No Longer on Mute: How a Quiet Girl Became the Leader Our NHS Needs, Episode 2

Lauren: You've spoken in the past about how much you love the nursing philosophy, and I'm wondering how much that has played into your years working as a mental health nurse? How much has that played into how you think about designing services, or leading as a chief exec now?

Jane Padmore: It's fundamental to me, on a number of different levels. Nursing, to me, is the privilege of being with someone right from birth through to death. You're walking alongside them. You're not coming in as an expert to tell them what to do or to give an opinion. You're there working in partnership with a person to find out not how to alleviate symptoms, not how to manage an illness, although that might be part of it, but how to have a fulfilling life and how to flourish in life. So you understand their goals and you're walking alongside them. It's such a privilege being a nurse.

And for me, that's me as a chief executive as well. I'm not the expert. If we think about CAMHS transformation in my organisation, I worked in CAMHS for 15 years. I've published a book about child and adolescent mental health. Heaven forbid I redesign the service. I haven't worked in CAMHS for years, and it would be my one perspective. What I need to do is create that culture and that environment for people to come up and speak up.

So it's the same sort of thing. To me, that's what nursing does. It helps to bring the best out of people. If they're living in pain, it helps them to find the best way of living in pain, as well as alleviating as much pain as possible. If they're in mental distress, it's helping them to come through that, but not telling them what to do and not being paternalistic. So to me, it encompasses everything.

And I think nursing is the best career in the world, not that I'm biased, because you can be in management, you can be in leadership, you can be an academic, you can be in business. The world is your oyster. If you get the foundation in nursing, there are so many avenues you can go down. I think there's probably a job for everyone. It's just finding your place in nursing in the right way. But it fundamentally directs what I do.

The other bit I was thinking about when you asked me that was that I also have my code of conduct. I'm a registered nurse. Whatever role, whatever aspect of my life, I need to abide by the code of conduct, and it's fundamental to how I manage things. But with that comes accountability. You could be a chief exec in the NHS at the moment and not be with a registered body. The fact that I'm with a registered body gives an added layer of accountability.

And it has been tested. A patient at my trust referred me to the Nursing and Midwifery Council for fitness to practise, and I was under investigation for about 18 months, with no case to answer at the end. I'd never met the man, but he was complaining about the way his complaint was dealt with within our organisation, and I was the accountable officer and a registered nurse. I cannot say that was the nicest experience of my life. But I am pleased that he was able to refer me, because it means I'm accountable and I need to think.

I've been very open about it in my organisation right from the beginning, which made me feel very vulnerable. But I thought, I know there are nurses within my organisation, and doctors and other professional groups, who are under investigation by their governing body. They may or may not have done something wrong; that's not the point. It's a horrible experience and it can happen to anyone, but it's right that people are able to refer us and that it goes through a process.

Brigitte: Yeah, for sure. It's interesting when you talk about your journey throughout the mental health wing of the NHS. You've been a chief exec for a period of time now, and a lot of people have a look at the acute space, with it being the avenue a lot of chief execs go down. You've never deviated from the mental health world. It's very clear that you feel very passionately about it, and that's how you've progressed up through the ranks. Why is it that you've stayed so steadfast in your path within NHS mental health care? And do you see that long term for yourself as well?

Jane Padmore: I'd say it's mental health, learning disability and neurodiversity, so the three together. I have absolutely no desire to go into an acute trust or a community trust. I wouldn't mind doing a joint community and mental health trust, but mental health, learning disability and neurodiversity is my thing.

I think it goes back to that really strong sense of social justice I have. When I look at people with mental health conditions, learning disabilities and neurodiversity, the way people speak about them and the differences in outcomes enrage me. It just makes me feel so cross. I know I could go into an acute trust and influence it from the other side, but I think I have a stronger voice being within mental health. If I'm in an acute trust, there are lots and lots of other priorities. Mental health and learning disability would be just one thing they've got to think about, and it would be watered down.

I started off as a volunteer, aged 16, with people with learning disabilities. That was in 1986, probably before you were both born, and I have worked in mental health and learning disability ever since. It's in my DNA now. I couldn't do anything else, and I don't intend to do anything else until I retire. Then I'll do something else.

Lauren: Many times in your career there's been a path that might have been easier, but you're so clear on the reason you're doing things: to have an impact. If the easy road doesn't lead to that impact, it's non-viable. I really, really admire that, because you can see it as such a common thread throughout a lot of the choices you've made in your career.

Jane Padmore: I do understand what you're saying. I feel really uncomfortable with the admire bit.

Lauren: No, it's fine. No, no, it's fine.

Jane Padmore: Only because, and it's really interesting, I was talking to one of our consultant nurses in our neurodevelopmental service the other day, who is also autistic. We were talking about how people will often admire this sense of social justice, but I can't not do it. It would feel physically very, very uncomfortable, and I would be thinking about it all the time. So I have to do it.

And sometimes it gets me into trouble. It's almost like a bubble that will explode in me. I'm not naturally someone who will speak up in meetings. But if it's about a sense of injustice or something not being right, it's a physical thing. I physically can't not do it.

Brigitte: Whether it's a conscious decision to model that really positive behaviour or not, do you find that the team you've built around you, and others within your organisation, naturally do the same because it's modelled to them? We've done a little bit of research on yourself and the Trust, and having watched you on social media for the last couple of years, it's so evident. And you've mentioned [name unclear] and the environment that she's created as well.

Jane Padmore: She's a powerhouse.

Brigitte: She seems it. But you and your collective team together, it's so evident, even just on social media, the mutual adoration that everyone in the organisation seems to have. It comes across as such a safe space, and it's not often you see that so vocally from all different levels of an organisation. So I wondered, from your perspective, do you feel that culture has really translated across the Trust, not just with yourself and your executive team?

Jane Padmore: So that's a tricky question, and I'll tell you why. Our staff survey results are really poor, with people not feeling safe. We have been on a really tricky journey of moving to financial balance, which means we have had to make some really tough decisions. We have tried to be honest about why we're making those decisions. We made a conscious decision at the beginning to explain that there is a burning platform. We're a £500 million organisation, and we're spending £550 million. We need to get that right. It needs to have a foundation. And that means people's jobs are at risk. It means services have had to change.

We have tried to drive it through improving quality. Ultimately, we think and we hope the things we do will improve the quality of services, but they're painful, because people have worked in these services for 10 or 20 years and they're doing a really good job.

I think it's growing, but this journey over the last couple of years, and probably the first year especially, so three years ago, we didn't handle very well as an executive team. Looking back now, I think we misstepped, we didn't communicate well, and we left some people significantly hurt in the process. I think we're reaping that now, and we're trying to turn it around and develop.

So I think that culture is there within the executive team and in some elements of the organisation, but we're spread across a vast area. We have over 6,000 staff and over 100 sites. If I do one site visit a week, it takes me two years to get everywhere. So people don't see me very often, which is why I'm active on social media, to try and be a bit more human and personable.

I was with the mother of a woman who died in our services a few years ago this week, and we were talking about some of the correspondence I get, both on social media and personally, from grieving families. It is really hard to hear, but it's important that I hear it. There's something about being the chief executive. They don't know me, they don't know my family, they don't know anything about me, but the reality is I am the accountable officer. I am ultimately responsible. And they're grieving and they're hurting, and it's important that we hear that.

I hold that, and I hold it in a way that doesn't dismiss what they're feeling. Staff that are angry, families that are grieving: I do not want to get into a battle with them about the rights and wrongs and the ifs and buts. The reality is I need to acknowledge their feelings and hold it. I am the chief executive. It's hard, and it takes its toll, but it is part of my job. If we're public servants and we really mean what we say we're here to do, then it's right that I hold that. I don't want the nurse or the doctor on the ground to be holding that. I want them to be getting on with the care of the people in front of them.

Lauren: That really speaks to what you said earlier in the podcast about being the guardian and steward for the Trust. This might be a controversial question, but you mentioned what you and your executive team are here to do, and what we're all here to do for the NHS, and the public servant aspect of that. What do you think that looks like over the next few years, when you take into account the CIP targets you've mentioned, and how difficult it is in general to create real, transformational, long-term change in the NHS? What kind of path do you see for the Trust looking forward?

Jane Padmore: I hold hope for the future. I'm an optimist, ultimately, an optimist that holds a lot of anxiety. But I can see the green shoots of improvement.

One thing I was thinking while you were talking is that one of my pet hates is when people say it's quality versus finance, because that's just not a thing. Good financial management is good quality, and good quality drives good finance. If I look at the main drivers of our overspend, it's independent sector beds and agency spend. Agency nurses and agency doctors are not bad people. It's not about their quality as practitioners. But if you have inconsistent staff, that's poor quality. If you've got people being treated away from their home area, that's poor quality. If we solve those two, we would have better quality overall. But I digress, and I can't remember what you asked.

Brigitte: You've answered it a little, I think, especially with the quality versus finance point.

Lauren: Yeah, it's what the path looks like at a time when cost improvement targets are so prevalent and every trust is battling them. How do you see through that and look to the future and the path forward?

Jane Padmore: It's important that the short term, the medium term and the long-term vision are each held equally. So I need to think about the here and now. For me, the here and now is managing and reducing the number of people waiting over 12 hours for admission from ED, and making sure that people waiting for beds in the community are admitted as soon as possible. That is the thing that's keeping me awake at night today: how many people are waiting in ED?

In the medium term, I'm thinking about how I put in the building blocks for the long term. It can't be one or the other. We can't be distracted by people waiting 12 hours in ED for a bed and forget to do the medium and long-term stuff.

My long-term vision is around really embedding continuous quality improvement, in its truest sense, in the organisation. That means it's not a set of processes, or a house on the hill that's the QI house, or "oh, that person does QI". It's a cultural movement in the organisation, driven by culture. It means that Joe Bloggs working on the wards feels able and safe enough to try something. It might not work, and that is fine. We learn from it and move on quickly. We fail fast and we move on. Or we succeed and we celebrate it. It's having a workforce that feels empowered to make those changes.

One of the things I've been really struck by on some of my service visits recently is some of the myths that are around. "I can't do that because of the way we're commissioned", or "I can't do that because this policy says so". Then I go back and it's nonsense. It's custom and practice. These myths have built up over the years, because we were seven CCGs that are now one ICB, commissioning has changed, staff have changed, and people think they can't move without anyone's permission.

It's like, seriously, if you're waiting for me to tell you... Someone rang me in my first week as chief nurse here and said, "We want to move the beds around on the dementia care ward." And I was like, "And?" "Well, can we have your view on whether it's okay?" And I said, "I have no idea. Give it a go. Do you think it's okay? I'm not a specialist in dementia care. I don't know your environment as well as you do." But the fact that they felt they had to ring me to ask my permission to move the beds was such an eye-opener for me. Why are you asking me?

So we need to move a culture where everyone is seeking permission, whether because they're scared of things that have happened before, or they don't feel safe enough, or they want to avoid taking responsibility themselves. Whatever the reason, I think the future of the NHS has got to be clinical leadership really taking up the mantle and making the change themselves, and the executive team stepping back and doing a lot less, but providing the cloud cover between the noise outside and them getting on with the job.

Brigitte: How do you think we then provide the clinical leadership, the psychological safety, the remit and the resource to be able to take risk and truly change things without getting caught up in a heap of bureaucracy?

Jane Padmore: I think you can only do it by doing it.

Brigitte: You figure it out as you go. Is that what you mean?

Jane Padmore: Yes. And people testing it. People might say, "Oh, Jane will stick by you." I was speaking to a group of our leaders yesterday when I went to open the Leadership Essentials course we're running for middle managers in the organisation, and we were talking about exactly this subject. I said, to be quite frank, there are times when you have to make a decision.

For instance, people get worried about breaching confidentiality when families ring. I would far rather defend you breaching confidentiality than defend you for not breaching confidentiality when someone's dead as a result. It's not binary like that, obviously, in day-to-day life. But it's almost like we hide behind "we're not allowed to do something", and forget there's a huge risk in not doing it. There's nothing stopping us from listening to carers. There's nothing stopping us from talking in generalised terms. But it's almost like we use confidentiality as a "no, we can't talk to you". And yet that family know that person far, far better than we do. But staff need to feel safe enough to test it.

Somebody in the room gave an example from one of our teams I had visited. They'd said, "We're really worried, because we're commissioned to provide a service within these four walls. If we've got a young person who is at home and won't come out, we can't see them." And I'm like, "Why?" And they said, "Because of how we're commissioned. We're not allowed to leave. It's not safe." And I went, "Why? Why?" All I did was ask why. They went back and found out it was a myth, custom and practice, and actually they could. And they gave the example saying, "See, we can."

By hearing that, the people in the room get more of a sense that they can test it and see. Whereas if I just stood at the front and said, "I trust you, I'll stand by you", it's going to be meaningless. They have to see it and test it and taste it.

Historically, as a nurse and as a chief nurse, I've been in inquests and stood on the stand. They are horrible experiences, no matter how nice the coroner is, and we have some lovely, really compassionate coroners in Sussex. You're in front of grieving families and you're putting forward the position of the trust, which can come across as defensive. You're being cross-examined by barristers. It is a horrible experience. And if we don't support our staff, that can lead to defensive behaviour that is actually higher risk. So I think we just need to keep talking about it, exposing it and modelling what safety looks like. There's no magic answer.

Brigitte: No. And it's those small interactions as well, like asking why, that build confidence over time. I'm in a very different world of building products, with teams of engineers, designers and product managers, and sometimes we'll have the same thing: "We can't do that", or "That's going to take us forever". The unlock for me has always been, "What would need to be true for us to be able to do that in three months, two months, two weeks? Tell me what." Having the conversation and getting it all out onto a whiteboard or a piece of paper facilitates the conversation, but it also allows everybody in the room to go, "Oh, is that actually something we can do?" It unlocks a new way of thinking. I do understand why you'd be apprehensive if you've been through experiences like that. But without having the conversation, you don't shift things forward.

Jane Padmore: That's right. The conversation, and then the testing of it. Because you have a conversation, but do you really mean it? When it really hits the fan, are you really going to stand by me? Are you really going to defend me and support me through this really difficult decision?

Brigitte: Yeah. And when that's modelled from the top down, it's really, really powerful. There are a couple of situations from the last couple of years that come to the forefront of my mind, where you have to stand up. As you say, I would much rather defend a team member that tried something new and it didn't work than stand up and say, "Well, performance is XYZ because we've been doing the same thing for three years and this is how it is." I'd much rather we experiment, try new things and challenge the boundaries to come to a much better process.

Jane Padmore: Yeah, yeah. It's growth, it's growth.

DrDoctor LinkedIn

Brigitte West LinkedIn

Lauren Wybrow LinkedIn

Jane Padmore LinkedIn

Sussex Partnership NHS Foundation Trust