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Wednesday 12 July 2017

Heather Caudle: a moment of crisis and opportunity for the NHS

By Alison Moore

Heather Caudle is a pioneer of partnership working and a rare black leader in UK nursing. As she joins NHS England, she talks to Alison Moore about her career and her take on the NHS

Heather Caudle is driven by a relentless positivity which permeates everything she does and translates into incredible energy – even her Twitter profile urges people to "dream, decide, do".

Now her energy and positivity are transferring to the national stage as she moves from being chief nurse at Ashford and St Peter's Hospitals Foundation Trust to NHS England, where she will be director of nursing for improvement. Her areas of responsibility include safeguarding, continuing healthcare, maternity, and children's and young people's care.

It's not her first major career change. "I have not gone up the traditional route in nursing, but was a mental health nurse who made the crossover into safety and quality in the acute general sector and was able to effect some change at strategic level," she explains. She says her philosophy has always been "in partnership you can make things better".

"I'm looking forward to working on a national basis," she adds. "My remit will be much wider and the impact of my work will be far reaching. This can be daunting, but I'm looking forward to the challenges and opportunities to help strengthen and improve nursing."

She has always been keen on using data and evidence to drive change and improve services. "When you are running an eating disorder service, you know when the clinician is successful by identifying changes to what patients weigh or by the number of times they engage in purging behaviour. It's driven by the data," she says.

"In project management there are always milestones, and there's a data side you always need to refer to to see if you're successful. When I came to Ashford and St Peter's I tried to implement the same ethos. In my own thinking, this is what I will be driving and supporting nationally.

"The new job requires someone who can both understand change and improve methodology, surpassing divisions between different professional groups [and] encouraging people to work together," she explains.

Another challenge will be working at a national scale, where Caudle will have to work collaboratively alongside other senior nursing colleagues. "This will mean, no matter what organisation we work for, senior leaders have shared goals and objectives, to drive improvement consistently across the country," she says. She also wants to develop messages that resonate with NHS staff who are not clinicians – a skill she admits she needs to work on

Cultural changes

Caudle acknowledges that many of the changes required in NHS organisations are cultural. "A lot of listening is going on in [NHS England] and it's really championed. It's not a tick box exercise, it's a real cultural thing," she says.

Caudle will have to get used to a lot of travel. While based mainly at Skipton House in London, she will make weekly trips to Leeds as well as visits around the country.

As an acute trust chief nurse, she is acutely aware of the pressing workforce issues that will be the backdrop to her strategic work on improvement. Not only is the NHS failing to recruit the nurses it needs, but she acknowledges issues with morale – which she describes as "up and down" – and continuing pay restraint.

While not underplaying any of these challenges, she cites her experience as part of a leadership team at Ashford and St Peter's which managed to buck the negative trends in the NHS staff survey. The trust has improved its performance on relationships with line managers and with people feeling their feedback was taken seriously when reporting serious incidents, using methods such as raising the profile of 'speak up for safety' guardians.

"The issues highlighted [in previous surveys] were leadership and the organisation learning from mistakes and incidents," she says. "We have focused on these issues specifically and have seen a significant improvement in our staff survey results. It was very much in partnership with the board, with the director of workforce and organisational development taking the lead," she says.

In NHS England, she says, "I will continue to work in partnership with others. It's about being able to describe the purpose, listen to the constraints people have and empower local leaders to address the issues. The role is also about being able to look at the data and respond."
She urges managers on the ground to take steps to boost morale and make changes that matter to staff. Managers need to listen to what staff say are the barriers they face – and then be open and honest about what real change is within their gift.

She sees looking at ways to make NHS resources go further as one the key aspects of Leading Change, Adding Value – the national framework for nursing, midwifery and care staff.

"Working sustainably is key. We need to focus on working more efficiently and working differently, perhaps more in partnership with others," she says.

More generally, Caudle thinks the NHS may now be at a tipping point where problems become opportunities, but stresses that the NHS has to manage that change successfully. She points to opportunities she sees to use the untapped potential of BME staff to help meet some of the current challenges, and is also keen to get a deeper understanding of what's going on with the nursing workforce. Why are nurses rushing to do agency work, for example What is needed to retain more staff and bring people back into the service?

She suggests the current problems may echo some of those from the early 2000s, but the answers may be different because there is less money to spend. Back then, the NHS could devise solutions, such as term-time or school-hours working, which are harder to afford in times of continuing austerity.

A circuitous career path

Caudle's path to the top was a circuitous one. She was brought up in a large family in Trinidad where she initially worked as an assistant teacher in a seaside village.

A turning point came when one of her students developed drug-induced psychosis and had to be looked after in a monastery. Visiting and supporting patients made her realise both how much her efforts were valued and that this made her feel good in return. "They were ever so grateful for what I did and my acceptance of them – there was stigma in both drug use and mental health. At that point I decided to go into the caring professions."

The experience led her to apply to train as a nurse in the UK at the North London Joint College of Health Studies. After qualifying she worked as a mental health nurse and then started to specialise in eating disorders. She also trained and qualified as a family psychotherapist.

One of the breakthrough moments in Caudle's career was redesigning an eating disorder service which was under threat, and developing an innovative model by working in partnership with a nearby trust. "It was the first time I had a real conversation with a director We were successful – the service is still going and is still one of the best in England," she says.

"We must work together to remove any opportunity for bias and unfairness, and challenge stereotypes about the characteristics of others…"

Off the back of this, she was approached to help release £2m of savings for an aspirant foundation trust while ensuring patient quality did not slip – a job that involved the contentious merger of two psychiatric intensive care units.

With a husband and two small children, a move out of London was on the cards. She was approached about a role in patient safety at Ashford and St Peter's and accepted it. Husband Jez now works from home, enabling him to take on some childcare duties.

Caudle's career progression has not always been smooth. She has been turned down for jobs she felt she was ready for and admits she has questioned whether her own ethnic background was a factor.

Glass ceiling

"What might have indirectly protected me was just not knowing what the rules were," she says. "I didn't know that these opportunities were not open to me. I didn't know the rules about the BME glass ceiling."

Visiting trusts, she has sometimes been shocked by the poor opportunities for progression available to BME staff. "I just didn't realise that there are hospitals where a nurse of a certain colour or ethnicity just did not move beyond [Agenda for Change] band 7," she says. "Even if BME candidates manage to get through to some roles, their fight may not be over as there can be problems with culture and environment in the workplace."

She supports the Workplace Race Equality Standard (WRES) but warns that it can only do so much. "It's a leadership challenge," she says. "The WRES is a measure. As someone who understands and appreciates data I can see it being helpful. However, we will not change the culture of the NHS by mandate. If you manage to create organisations focused purely on achieving the right culture and providing the highest quality compassionate care, that is when the BME issue will be resolved."

She adds: "We must work together to remove any opportunity for bias and unfairness, and challenge stereotypes about the characteristics of others – remembering that sometimes what we have always known and done might not be the appropriate course of action for current, future and even more complex problems."

The Breaking Through course – run by the NHS Leadership Academy – influenced her to look at other demanding jobs and led her into the world of safety and quality improvement.
Caudle says her working life has influences by a strong "moral compass about helping others" and very much inspired by her strong Catholic faith. She is keen to carry her focus on helping and communicating with everyone regardless of status into her job at NHS England. But she's clear that she will miss life at Ashford and St Peter's: "One of the porters said to me, 'We will be sad to lose you – you're a legend, you're smiley and we can talk to you.' I hope I can continue to be recognised in this way when working in my new national role!".

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