Suhail: [00:00:00] Welcome to Voices of Care. In this episode, I’m speaking to Karen Bonner, Chief Nurse at Buckinghamshire Health Care NHS Trust. We’ll be discussing the provision and promise of the NHS long term workforce plan and the thorny issue of how to create a truly inclusive culture. 

Karen: [00:00:15] I’ve been NHS long time, as you mentioned, and I’ve never quite seen this many competing things going on at the same time. We welcome this new strategy along with the new flow of money that will help to support that as well. I think it’s a recognition that we need to invest more in the resources and our people are fundamentally the most valuable resource and therefore it’s important that that is acknowledged. This is a societal issue. This goes beyond the NHS and I think it’s important for us to recognise that says something about how we look after the people, but also the public themselves. How they treat our staff is fundamentally something we do not talk enough about, and that in itself has the impact on the individual’s report about how they’re feeling as well. So, you know, they’re not always treated with kindness by the public either. And discrimination happens from the public as well as within the, you know, sort of within the people that we actually employ. 

Suhail: [00:01:12] Hello, I’m Suhail Mirza and welcome to this episode in season two of Voices of Care. I’m joined today by Karen Bonner, the Chief Nurse at Buckinghamshire Health Care NHS Trust. The Voices of Care podcast seeks to get to the heart of the issues facing the health and social care sector, and by talking to leaders about how we can enable the health care workforce of the future. It’s been a seminal year for the NHS with the publication of the NHS Long Term Workforce Plan. We’re here to talk about its promise and the challenges it may face and how we can transform workforce, in particular nursing. Who better to talk to about that than my guest today? And Karen, welcome. Thank you for giving us your time today. 

Karen: [00:01:46] Thank you. Thank you for inviting me. 

Suhail: [00:01:48] No, it’s my pleasure. Before we get into some of the detail of the conversation, I thought we’d take this chance to hear a little bit about your role at Buckinghamshire. I know you’ve had an illustrious career, very celebrated, all the leading London NHS Trusts, but Buckinghamshire is your focus at the moment and there’s a strategy there and it’s of course renowned for its world famous Stoke Mandeville Hospital. But of course it’s a broad range of services in the community as well. 

Karen: [00:02:12] Yeah, indeed. So thank you. So Buckinghamshire Health Care. I’ve been there for just over three years. I had the pleasure of starting there on the 30th of March 2020.  

Suhail: Perfect timing.  

Karen: Absolutely. I thought I’d go big. So yeah, Buckinghamshire is an integrated, acute and community organisation. It’s spread over the whole of the county and it’s actually quite a long county and therefore we service people from across the county. It actually quite has pockets of real affluence but also has pockets of deprivation. So we have community services, so going into people’s homes, but we also have community hospitals and then we also service the emergency services as well. And our accident emergency, which is based at Stoke Mandeville Hospital, and then we’ve got Wickham and they’re the sort of two main hospital sites as well. So yeah, it’s a very large and complex organisation, but we are fortunate that we’re able to also provide care across a complete pathway into people’s homes.   

Suhail: [00:03:12] And there’s quite a lot of transformation because your strategy is laid out. The fact that of course like many places, you’re seeing a dramatic rise in the absolute number of the population, but also in particular in that cohort of people who are 85 plus. 

Karen: [00:03:24] Yeah, absolutely. I mean, it’s an ageing population. And there are new houses also being built in the area. So it is a growing area. Sometimes people will move outside of London to live in Buckinghamshire, but they often go back to work in London. But yes, it’s an ageing population, so we do focus a lot, particularly around our frailty services and obviously our community hospitals and services for those older people. 

Suhail: [00:03:48] You cover the whole community and obviously the direction of travel, as you know, of course in policy is now to move more and more services within the community and we need the workforce to be able to deliver that. So I wanted to touch upon the fact that obviously if anyone looks at the press, there’s been a tremendous challenge: the 7.5 million people for elective surgery, 112,000 vacancies, industrial action. Your longevity and experience – you’ve seen lots of things come and go in the NHS. How bad have you seen the situation at the moment in terms of the workforce challenges and crisis? Is it as many of our other guests on the podcast have said, the worst that it’s ever been? 

Karen: [00:04:25] Well, I think we’ve just come out of a really difficult three years and I think we also have to frame the context and I think we’ve never known anything like it. So we’re recovering from something nobody’s ever experienced before. So there are new challenges. And I think where the public sometimes feel we’re over the pandemic, we are still very much trying to catch up from that. So it is definitely I’ve never been.. I’ve been in NHS long time, as you mentioned, and I’ve never quite seen this many competing things going on at the same time. So I think we’re recovering. So the waiting lists on top of the fact that yes, there is industrial action and on the fact that we are obviously trying to ongoingly transform services and we’ve got new, as you know, new publications around how we should do that. So it’s a really difficult and also new time for us all across the health service. And obviously many people are still recovering. We’re all still trying to recover ourselves as individuals from the last three years. 

Suhail: [00:05:20] No, absolutely. And it’s a seminal year, of course, 75 years, NHS, Windrush. There’s so many things that are worth celebrating. And I think the publication of the NHS long term workforce plan is itself been an act that I think people have welcomed. It’s seeing projecting a huge demand and how to meet that demand by increasing the workforce dramatically across all sectors. Nursing, we’re seeing doubling nearly of training places. Just as a big context how has it been received? You’re a nurse leader for many years. It’s welcoming and it paints quite a potentially positive picture over the over the longer term. 

Karen: [00:06:02] Yeah, I mean, I welcome it on a personal level. I think, you know, we had an interim plan some years ago that didn’t come attached with any money. And so we welcome this new strategy along with the new flow of money that will help to support that as well. And there’s been a I think it’s generally it’s been well received. There’s always going to be concerns about how we then deliver that. And that’s the work we’ve got to do is how do we then make that real? Because it’s like any plan, you have to make that real. And I think that we, I think it’s a recognition that we need to invest more in the resources, and our people are fundamentally the most valuable resource. And therefore, it’s important that that is acknowledged and that does do that. And I think we welcome it. It’s now about how we then deliver it. 

Suhail: [00:06:45] Well, we’ll be touching upon that for the rest of this conversation. But before moving on, one of the goals of the plan, one of the objectives of the plan is to reduce the historical reliance on the international workforce, dropping it down from 25% to 9% over time. I wanted to take the opportunity because you’ve worked with many of the clinicians internationally, to perhaps take stock of the contribution of the international workforce because they face their own unique challenges. And yes, we have to grow our domestic workforce, but they played a huge part and continue to play a huge part in the NHS. 

Karen: [00:07:20] Yeah, I’ve been quoted a lot to say that the health service is built on its international colleagues and you know, from the Windrush right through to today, we cannot deny that the health service is built on that. And I think it’s important for us to acknowledge that. And it’s also important for us to recognise that. I’m a descendant of the Windrush generation. My parents came here as part of the Windrush generation. That generation were the fundamentally were key to the building of the health service. And consequently, since then we’ve continued to recruit from international colleagues from the Philippines, from India, from parts of Africa and previous iterations as well. And I think we should acknowledge that they will always fundamentally be in the fabric and the DNA of the of the health service. I don’t think anything is going to change that. There are still generations now with other children being born in the UK that have gone on to go into the health service, including myself, who went my mum worked for the NHS briefly at Stoke Mandeville Hospital, actually as support worker. And so there are many of us that will continue that legacy. So whilst it may not be directly internationally, we will always be in the fabric, I think of the NHS. So any plan, I think it’s important for us to acknowledge that as well. But I do think it’s important as well for us to grow the homegrown talent. It’s very important for us to acknowledge that we do need people from the UK as well working as part of that system. It is, you know, employment rates high. There are opportunities. We’ve got many, many vacancies across the health service. So I’d encourage anybody to look at a career in the health service. And I think if we can encourage and support that locally as well, I think that’s really important. 

Suhail: [00:08:56] Absolutely. And that will be fundamental to growing the numbers. We also have the question of retention. There’s a lot of commentary around we can’t recruit ourselves out of a retention crisis. And I wanted to just touch upon the idea that the plan talks about embedding the right culture. You reference the people plan from 2020, the people promise all of these types of things, but I want to hone in on inclusivity. It’s an area where you’ve been recognised across the health care spectrum for your contribution, and I know you’ve been on the Strategic Advisory Board on the res data. There’s a long way to go. There’s been some great things that have happened, but if you look at the numbers from the NHS staff survey, we’re looking at a very diverse workforce which should be celebrated. But 1 in 10 reporting that they face discrimination from their managers and colleagues. So it’s a lot of work going on that needs to be done. 

Karen: [00:09:50] Yeah, I agree. And I think we should acknowledge that whilst we’re recruiting people and there are people from diverse communities, including myself, we do need to do more around how we support and get that sense of belonging across the health service. I also recognise that this is a this is a societal issue, this goes beyond the NHS and I think it’s important for us to recognise that. It says something about how we look after the people, but also the public themselves, how they treat our staff is fundamentally something we do not talk enough about and that in itself has the impact on the individual’s report about how they’re feeling as well. So, you know, they’re not always treated with kindness by the public either. And discrimination happens from the public as well as within the, you know, sort of within the people that we actually employ. So I think it’s really important, but I think it’s really important that it’s an individual accountability as well as a collective accountability. And that’s where we need to get to really make the cultural shift that we need to. The sense of real belonging, that we are a community of people from many backgrounds, how we help people to feel that sense of belonging. 

Suhail: [00:10:52] And have you seen good examples of that happening? Because I’m glad you’ve highlighted the fact that people usually hone in on the idea of the discrimination faced from colleagues and managers. But as you say, this is a big issue. You’ve called it out. Patients themselves unfortunately, there’s instances of discriminatory behaviour. Have you seen good actions over your time you’ve worked at? Period. Chelsea, Barts.  The full gamut. Soe good examples of where actually strides have been taken. 

Karen: [00:11:18] Yeah, I mean, there’s some great examples. Obviously, you’ve mentioned already that I was part of the workforce Race Equality Standard Advisory Board for many years and I was privileged to sit on that very early on after not long after its inception, really in order to support that sort of advisory piece. And what we feel happens really at working at the front line and feeding that into that. So I think there’s some great work going on and there are many organisations that are taking some of that work and embedding in good practices. You know, in my time at Chelsea, we worked very hard to set up their networks and fundamentally build that into the fabric. And with executive sponsorship and real holding the board to account to getting the people in the organisation to hold the board to account for some of the experiences that they are having. And I think that’s really fundamentally important. There’s a new pledge now for all board members to have a, you know, an objective in their part of their work and appraisals around equity. And I think that’s fundamentally important because that’s where you get the individual accountability. At Bucks, we’ve worked really, really hard. We’re working very hard and we’re nowhere near where we need to be. But my board has been very committed to make sure that they’ve got a diversity at the board level, and that’s where it really starts. 

Karen: [00:12:31] If you start to see the leadership really shifting in its makeup and it’s and it produces people much more innovation because you’re thinking differently. We’ve got people from different backgrounds. You know, I’m sitting on the board and, you know, coming from a different background, different upbringings really helped with that innovation and I think it starts with the board. So places like our organisation are starting to make that shift and change and you’ll start. And what we see is that starting to then shift how the rest of the organisation starts to think about inclusion and their responsibility and their accountability. And we’re seeing much more diversity at the senior leadership at below the board level. And then you’ve got to get right down into organisations as well. So there’s lots of good work going on. I think what’s really important is, is that it’s — you have to keep at it. And what I want to really emphasise is that you can put action plans together. We’ve all got them, lots of them. We’ve all got action plans. But you have to keep at it. You have to constantly be looking and constantly evolving and always not being afraid to hold the mirror up to yourselves. 

Karen: [00:13:34] And we do that by constantly asking ourselves and looking at what our people are telling us. And we have networks that come and sit and share their experiences with us at board so that we are really starting to get into “what does it really feel like to be part of the organisation?” And it goes back to how do you shift the culture and culture can be shifted by what are the behaviours that you’re willing to accept. And so we’re not willing to accept the racism that some of our colleagues experience, whether it’s by their colleagues or whether it’s by the public. And so by having saying that out loud helps to support how people then start to focus in on their minds, on that. And I find because we do that, I get much more reporting, we get much more reporting of incidents now than we did before, which enables us to address it, because if it’s not reported, it’s very difficult to address. And also the fact that shining a light on it means that everybody individually has to hold accountability. And at a board level, all of my colleagues and, you know, not exclusive to me, have to hold accountability for that. 

Suhail: [00:14:37] No. And that’s encouraging to hear that actually people are willing to put themselves forward. And obviously the NHS have published their equality, diversity and inclusion improvement plan that you’ve alluded to with, I think, six high impact actions, including board representation. And the other issue that they do cover of course is equity in terms of recruitment and having a representative process to encourage people because you’re talking about encouraging people to join. That process has to be inclusive and obviously to narrow the scandalous fact that there’s a gender pay gap, for example, that still remains. 

Karen: [00:15:10] Yes, absolutely. And along with disability gaps and disability as well. So it’s really important that all those things are focused on. I think the other thing I would also say is, is that it’s not just about numbers and it is about representation. I say it’s not tokenism. This is not tokenistic. You know, we don’t want people just to be recruiting because it’s they need to know it’s the right thing to do. It’s the right thing to do for the organisation. It’s the right thing to do for the people. And therefore, it’s important. So I know the fact that people see me as a Chief Nurse and how that inspires them to think about their careers differently. So that representation is so, so key. 

Suhail: [00:15:44] And also to communicate that very effectively. 

Karen: [00:15:47] Absolutely. Absolutely. And I think it’s important that it’s not just about, you know, I’m not the only voice on the board talking about equity. So because I come from a diverse background and because I’ve been impacted on it on a personal level in work and outside of work, that actually for me, I’m able to share that story, have honest, open conversations. But also all of my colleagues are also part of that journey as well. So I’m not the only person in the room. And I think when it comes to the recruitment, what’s really important is to individually think about the way that you recruit, but also thinking about what you’re doing in that recruitment process, how you hear, how you listen, how people speak, how they present themselves, the expectations that we often have of people. So I think it’s really important. So we’ve tried, we’ve got, we’ve done some work around having debiasing all of our processes and making sure. So sometimes even looking at an application and pulling people into an interview, getting them in the room, looking at different ways of recruiting people. Not everyone, you know, puts everything down well on paper, but also making sure that the process is fair. 

Karen: [00:16:48] And that really started with my recruitment. So when I came for my interview in 2019, Covid wasn’t even on anybody’s radar. I remember coming into the interview process and feeling that I was really treated fairly. That, you know, there were a diverse group of candidates. There were two men, two women, there were two from different backgrounds, including myself and everybody was really friendly, welcoming, really kind. So you felt, because you’re also forgetting sometimes that we’re on interview too, so do I want to work for you? And therefore, when I left that day and we had a number of different events, I went around and did stakeholder events. Everybody was welcoming. I felt I’ve been treated fairly. Whatever the outcome will be, I need to have felt that. I felt that I was treated fairly and that’s how I felt. And we are doing our best to try and make sure that that’s how people feel inside the process. Therefore, whatever decision is, you want to make sure that everybody is treated fairly. 

Suhail: [00:17:45] Absolutely. And that, I think, is going to be crucial for retention. Turning to the point of growing the workforce under the plan, there’s some startling numbers, of course, to increase… There’s already an existing commitment from the manifesto of the government from 2019 to increase nurse numbers. But the next 15 years, the vision is to double these training places and grow, particularly nurse specialists with mental health, learning disabilities and nurse associates. I wonder you’ve been involved in the training of nurses. You understand this subject so well. The plan talks about levelling up the training opportunity. What sort of pathways will we need? Because we’re we have the pathways now. But do you see the need to innovate in terms of the way, in terms of flexibility that we offer people in order to train as a nurse? 

Karen: [00:18:31] Yeah. I think there is definitely some room for some innovation and we could already see different pathways. You’ve got the associates, you’ve got the apprenticeships. You know, I started out my journey with very few qualifications from school and at the time there was the enrolled nurse training, which was open to me and it was a two year training. I sat on the register. It’s not dissimilar now to the associate nurses, and then I qualified, sat on the register, worked for four years, then eventually did a conversion course a year, four years later, and got my state registered level one. So people like myself have benefited from different avenues into nursing. You know, that was that was 30 years ago. So it’s not a new concept. But the reality is it’s important that we are a profession that is a degree profession. It’s important that we have that academic piece of our work. So I think it’s really important for us to do that. It’s really important, but people should come in and be able to come in in different ways. You know, if you haven’t done well at school, you can go in and do an apprenticeship. If it is that you come from a different place and change your mind about where you want to be, then coming in and doing some of that nurse associate support worker roles and then eventually going into different routes into nursing. I think it’s welcomed and I think it’s important for us to recognise that we have to have different ways for people to get into the profession. 

Karen: [00:19:48] It’s a great profession to be in. I think people don’t always realise as much as how many different roles there are, you know, diverse, different roles across nursing and therefore opening people’s minds. I think some of the TV programmes, some of the inside sort of, you know, fly on the wall documentary pieces have really helped people to understand what it’s really, really like. And therefore, I think the more we can help people to understand about these roles, the better we can hopefully inspire young people. So we’re doing some things at Bucks in schools and I’ve done that. When I was in London, we used to do a primary futures inspiring women at work here in London, where you go into schools and start to really help people to see what it’s like working for the health service and what they can aspire to do. And I think the more we can get into schools as well as trying to do all the things that we’re doing as well so we can start to inspire the next generation as they come in. 

Suhail: [00:20:38] So it’s very much personalised. As you say, the degree is there, it’s meant to be there to honour the depth of knowledge and expertise that nurses need to have as clinicians and more and more responsibilities falling on nurses in terms of not just acute settings, but community settings. I think people don’t realise maybe we can touch upon that because the perception that people have is that nurses in acute hospital settings by the television and all the rest of it, but actually nurses play a huge role in social care and in community provision. 

Karen: [00:21:07] Absolutely. Absolutely. And I think that you’re right. So it’s often. Even like you think about the NHS, you think about hospitals, you think about nurses and doctors. You know, there are over 350 roles across the health service and so therefore there are so, so many opportunities. But you’re right. Nurses play a huge part from the moment people are born. You’ve got your midwives, you’ve got your midwife assistants all the way through into the community services. So district nurses, primary care nurses working in GPs, health and social care, really, really important and fundamental in people’s homes, keeping them at home, caring for them in their own location. And we are fortunate at Bucks to be an integrated, acute and community trust. Therefore we do deliver that care. And I think understanding the broad range and help people to understand what nursing is really about is really important. So changing that perception, it’s not just hospital, it is community, it is primary care. And in other parts of that patient’s journey as well. 

Suhail: [00:22:07] And I think the broader picture that nurses can actually now, as you say, we’ve got the promise of the integrated care systems now which are here. You’re part of an integrated care system where there’s we’re seeing joined up thinking. Just very briefly, that’s now opened up the possibility of multidisciplinary teams, nurses and clinicians and non-clinicians working across a place and a neighbourhood and a whole system. Have you begun to see some more diverse opportunities for professionals to experience these different pathways? 

Karen: [00:22:39] Yeah, well it’s still fairly new, so I think we’ve just got to acknowledge that it’s still fairly new. And our system, which is our, we call it BOB, which is Berkshire Oxfordshire and Buckinghamshire, is still very new and still maturing. So I think there’s still opportunities for us to see the real opportunities that come within that. But yes, absolutely. The fact that you should be able to see your career across a system and patients don’t just access things and boundaries. So even Buckinghamshire butts up against Oxfordshire, we have to transfer some people to Oxfordshire and people from Berkshire, we get people coming from Milton Keynes, which is the other end of the county. So actually, you know, working across the system will should help, the patient, should help their journey. But also we’ve got to see careers across systems, so that actually you can start to shape your career very, very differently. So you might work, you might start out your life in a hospital, but you might end up then going into the system, which will be very, very different. So I think there’s a real opportunity for both the patients and the people working across the health service. And I think if we can just cut down some of the barriers and people moving around, whether it’s patients, should make it much, much easier and also hopefully use our resources much, much more effectively as well. 

Suhail: [00:23:52] Which is a big imperative under the plan in terms of productivity. And that’s paints a fabulous picture of promise under the plan. One of the key threads for me looking at the plan and I think it’s made express, is that the importance of leadership. For making all of this happen is going to require leadership at every level across the system. And there was a report, of course, Sir Gordon Messenger and Dame Linda Pollard, expressing the idea of a of a collaborative and inclusive leadership. And they’ve called for standardised leadership training. But and they talk about a window of opportunity. Now, you’re a very inspiring leader. You’ve given us this story about how you’ve started off as effectively a nurse associate would be today. You’re a Nye Bevan, graduate, master’s degree holder and Chief Nurse. It’s fantastic. You’re the perfect person to tell us how important is leadership going to be? What does that look like? And do you have any tips for people who are starting their journey as nurses who try to follow your footsteps? 

Karen: [00:24:51] That’s a huge question. So leadership is key. But I think we’ve got to redefine what leadership means in a way that there are leaders throughout organisations. Leadership isn’t always just at the top, you know. You know, the health care support worker could actually run a ward some days or the community services as well. So I think it’s important for us to redefine leadership at all levels throughout organisations and that allow people to demonstrate their leadership skills at any moment. So, you know, it’s really important not to think about leadership just as the board or the person that’s got the title manager actually, because you know, there are many great leadership examples. If you walk out into the community services now of people leading their services and their teams and they may not even be that senior in regards to seniority, because if we can break down that hierarchy and enable people, I think is really important. But I think what’s really important is how you lead with real courage and compassion. And I know that that feels like a word that we’ve bandied around a lot. But, you know, there’s a bit about, you know, compassion is not just empathising, but doing something about that suffering, doing something, doing taking responsibility to really lead with real heart. 

Karen: [00:26:04] And I think that that’s very different to probably how we’ve seen leaders before. So that you start to be a bit more open and compassionate, but also that makes you a little bit vulnerable. And vulnerability in itself is really important, actually, because we are leading lots and lots of people who sometimes they find it hard and it is a hard it is hard and it is tough. And actually, if you’re just always sort of this tough leader that just feels like everybody should be a certain way, that isn’t really going to be conducive for the well-being of our people. And the well-being of our people is really important. So leadership, kindness, compassion, inclusivity, the bits we talked about, how do you become an inclusive leader? And that means you do have to hold the mirror up. You are going to have to be uncomfortable at times. You’re going to have to lean into the things that you’ve got to do, in order to continually evolve and never think that you’re there. I don’t think I’m there as a leader. I’m always evolving, and it’s really important for us to evolve as leaders. And without that, we will not progress or deliver the things that we need to. 

Suhail: [00:27:03] Bring your authentic self. And seeing vulnerability actually as an aspect of your quintessential humanity.  

Karen: [00:27:10] Absolutely. And it’s a strength. It’s not a weakness. It’s a strength. And the courage for which we lead is really important. And that does mean you’re going to have to sometimes be vulnerable and admit that you’ve done something wrong or you’ve made a mistake that makes you very human and therefore you connect better with people. It shifts the culture and the ability for people to see you differently and allow themselves to be vulnerable, too. And therefore, leadership is really key in all of this. We’re going to have you know, I sit on the board. We’re going to have, you know, the chief exec, the board members who are there steering the organisation. But you also got to be remembering that you are there representing the rest of your workforce. I represent over the 3500 nurses and midwives and support workers in my organisation and the allied health professionals in my organisation. So when I sit at that board level, I’m not just there for myself, I’m there. So therefore listening and really hearing and bringing those voices to life at board level and know that they’re speaking through you is really important. And therefore listening and being able to be accessible, being kind, being open and being compassionate and being willing to evolve, I think is going to be really important. And I welcome all of the work from The King’s Fund around compassion and kindness and leadership. And the direction of travel for which we are taking that journey actually, I think is really going to be important for the future of the services that we’re all delivering. 

Suhail: [00:28:31] On that inspirational note, Karen Bonner, thank you very much for your time and for your openness. 

Karen: [00:28:36] Thank you for having me. 

Suhail: [00:28:37] It’s been a pleasure. If you’ve enjoyed this episode of Voices of Care, please like follow or subscribe wherever you receive your podcasts. And if you want to find out more about how we are truly enabling the healthcare workforce of the future, please visit newcrosshealthcare.com/voicesofcare. In the meantime, I’m Suhail Mirza. Thank you very much. Goodbye and look forward to seeing you on the next episode.