Justin Ash - Voices of Care, Episode 11.

It's very kind of you to invite me. It's always a pleasure to see you.

Yes, so COVID was a defining period for the independent sector because we played such a vital role in providing NHS services. And I think it's absolutely true that millions of people got treatment who would not have done otherwise. And that was a fantastic partnership with the NHS. Coming out of that, first of all, we have a role to play in reducing waiting lists. That role is being played by many providers. Spire is absolutely doing that. And I think that is well recognized. We've also got an important role to play in choice. So, I think it's well understood that Spire's self-pay and private business is growing robustly. And I think there's reasons for what we've done at Spire which are driving that growth. But generally, people are looking at private health care. They are seeing waiting lists. They're wanting to be seen either faster or at a time of their choosing. They're wanting to get diagnosis quickly because they're worried. And they're seeing that they do have a choice. And when they get the choice, they're really pleased with it. And I think that is changing attitudes to private health care generally. And all the research you look at, our research, IHP and research, research within any newspaper, shows there has been a fundamental shift in the role that people see private health care having in their lives.

Sure. Well, first of all, we know that the GP service is hard pressed. Yeah. And that reflects in the fact that many people, if not all, are saying that they're finding it hard to get a face-to-face appointment. And that's an important part. So, we've got Spire GPs in every site at the moment. That is our fastest growing service. As soon as we open up new slots for face-to-face appointments, they're typically 25 minutes because there's a strong desire to actually sit down, build a relationship with the GP. And by the way, GPs want that relationship as well. So, that's growing very fast. And secondly, the demand for diagnosis is growing equally fast. Pathology, X-rays, MRI, etc. So, we have now identified 10 sites where we're going to open Spire clinics, which are a combination of diagnostic centers, GP stroke community type services, and non-general anesthetic treatment so that we can take a bit of pressure off our hospitals because they're very busy. We can provide treatment in the community, and we can provide increased access to that entry points into health care because it's actually the entry point that people seem to be having the most difficulty with.

So let's talk about quality first. Since people are starting to pay more and more for their health care, then quite apart from the obvious importance of quality and governance in health care, it's even more important because people are putting hard-earned money into health care. And the only way that the independent sector is going to thrive is providing the very highest quality of care. Now, there's been lots of excitement around digital health etc. Although that market has somewhat come off. And I think the reason for that is eventually, if you are unwell, you will come across a clinician. Be that an allied professional or a nurse or a health care assistant or a doctor or a consultant. And that workforce will remain at the very heart of all provision. It's very important to remember that. There are no simple solutions to the fact that the workforce is key to everything that we do in our success. And yes, it's true. There is evidentially a workforce crisis in the UK. There's a workforce crisis globally. You can read about this in any developed nation. There's also workforce crisis, by the way, in low middle-income countries of a different nature. Mhm. So, we have to be hugely alert to this, not just as providers, but as society, in fact, because everything that we do, including tackling climate change, going to work, joining time with our families, is prestaged on the fact that we have good health. And ultimately, that good health is provided by the workforce, which is why I'm so passionate on the topic, and why we're putting so much effort into thinking and acting on this at Spire. And we know the numbers. In the UK, we're short somewhere between 130,000 and 180,000 healthcare professionals. Globally, that's something like 10 million. Many of whom, by the way, are in low middle-income countries. So, I think by any definition, that's a crisis about which we'll need to do something.

To me, it's a shame that nurses and doctors feel they have to go to agencies, because really, we should all be providing them a home in our hospitals and clinics, where they feel sufficiently well rewarded that their work-life balance is sufficiently flexible, that we can accommodate them without them having to become agency, which in many ways is a floating service. There are arguments it's less safe because you don't know your colleagues as well. You're going into relatively complex situations at relatively short notice. So, I think part of our mission as health care providers is frankly that the agency business doesn't need to exist because everyone's either working full-time or on the bank, which is sort of more flexible way of working. I think, however, you can't blame people for wanting to make that choice. And we have long-term relationships with many agency nurses who are excellent. There are some excellent agency providers. There are some who are I'll use the word cautiously looking like they're profiteering from a shortage of workforce. And I think that needs a careful think and possibly some regulation because every pound that goes into excessive agency margins is a pound that's not been spent developing the workforce. So, if as providers we all have huge responsibility towards the workforce. And I think agency providers have a responsibility to act reasonably and proportionately in that environment as well.

Yes, so apprenticeships have been transformational for Spire. It's the only way to put it. We started relatively small. We've now got a workforce of 14,000 of which 500 and growing are apprenticeships in all sorts of areas. Of those, 200 are registered nurses. I think we've got the largest apprenticeship program for registered nurses. I mean, the bottom line is we have to grow our own. We have to develop more people in healthcare generally, not just in nursing, but in all the allied professions and the supporting roles. What's wonderful about apprenticeships is you take and they're not all young people, but people from all sorts of backgrounds. A lot of them have worked in food service or restaurants or you know, they've worked as security guards and they've come into healthcare. They've typically come in to do a job like housekeeping, etc. And then they've been inspired to take an apprenticeship and maybe become a nurse. So, the first thing is we're bringing people out of some sectors where employment is going down and creating new roles. We're inspiring them to become healthcare workers. They bring enormous energy, by the way. They get a very professional training and out of it you get a registered nurse. And since we need tens of thousands of these, I can't see why everybody wouldn't lean into apprenticeships. Now, of course they cost money. We use more than our levy. Mhm. We have additional levy funding. We've spent way past our levy on this because it seems to us the way to secure the future. Now, those nurses will be free to go and work in the NHS. They do placements in the NHS. By the way, in addition, we take many nurses on placement from their NHS training. And I think the second theme is this connectivity between independent sector and the NHS. We always talk about helping with waiting lists. It's actually in the workforce that we can actually have the most connection because we've all got the same vested interest in creating fabulous healthcare workers. I think we'll expand that program. It takes quite a time to get into it. These have to be rewarding experiences. They have to have the training has to be good. We work with the University of Sunderland. Some of it's online. That's all got to work well. The placements have to be good. But also the truth is after a year, we have health care assistants providing fabulous care and for the teams in the hospitals, they just love teaching and coaching. So it's changed our culture. So we shouldn't think of this as we're supporting 500 apprentices and aren't we good looking after them. They are transforming our business with their wonderful enthusiastic contribution. And I think expanding this program, you know that I started my career in food service. This interchange between professions and sectors is a revelation. So there's so much that's good about this. I just hope everyone leans into this more.

Yes, so I wear two hats here actually. One is chief executive of Spire where we now have over 450 nurses who've come from overseas, mainly the Philippines, and they're making a wonderful contribution. It's a very focused recruitment. We focus a lot on pastoral care. They're supernumerary for months whilst they get trained. And I think it's fair to say that many of our theaters in particular, we would have theaters shut had we not done international recruitment. And it is a fact that it's an important part of the UK healthcare workforce today. And of course, you would aspire to have many more people developed in the UK and that's apprenticeships, but it's an important part and it creates opportunities for those overseas nurses. Now, I also chair a charity called THET, which is a healthcare workforce charity. We're present in 13 low middle income countries. And we have two observations. The first is that diaspora who work in the health service in the UK are experts in our midst. And I've been out in Ethiopia where we do a lot of work. And the learnings that people who come from overseas bring us about how you can deliver healthcare in the community with limited resources is a rich resource for the NHS. And secondly, we have to be incredibly responsible about sourcing from overseas. Draining the healthcare systems of low middle income countries benefits nobody. Equally, if somebody has a right to work, they have aspirations. So, I would call on us all first of all to celebrate the role of international workers. They're an important part and they make a vital contribution. But secondly, to come together with the sector and recognize our responsibilities to the rest of the world as we do that.

Yes, we focus enormously on retention, and we do have leavers. We probably have more leavers than we'd like to have. We have a slightly older workforce because we have a very loyal workforce, but eventually they do get to retire. And we bring new people in, and you then you've got to think about how you blend new people into teams who may have worked together for a long time. So, part of retention is just being sensitive to where people are in their journey with Spire, and making sure that those joiners fit well with the existing team. And I think people don't think enough about the culture, not of corporates or trusts, but wards and theaters. They've all got their own culture. So, we spend quite a lot of time understanding, getting feedback, doing engagement surveys to understand the culture and the microcultures, and making sure they all function well. Freedom to Speak Out Guardians are an important part of this. So, we have obviously a very live Datix system for clinical notifications, but we have Freedom to Speak Out Guardians, which of course can report on clinical issues. But of course, what they tend to report on is workforce issues. Yeah. And most of the workforce issues that we see through Freedom to Speak Out Guardians are to do with team dynamics. All right, so these are a hands-up saying I don't feel quite comfortable in this team. So, the internal focus around speaking up, openness, listening, and responding appropriately is key. Then you've got the much broader agenda of mental health and well-being. So, we have invested a lot in mental health champions. So, we have a mental health first aider at least one in every hospital and every site. We have coffee evenings online that people can join to talk about their mental health. Because people are stressed. Actually, by the way, they're as stressed about their home lives as they are about work. Right? You have got a cost of living crisis. Absolutely. And obviously, our responsibility is to pay appropriately, but even if you do that, doesn't take away the fact that there is pressure out there. Learning and development, we've got a thousand colleagues in learning and development. Again, if you look at what really motivates people, being stuck in a job without development can be a source of stress. So, we've really focused on this. I'm sure we can do more. Clearly, we want to hang on to people, not just to aspire, but then the healthcare workforce overall, I sense that things are more acute in the NHS given the pressures they face. And I've seen but there's some very good initiatives coming out of the NHS to support colleagues. So, I think they have understood probably before we did that you cannot deliver care without your workforce. So, retention, well-being, mental health support, it's not just important to do, it's obviously the right thing to do.

Yeah, so we have a number of those. Fair pay is obviously part of that. We think we do and we've given some much larger pay rises this year, particularly to the lower paid than we have done in the past. And we're all going to have to stay very aware of that as well. And of course, that helps drive inflation in the healthcare sector. And we're managing that in other ways which aren't related to workforce. So, in a way, the independent sector has got the best of times and it's got some challenges because we have got unprecedented demand. It's actually quite a responsibility to meet that demand. People sometimes talk about it as 'Hooray, the independent sector has got loads of business.' We have a responsibility to treat all those patients. And we're not going to do it without an engaged, retained workforce.

Well, first of all, I think the independent sector has come quite a long way recently. I think as little as five years ago, you could say that it wasn't transparent, that not everybody was up on their game in terms of quality and governance. We've certainly transformed that at Spire and you can just see from the CQC scores that that's transformed in the independent sector and that has to continue. There's a question around transparency on pricing, which obviously FIN is part of and around consultants practice. And that's a little bit complicated because there is obviously a debate. How much is a knee procedure? It depends a bit on the procedure. But that's work that we've done in making things more transparent that FIN will work on. And as this becomes more of a consumer sector, which is what's happening, then the pressure will be on those who aren't transparent to become transparent because that's what consumers demand and we see that. I would hope that we are now seen as an integral part of the health care system. I always draw it as here's the NHS and people think here's the independent sector as a little box outside. I think the way to think about it here's the health care system with the NHS and independent sector inside the box together and I think that is the case and as a patient you are almost certain to have an NHS patient pathway at sometime in your life. You may also have a private pathway. Your private and NHS pathways by the way on one treatment may overlap depending on what's happening and I think trying to create artificial barriers helps nobody particularly the patients and I think those barriers are breaking down. I think choice matters. Imagine the world in which we had long waiting lists and all you could do is wait and you had no choice. But you can argue is it fair that some can afford to pay and not others to which I would say well everybody who pays to go privately is taking themselves off the waiting list. And it's important in my view that independent sector providers also help with waiting lists so we're both part of the solution but also providing that choice but I do think that choice is important because the choice creates options for people. It creates space and I think this narrative will evolve and the proportion of private and NHS support will change over time. I think primary care and the role of the independent sector will grow which is why we're building clinics, it's why we're moving into private GPs. I think it'll be a vibrant time. It'll always be a subject of debate, right? Health care is the ultimate political topic in the UK. If you work off the premise that the quality of the services we provide is high, the care, the systems, the governance then it's debate about well it's a good service, how do people access it, where do you grow it. I very much hope that we will become both larger and more integrated, more recognized, and that as a consequence we'll have a better health system, and I firmly believe we can and are contributing to that.

Absolutely. Well, first of all, we should think of say nurse's journey as NHS, independent sector, NHS, and that happens quite a lot. I also see collaborative working where people are working for us maybe on an ITU that we have open 3 days a week. They're working in ITU in the NHS. They're sharing skills. I think it's probably the area where we can most quickly break down the barriers and work towards a common goal, and I see it starting to happen.

Thank you very much. My pleasure.