Innovation Insights with Medway NHS Foundation Trust

Charlie: We understand that you’re doing a bunch of really exciting things in regards to innovation at the Trust. You’re involving all sorts of different stakeholders, but before we get into that, do you mind just sharing a bit about you, what your role entails, and what’s strategically important to you at the minute? 

James: I’m the Chief Executive at Medway NHS Foundation Trust. We’re a hospital in the South East of Kent. We have a population of around half a million people. We employ about four and a half thousand staff and have a budget of around 300 million a year. Your point about what’s important has probably changed over the last year unsurprisingly with Covid-19 and the impact of that. Although I think there’s still similar themes. Workforce would have been a  topic for us to consider importantly and strategically a year ago, two years ago. Perhaps it’s more important now than ever before but for very different reasons with regards to how we take care of our workforce in the NHS because of the last 12 months and the impact. 

Alongside that, quality of care is always going to be a priority for us.  But one thing that’s really good that is emerging perhaps more so than ever is the introduction of technology in the NHS and how that can support both workforce and quality of care. So that’s certainly been our focus over four months, and as we head hopefully into better times from a Covid perspective we can really start to embed some of those changes into practice.     

Charlie: So you’re talking about technology accelerating into the NHS. I’m assuming that like many organisations, the accelerations are somewhat caused by Covid-19. 

James: No doubt the pandemic has certainly accelerated some introductions of technology. You and I previously talked about outpatients for example.  Outpatient work has traditionally been done in pretty much the same way in the UK for a long long time or certainly in the English NHS system which is you receive a letter and you come into the hospital, you see a doctor and you have follow-up appointments.  We couldn’t do that during Covid so we moved pretty much most of our outpatient work onto an online portal which for large groups of our community is a preferred method. Going forward it’s certainly more efficient for them and in some respects more efficient for us. There’ll always be a group of patients that can’t have that type of care but it’s certainly something that I think will stick post Covid.  

Charlie: I can really see that being an impact on so many levels. I know I find a hospital quite a stressful environment because the connotations it has of people that mean something to me in the past being there and being ill so the whole ability to not have to go back into that place that can cause stress and it being more you dealing with it in your own home environment seems beneficial to the patient on that level too. 

James: I definitely think we forget sometimes because we work in hospitals every day. You know for me this is 25 years this year that I’ve worked in the NHS so hospitals are pretty much day to day for me but for you and for others they have different types of memories.  Sometimes it’s your relatives passing away with negative connotations. Sometimes it’s quite a scary place to come into so we’re perhaps respecting that more and acknowledging that more now post Covid.  

As we move into a post Covid world there are better ways in which to engage patient groups, and I would say if you take the learning from other parts of Europe including Sweden, Denmark and Germany, this is fairly common practice actually. That introduction of technology into healthcare is much more advanced than it is perhaps in the English NHS system.  Again not not a criticism, there are parts of the NHS that have fantastic technology but at Medway it hasn’t been as great I think over the last decade and we’ve made some head road in the last two or three years, but certainly as we head into the next 12 months we will begin to see more technology supporting the provision of how and where we provide care. 

Charlie: It’s really interesting because in the conversations we’ve had in the past James, something that I’ve noticed in your leadership style is transparency and honesty like where the organisations are at in various parts of its journey. Don’t you find that transparency is almost a part of innovation like you’re only going to get great innovation if you’re really transparent about where you need it. Do you find that’s an important character trait to have amongst your senior leaders and managers? 

James: When it comes to innovation, you can only be yourself, you can’t pretend to be someone else. For those that do that and try to emulate other people it tends to fail because it’s not authentic.  

To your point about technology, unless you’re honest about what your starting position is and you hear it loud and clear, you know particularly from our clinicians who I have to say are very rightly vocal around the frustrations that they have, through to our clinical clerks who in some cases are working with an infrastructure which is outdated. We struggle with modern day technology that supports how our teams can access even fairly basic IT systems. So I think you’ll be honest about what the starting position is but also be honest about what’s realistic about where you can get to because of course cost is always going to be a factor in the NHS. Maybe we’ve suffered a little bit from this kind of buy cheap buy twice mentality so we get the cheapest sort of version and then find in a few years time it’s failed or out of date so we spent a lot of time in the last couple of years really thinking about our digital strategy and how we needed to a catch up but also then perhaps take a big stride forward as well about what we’re investing in over the next couple of years. 

Charlie: Interesting. One of the things I’ll play back to viewers is that it’s this transparency that you have at that leadership level which seems to create this open organisation. Where you get a good flow of information coming up to you guys as leaders from operators including clinicians in particular. They know that you’re transparent about the state of the organisation so they’re quite happy to contribute up into that reality, which is a perfect breeding ground for solution building. 

James: The challenge for us as leaders is you’re not just listening, you’ve got to do something about it. It’s certainly not perfect and we’ve still got more to do to hear more of that and then take action. But I hope as we head into the next 12 months our clinicians in particular will see that we’re listening and that we are then taking action to address some of the issues that they told us about.  We can’t fix everything because we’re dealing, as I said earlier with in some cases a low starting base which means the investment ask is a bit more and it takes time as well to develop the right systems rather than just any system. 

That’s the importance of the digital strategy because it sets out a really clear road map of where we’re going to be over the next three to five years as a hospital. For the clinicians that is really easy because you can look at it and say they’ve heard me, they do want to introduce an electronic patient record but it’s going to take them maybe three or four years to get to an end point but in the meantime all of these other things are happening which will make my life a lot easier as well so we absolutely are listening to our clinical teams but in some cases we need to catch up with them a bit.  

Charlie: It’s really interesting and I’ll let the viewers know that I’m actually going a little bit of script here because some of what James is saying I find really interesting. In that I hear that at Medway you’ve got no shortage of suitable ideas coming from the ground up. Actually I hear something about prioritisation in there and because we’re speaking to a CEO you must have got to where you are today James because you’ve got a good instinct for priorities. Can you give our viewers any tips of ways in which you look at identifying a priority above you know one from another?

James: I think as a CEO you’re only ever as good as the people that you have around you and part of what we’ve tried to do is create individuals who can do that on my behalf or the board’s behalf.  We’ve got a team here within Medway Innovation Institute, which is not quite a separate organisation but a product within the hospital, which is clinically led. Although we have our Director of Transformation for hosting it and it’s led by one of our consultants and one of our matrons they become the face of the Institute because that in turn then generates more interest from other doctors and nurses. So they see us all the time but seeing doctors and nurses lead improvement programs and innovation, certainly it sparks their interest rather than us. 

These are the people that will have the ideas. They see patients every single day, they know the frustrations that their patients have, they know their own frustrations. When we developed the Institute, that is what we call the vehicle for change, and that means no idea is ever given a no. What we’ll do is what you’re describing which sits with our digital strategy and our hospital strategy and therefore what can we put some fast legs behind whether that be resource or money, so people or money, to get them alongside the clinical teams to see whether this can really fly. So it’s a bit like a startup mentality. 

When you and I last spoke I talked about one of our consultants having an idea about creating effectively a specialist centre here at Medway for something called deep infiltrating endometriosis. It’s a quite a rare condition but it’s a condition that is really debilitating for many women and often can lead to infertility, and often the women wouldn’t really know much about it in terms of fertility impact. So consultants get in touch through the Innovation Institute and through a Chief Exec scholarship which I fund each year.  This is something that we believe our population needs. Now we don’t have one anywhere else in the local area so we’ll be getting you know complex referrals in from elsewhere and that consultant will go from just having an almost like a dream of creating this centre through to it becoming a reality just because we were able to listen and get some people alongside him to support. 

So I don’t think there’s ever just me that has the role of prioritising. I might have the sort of the ink on the signature, but we’ve got a team of people here who get alongside and can fast track those ideas.  

Charlie: It sounds like you utilise a rich skill of leadership to help qualify based on their area of skills and expertise. 

James: In the leadership roles that we have in the NHS, we’re lucky in many respects because in my team I’ve got a doctor, a nurse, I’ve got an operating expert, an HR expert, a finance expert. Whilst I might sort of play in parts of those gangs from time to time, they are the expert transformation director. It’s those people who then come together and say okay finance director, I can give you £10k to get that going, I need the ops director alongside and the nurse director. 

You talked about authenticity but it’s also about giving people the autonomy and the empowerment to get going. But also acknowledging that some of those ideas will fail, so failure is part of learning. If we fail well then there’s a quote, I can’t remember who said it, but it’s something like if you haven’t failed you haven’t tried hard enough. So you are going to fail at some of these things, so let’s create an organisational culture that says that we are going to get stuff wrong but let’s give it a good go. 

Charlie: In the spirit of talking about failure, can you remember a failure in your career that really taught you something, a lesson or anything? 

James: There’s probably loads. I always reflect on the decisions that we make, are they the right ones or were they the right ones. I think to your earlier point about Covid, we’ve had to make something really difficult, in some cases kind of really morally challenging decisions across the NHS. Or things that we’ve done or not done. I think they’re the ones you’d think okay, I hope it doesn’t but if this all happened again what would we not do again or what would we do quicker. So I think as a leader you’re constantly reflecting and learning on the things that you haven’t done well versus the things that you likely have done sort of okay on as well. 

Charlie: It’s a really interesting point because I speak to leaders every day and ask them about what innovation means to them and quite often I hear it’s new technology or it’s a new invention. But actually what you’ve spoken about there for me is normal everyday innovation. Innovation to me is just doing something better than it’s been done before and it’s through deconstructing what’s happened in the past, we can rebuild those modules to deliver better outcomes the next time around and that rebuilding is innovation itself.  

James: Completely agree. We’ve done lots of really good work on changing the culture at Medway over the last two or three years. Medway suffered six, five six years ago of being in special measures and came out of special measures in 2017.  Since that time we’ve made good head roads in terms of improvements. The perfection path is never beautifully linear, there’s always things that go wrong and we work in an industry where when things go wrong they affect our patients and our staff so they’re never positive positions. But like a setback, you have to then think about how quickly you react and acknowledge that you’ve got to get better and part of that is the culture. 

I mentioned ownership, accountability, empowerment all those things that are part and parcel of good leadership. Our job is to then push that down into the organisation so that it permeates all the way through. What we want is for them all to describe themselves as leaders because they are leaders of whatever they’re doing in our organisation. 

So i’ll give you one really brief example. Whenever you see doctor and nurse programs on the television, the focus is always on doctors and nurses right? I always give the view that the doctor and nurse wouldn’t even be able to go into the theatre unless it was clean and that work is performed by our group of housekeepers. The patient wouldn’t get to the theatre if we didn’t have one of our porters taking that patient. When a patient is in hospital they don’t get fed unless our catering team supports the provision of good nutritious food during a patient’s day. You start to understand that the leadership role is actually much bigger than me or the executive team, it extends itself right the way through the organisation because if they didn’t do their component part the whole thing would fail. 

Charlie: So many patient touch points where you’ve got room for leadership in the depth and the breadth of the organisation. I love that. I guess the dream would be that some people who support the hospital in some of those ways that you’ve talked about there end up watching this video James. On the basis that they do, have you got any tips or tricks for them? Bear in mind that they might not be within your Trust. How would you go about elevating an important solution to an opportunity or a problem that exists in their area of the trust? 

James: If you take the example of housekeepers or our catering teams, they have probably more interaction with patients than probably other clinical groups because they see them fairly regularly throughout their time in hospital. Previously much of our food booking system was manual, so I would give you a slip and you would say what food you wanted, i’ll take it down to the catering team, they would look and then bring your food up. So many different manual touch points and more importantly manual points for potential failure. It’s no different if you went into a restaurant where it’s done electronically, so you enter the details that go straight to the kitchen and then it’s literally a pickup, and then brought back up to the ward. 

It’s those obvious things, sometimes maybe not as innovative as the endometriosis example I gave, but certainly much more powerful in volume terms to the number of patients who it would be so much more beneficial to have it all done electronically. But it’s a very basic system that already exists in most restaurants in the world.

Charlie: What I love about that example is it takes an unlikely area of the organisation where you think innovation can’t come from. It proves that they have a touch point with your customer, a patient and that touch point helps them to see a way that they can deliver a service to the patient that actually makes their stay with you much less stressful and as easy as possible. 

With that in mind, I’ll ask you to talk a little bit about the vision and the purpose that you guys have and how you find aligning the whole organisation to that is like?  

James: We have a vision for the organisation that we call providing the best of care through the best of people. Fairly obvious that our aim is to provide high quality care to our patients, but we only do that through hiring the best people. 

What we find is that unsurprisingly we have parts of our organisation where that ethos oozes out in every single interaction. Our critical care department is rated as outstanding so that’s the highest level of regulatory rating you have in the English healthcare system. Maternity services are also rated outstanding. 

These are areas which you have the best amongst the best of services. The culture there is really strong, the leadership is very strong, but importantly the quality of care is also very strong.  You come into other parts of the organisation and they’re still on that sort of trajectory to get to a better place and they have a lesser rating. It doesn’t mean necessarily that leadership is poor or that the quality of care is poor but there’s more to do in evidencing that, and for that to become an everyday reality rather than something which happens one day but not another. 

When you try to bring all these business units together across the hospital which is probably a couple of hundred, you’re not going to have one picture of the world because you are dealing with very bespoke units within the hospital. Our test is that we’ve got outstanding areas that we can learn from. How do we apply that to one that’s probably needing a bit more support, which is something we’re beginning to do this year. 

Charlie: I don’t know of anyone yet that I’ve spoken to throughout this pandemic where it hasn’t completely ripped up the rulebook of how we go about business as usual. I’m guessing you’re no exception. Now James you talked to me in the past about your RNI strategy but for people watching, would you just give a high overview of what that is and in particular what would be really interesting is what’s come out of it? And again when you talk about what’s coming out of it, I’d really like to know what the benefits were? Because I think we often disconnect innovation and benefits and innovation is to deliver benefits of some kind. 

James: Completely agree. We have a really clear innovation approach through the Innovation Institute, I mentioned earlier, which acts as that vehicle for change and assessing how we prioritise our interventions. 

But on the more research side and how we use an evidence base to support some of that, we’ve got again a very active research team who are constantly not just leading research but assisting in research from all your trusts up and down the country. Pre-Covid that included things around patient outcomes. So sometimes that’s looking in the UK, sometimes that’s looking overseas, and thinking about what the other parts of the wider healthcare systems are doing that perhaps we’re not either at Medway or in the UK. 

One of the outputs of that was three years ago now, we introduced something called robotic surgery at Medway. t is exactly as it says, it is effectively a robot performing surgery being administered or driven by a clinician, by a doctor.  But that doctor doesn’t need to be in the same room and you could argue over time probably doesn’t even need to be in the same country. It’s firstly just amazing to think that can happen, that this can be facilitated elsewhere. 

But the benefits of the patient are the biggest ones. So firstly it’s less intrusive because the manual dexterity of the robot is such that you then have less scarring. It’s kind of straight in rather than scalpel, and all those sorts of things. So it certainly is better for the outcomes for the patient, the length of stay in a hospital for the patient is shorter and the recovery period for the patient is also shorter.  We invested in two two robots, one that we used for training because we had one consultant initially who was able to work the robot which he loved because of course he was the only one doing it. But then he had to train other people which he’s now done. Now we provide training to other hospitals for their clinical teams as well. 

But that was something which came again from one of our clinicians who talked about this robot and now we’re using it for a whole range of different surgeries, some cancer surgeries and urology surgeries.  It’s an amazing intervention. In the American healthcare system I think they’re fairly common practice. I think in the UK there’s certainly more coming online but we did that clearly off the back of the evidence base that it was better for the patient to have robotic surgery than it might be to have more traditional methods of surgery. Alongside that, clearly for new emerging and junior doctors, who are coming into the world of medicine, how much cooler working a robot is than doing it through the old-fashioned route. It kind of acts as a recruitment initiative as well to say come here because we’re performing literally world-class surgery.  

Charlie: It’s fascinating as well how you guys have pioneered something, but you’re not ring fencing that knowledge at Medway. You’re proud of what you’ve done and you’re telling stories that other trusts want to hear and so you’re accelerating this technology and ultimately the benefit to patients that go well beyond the boundaries of your Medway area. Which I think is really cool as well. I love it when an innovation starts small somewhere and then the ripple effect can be felt way beyond that.  

James: That’s how medicine evolves isn’t it. Medicine is formed sometimes in really small parts and then it only grows if we share. The Covid vaccine is a really good example of that where AstraZeneca that Oxford university developed has been distributed all over the world. It’s crazy to think that those geniuses have created this vaccine and it’s shared across the world, and I don’t think it’s any different to how medicine has evolved more generally. For hospitals, when they have something worth sharing it’s right that we share that to as many as we can. Fundamentally we’re all here for the same reason which is if our patients can have less stay in the hospital, they get better quicker and they get back to sort of normal reality quicker than they would ordinarily, that’s a huge benefit to them and their family. 

Charlie: I’ve never really thought about it in those terms before. But you’re absolutely right,  the character traits of good innovation practice are almost baked into the NHS because of what you’ve said. It’s that as humans we innovate in adversity and there’s no greater adversity that we face than something wrong with our health or the health of a loved one. I love that you’ve drawn our attention to the fact that as a sector, you guys have been doing this forever.  

Now you’ve talked about your Innovation Institute, and peppered it into some of the things we’ve said so far. How did it come about and what was the genesis for your Innovation Institute? 

James: It came from an idea of how we can attract physicians to give us ideas. It wasn’t just about innovation, it was more about improvement at that time and it was started with a conversation around we’re getting some ideas but are we connecting well enough with our clinical workforce. We felt that we weren’t and we needed to do more but we also wanted it to an institute that was clinically led so it had doctors and nurses primarily leading it. 

We could have set it up you know tomorrow and quite easily put our faces over it and said give us your ideas. We consciously didn’t want to do that and we engaged with the marketing organisation to create a logo but really to understand what would be its purpose. Because it would have been very easy to create it and then for it to just sit there and do nothing and just become a logo. 

So it came out of a really simple conversation and then over a fairly lengthy time, six to eight months. It took lots of planning and we were conscious that we didn’t just want to open it and then it felt flat so it literally has its own website. It still sits obviously as part of the organisation but it has its own website and its own brand identity. It has its own leadership structure and all of that is designed in such a way that it feels and looks different to what people might have experienced before, and that was a really conscious thing.  If we’d done perhaps what lots of NHS organisations have done which is I send out a note asking for ideas, here’s a sort of boring link to a very boring platform – it’s those sorts of things that sometimes put people off. It needs to feel exciting and people need to be excited by it. 

Over the last six months or so people have been excited about the Institute, but more importantly they’ve seen the outputs.  Our director of transformation created a document called the first hundred days and this was the commitment that we needed to show. Almost a return on the investment. We put all this time and effort so the first hundred days document is really inspiring to see what can be achieved. It’s still in place today and people are still putting ideas through, and the one message is that we never say no to an idea. 

Charlie: I love that it sounds like you’ve really started in the correct way by clearly defining the purpose and making sure that the purpose is understood and bought into by everyone and then in its kind of owned by everyone. What’s great to see, and that I’d personally love to see more leaders recognise, is that this is a mandate from you to your organisation that innovation is the engine room for change. It’s that if you want to keep on being at the forefront of excellent patient outcomes and patient service and be an incredible place to work, which of course attaches to the first point there the better patient outcomes, then innovation has to be an engine room for that. 

You mentioned earlier that this hasn’t just got the CEO’s face on it because as you pointed out, there’s no way you can touch all the many thousands of people working for you, but your leadership team probably can. 

James: Yeah the Institute does not have my face on it. It was a conscious decision that it needs to look and feel different from the norm. It needs to look and feel clinically-led because that is what attracts clinicians to engage with other clinicians about the ideas that they’re having. 

It doesn’t mean that it’s a substitute for talking to me because I would happily talk to any of our clinical teams as I do about their ideas and sort of reflections. But it creates that vehicle, as you say, to say look we’ve got this Institute, it’s delivering tangible benefit to patients, it’s delivering tangible benefit to our workforce and it’s also investing, and in some cases heavily. 

We put roughly speaking about £10k behind those priority ideas to get them going, acknowledging that we might need to come back through a business case to do that with the board signed off. A five-year investment program was put together for our electronic patient records. So this is moving away from paper-based records to electronic. It sounds alien that this doesn’t exist already, but that means all records being on the online platform. That’s a significant investment for any hospital and I would hope that shows not just to our community but our clinicians that we genuinely, you know going back to what you said at the very beginning, we have those priorities of workforce, we want our workforce to feel that they’re working for an organisation that listens in terms of their frustrations. It will certainly improve quality of care no doubt, and the enabler to those things is technology in this instance.   

You kind of start to bring those boring sometimes strategic words into a reality. That if you give us an idea we’ll get alongside you and try and develop it. Sometimes it’ll work, sometimes it won’t. Those that don’t, you either kick them to the curb and you move on or you evolve them a bit more and say actually with a bit more tinkering, could we do something different with that. Now the benefit of that Charlie, is that because we engage so many different people, they all have different ideas. You’re not working with the same group all the time and that’s to bring a bit more energy, a bit more excitement but importantly more ideas. 

Charlie: It’s a really interesting topic isn’t it, diversity and inclusion of thought. It’s just so powerful to the end result that an innovation should deliver. Historically we tend to design solutions as leaders in small groups of people that look like us and speak our language, but we’re often far removed from the cold face of that opportunity or that problem. I imagine as a leader in the NHS, diversity and inclusion is always front of mind. Have you seen good depth and breadth of engagement from across the organisation? Is there room for more advancements there?  

James: To your first point about diversity and inclusion of thought, I think it is such an important concept. If I think of my team,  if I had 10 people who were all the same, it could be quite hard to manage 10 big personalities. Sometimes I know we benefit here from our HR director for example who will often wait until all of those sort of louder people have had their their say and then all of a sudden he’ll ask one really pertinent question that no one’s thought of and it kind of stops people a little bit and then we kind of regroup. It’s those sort of thought processes that different people bring that I think is the powerful part to innovation because sometimes, you need someone just to say have we thought about that. 

Diversity and inclusion of thought more generally, I think there’s always more to do to get to particular, sort of less represented groups in the hospital, in any community. I would certainly like to see more in the way of engagement in some of those harder to reach groups. I don’t mean just ethnicity or race, I’m talking in the broader spectrum of diversity and inclusion. So this includes everyone having a voice in the organisation regardless because as you say the ideas will come often from one person making a really small comment that then sparks an interest in somebody else that then grows legs. And in the end, you start to create something which is quite powerful just by listening. 

Charlie: An obvious one there is just extroverts and introverts. Extroverts that are very forthcoming with their ideas, that want to be known for them. Introverts don’t have any less ideas, they’re just not so loud with the megaphone about how good their idea is.  

James: In part the test of a leader, I think sometimes is assessing who in your team is the extrovert versus the introvert. But also understanding how those two groups can work together really powerfully. Sometimes you want the extrovert to listen a bit more and you want the introvert to maybe speak a bit. But you have to manage that because you can’t just chuck them in a room together and say come back out with a great idea. You’ve also got to allow those ideas to sort of emerge and flourish over time based on how those two groups particularly work together. 

There’s a  book called it’s a Zoo Around Here, it’s by a guy called Nigel Risner, and it’s a bit like a psychometric test. The end point is that it gives you a connection to a particular animal and the good thing about this book is that it tells the animals how to interact with each other. So there’s a monkey and an elephant for example. The elephant is more the introvert and the monkey is more the extrovert. What it does to the monkey is tell you how to interact with the elephant and it tells the elephant how to interact with the monkey. It sounds a bit crazy, but the important thing is that if i’m a monkey and I run into the elephant being overly excited, I’ll really annoy the elephant and they’ll just switch off. Likewise if the elephant goes into the monkey’s office and doesn’t have some energy, the monkey has magpie syndrome and is already thinking of three things over here. So it’s a really nice but really really simple way of alerting us to some of the things that we perhaps need to stop ourselves doing that we do normally and tells us how to interact with other people. 

Charlie: I think that communication again is an important ingredient in the innovation recipe. I love recommended reading so let’s make sure that we get that in the description in the YouTube channel. If you’ve got questions for James again do fire them at us, we can forward them on to him and if he gets time in the midst of Covid-19, we’ll try and get some answers back to you guys. James, it’s been an enormous pleasure getting you on camera and just authentically sharing your views on these things. I think it’s really important that we listen to one another, we share experiences and we constantly keep innovation right at a north star position. Innovation helps us get to where we want to go and so whenever we can get someone at the top of an organisation like yourself talking about that north star alignment it’s incredibly useful so, thank you.