thinking this is not a career for me. And beyond that, to work with them, with nursing and with therapies and other professions and get people encouraged.

They need to stop manager bashing because actually if you're stuck on a waiting list somewhere it's almost certainly because there's not enough management resource to make sure you're moving through that pathway properly and they need to start moving away from being overly obsessed with acute hospitals and thinking really carefully about primary and community care and supporting investment into different models of primary and community care access enabled by the expertise that sits within acute hospitals and I haven't said nearly enough today about social care and the fantastic community assets that are out there. 

The best way to keep people out of hospitals is for them to be embedded in a social context where they've got friends, they're active, they eat relatively well, there's green spaces around them. Otherwise all that happens is they turn up at our front door and we pick up the pieces at the end of the pathway. 

Matthew Taylor

So on that last point, Matthew, I think if one's critical of the NHS, nationally one would say that we sometimes aren't clear why we're doing something, but we over-specify how to do it, and when I'm hearing from you, we need to be clear about why we're doing what we're doing, where we want to get to over the next ten years, but recognise the way you're going to approach that in Barking and Dagenham is going to be different from the way you approach it in, I don't know, Lincolnshire or Cornwall or whatever, and give local leaders, particularly working together, the latitude to come up with solutions that work for their place. 

Matthew Trainer

Yes, I think so, and I think to be really clear about the purpose of what you're doing, what you're doing as an organisation and to recognise that actually the strategy you employ to deliver on that purpose is quite different depending on the context you're working in. 

I think on the whole actually some of the big access targets are pretty good. I was a big fan of 95 per cent A&E, thought it made a lot of sense. I think the staff survey tells you a lot about what the workforce is doing. But I think there is, there's an extent to which we've moved from CCGs and all that, you know we've now got ICBs, we've got places, we've got trusts in between and acute provider collaboratives, et cetera. I'm not sure we've necessarily de-layered the structure is NHS. 

It'd be nice just for a bit if we just didn't change anything for a while. Let folk get on, build the relationships, build the trust that you need locally. And actually off the platform of that trust, that should allow us to make some of the investments we need to make in different models of care to try and change some of these pathways. 

So I'd say optimism, hope, sort out the junior doctors, and please don't restructure us for a while. And let us crack on. 

Matthew Taylor

And a bit more capital investment. Definitely. I'm just saying that with you because there's a wonderful great similarity between what you've outlined as a leader and what we have put in our own manifesto. Which is a wonderful accident. 

Matthew Trainer

And wouldn't it be nice to have three to five year capital allocations? 

Matthew Taylor

Yeah. But as you say, no major reorganisation. Let's see what we can do with what we've got. Well, Matthew, thank you so much for your time and for the time I've spent in the hospital. It's been inspiring. 

Matthew Trainer

Thank you. And the people that work here, the staff here are inspiring.

Matthew Taylor

I saw that. 

Matthew Trainer

It's a privilege to be part of the team here. Because, sometimes it can be very frustrating and it can be difficult and stressful et cetera. But there's not a day where, if I'm sitting in my office feeling this is hard, the best thing to do is get out on the wards or go and have a walk through A&E and you come out and think, what a great bunch of folk, there's no better place to be than this. 

Matthew Taylor

100 per cent agree. Thank you.