Impatient for change: Prerana Issar on leadership and the NHS workforce

Hello, and welcome to The King's Fund Podcast where we talk about the big issues and ideas in health and care. I'm Helen McKenna. I'm a senior fellow here at The King's Fund and I'm going to be your host for this episode.

Today, we're sitting down with just one guest to explore their leadership role and the ins and outs of their career journey. That guest is Prerana Issar who is Chief People Officer for the NHS.

Prerana, welcome to the podcast. We're really honoured to have you with us today.

Who I am and what I do... would that take a long time (laughter). I'll try to summarise. I grew up in India and both my parents were in public service. They both joined the civil service when they were fairly young and then they worked hard to make life better for us people of India, for their entire career. A lot of our dinner table conversations were about the work that they were doing. For instance, my mother ran the largest midday meals scheme in the world and I remember her discussing how to get food to tens of millions of children every day in schools that didn't have anything else to eat. That really helped me to see the kind of inequality there is in the world and what can be done about it. That arc of how can we make this world a better place for everyone has really been a part of my DNA and my growing up.

Then I studied to be a psychologist and then did a business degree and joined Unilever. 15 years with Unilever in different countries. Then I joined the United Nations in the humanitarian side of the UN, that was for six years and five months ago, joined this amazing enterprise, this amazing idea called the NHS.

It feels great and I think when people ask me, are you settled in and I say, it feels like five minutes actually, the five months, and it's been amazing and intense and very, very inspiring. The people that I've met, especially on the frontline but everywhere, are just so passionate and committed to providing the best care for patients.

I get asked this a lot and I thought about it a lot so I can share what that thinking and feeling process was because it was an entirely - it was head and heart and gut as well. It was a combination of the journey of my life and my work and my family including my children, and what the NHS is trying to do at this moment. I think when we look back, 15 years later, this year and the next three or four years will be really defining years for the NHS. It's a big opportunity to make a change, to continue to evolve and respond to some of the challenges, healthcare challenges that everybody else in the world is facing, but that the NHS has been addressing for a long time.

It was the desire to make a difference at scale. That's one of the things that from the country I grew up in and the work that my parents did, it was about how to make the biggest difference you possibly can. I have a sense of urgency about how much time do I have and I'm not sick or anything, but I just share that because my father passed away five years ago and I always had a sense of impatience about making things better, so why should it take 50 years, why can it not be ten. That kind of question. But after he passed away and I had this real up-close experience of how short life is, he was fairly young, and then saying okay, how do I make the most of the energy and the time that I have.

This role ... and I got the call from the head-hunter, I had never spoken to this head-hunter before so it was really out of the blue. I was driving and she said, I wanted your email address to send you a job specification. I said, what's the role? She said, it's the Chief People Officer for ... then there was this pause and I could almost hear the drum rolling, da da da da da da, the National Health Service. I remember saying, can you give me a second? I pulled over and then I had a conversation about the role. I thought I would learn a lot and I would also be able to make a contribution. I have friends who are nurses and I have a friend who is a GP, a very close friend, so I had my focus group with them and understood what some of their issues are and just was so inspired by what they do.

Then I watched some videos, Dispatches and YouTube videos of people doing emergency care and paediatricians and at the end of one of them, I just wept because there was this doctor who was from outside the UK and he had just finished a shift where he said he had to tell three people that their family member didn't make it in the emergency room. Then he just sat down and just wept and he said, this is the hardest thing, when I can't actually save the person I want to save, which is everybody. But his humanity and his compassion and his skill and resilience, I wept along with him. He will never know me but I was very moved by seeing his work.

I do, I think it comes from, again where I grew up and having the privilege of a good education. Privilege comes in different ways and we were not wealthy at all but I had a great education. I had parents who said we're very lucky to have what we have and what are you going to do about it. This is the message I say to my kids. We can't wait for somebody else to solve what we think is wrong. If we can't do it with all the advantages of education, then who is going to do it?

So, a real sense of responsibility. I spent some time trying to articulate what my purpose is, what brings me to work every day and it's to make a positive change in the world. To be a catalyst for positive change in the world especially for those most excluded. That comes out of some personal experiences. One of the things that really drives me to do things is a real desire to shift inequality in the world, whether that's inequality for women, for people of ethnic minorities or people from the LGBTQ community it's that exclusion and the impact that has and the unfairness of course, and the injustice of it that really drives me.

Definitely between the humanitarian sector and the NHS, I would say, the similarity is making a difference to people's lives every single day and saving lives. That's a similarity. As I mentioned earlier, we all at the heart of it want to do a great job every day. We want to be able to fulfil our purpose. We want to do a job where we are valued and included and heard, where we can make changes for the better. That's the same no matter where you work.

The difference is in degrees, I think. In the NHS, I'm just amazed at the complexity of what the people have to perform. It's just the variables, the constraints, the complexity of health care and long-term health care is incredible. People just, I think they don't even realise what an incredible job they're doing compared to so many other sectors which are much more, I think profit is a very simplifying objective. I'm not knocking it but it definitely is less complex than saying how do we do provide health outcomes to a population, the city of Greater Manchester, or rural Norfolk. That's what they're doing which is very different from any other sector.

I would say public scrutiny as well is very different from any other sectors.

That would be great.

The scale of the challenge is across multiple variables or multiple fronts. There is a challenge, and you said the number of staff, so there's a challenge on having the right number of people in the right places because if you overlaid the vacancy numbers, there's then which geographic areas in the country because it's not uniform. It's also which service priorities because if you take community nursing or you take mental health or some of the cancer specialities then there are differences in availability of staff and skills. But there's also the skills and the multidisciplinary nature of the work that's shifting.

So, the scale of the challenge I would say is having the right culture. A culture where we can make sure that people have the space and the ability to speak up when they need to especially about patient outcomes, where they get the development and career progression that they want and where there's a sense of belonging to the team that they work in. Where they have the leadership that really helps deliver the outcomes and then the whole piece about number and skills of staff and that combination that I just spoke about. The workforce redesign and workforce supply aspects of the people planner are absolutely key, whether it's number of GPs, whether it's the nurse clinical placements, and others ... there's a real focus and challenge there.

Retention is also an issue because it's not only bringing the right people into the door but it's also how we are able to retain them. We do have attrition, more attrition than we should.

Then the last piece is the new operating model with the system ICS, integrated care systems, and what workforce implications exist for working across different entities whether it's local government, social care and health care.

So, that's the scale of the challenge. It's easier to sometimes mention vacancy numbers but behind that is a lot of complexity in terms of how we can make sure that we have them in the right place, that they're supported, valued and able to deliver the care that we all want.

Absolutely. It's daunting every day and I don't say that lightly because what that means is the fact that no other country has attempted a workforce strategy of this scale, it means that there's no model. There's no manual. There's no other example that we can say we can do it better than that or we can take some elements, learn from that and add our own. We will be the pioneer. We are the pioneer. We were the pioneer with the Long-Term Plan and we are the pioneer with the workforce strategy.

How can we make sure that everybody who has either an impact on the workforce or impacted by the workforce, has knowledge about it, is involved in creating this plan? What's daunting is that the scale of the challenge, as we just discussed, it means that we need to manage expectations about the time in which this can be addressed. Issues that are decades in the making don't get fixed a year or two in. You need to have the patience and the consistency to create a sequence of interventions and changes and build on each other. All our workstreams are mutually reinforcing so we will be moving a massive system and using every lever to do that. Exciting and daunting.

First, I just want to acknowledge and recognise the great work that Julian Hartley led on the Interim People Plan. That was Dido, David Behan and Julian. What that meant was that we have a really good framework and key priorities they put down as part of the Interim People Plan. A multi-year review is what we were hoping for and that was the commitment for saying after a comprehensive spending review, two months' later we would publish a People plan.

That hasn't happened. We still are going to publish a full People Plan before the end of the year. The difference will be that it will need to be refreshed as we get more clarity on what the resourcing and funding opportunities will be going forwards. We will still be putting forward priorities, the challenge will be that we won't have clarity on the funding for a while. There is a silver lining. There's always an upside as well which is that this will mean that it is a dynamic document, it is a dynamic strategy and we can keep updating and refreshing it in line with the changes and the context.

It's absolutely critical. Absolutely critical and I have spent a lot of time in the last five months thinking about this and talking to people about this and my question was, when there is a lot of conversation about how leadership needs to look different and be different, why have we not made more progress? Why have we not made faster progress? I'm definitely impatient on women in leadership and more diverse and ethnically diverse leadership.

I can see a couple of reasons why and some of the obstacles and our accountability framework in terms of appointments is one, for sure. The other is that some of our processes haven't really been thoughtfully created to create a different outcome so we can't run the same process and expect a different outcome. I've myself experienced where if we make some changes, we can make it a much more equal playing field than we have in the past but it's just not acceptable that the top of the organisation looks like it does. There are more and more people who believe that to be true so I'm very optimistic and I think people will have to bear with me because I'm going to be beating this drum very loudly.

I think the key inspiration has been from my parents and especially my mother because she was in a role that was very unusual for women to take up when she did and I saw her not letting expectations of society and social norms stand in the way of her sense of mission and her sense of making a difference. There is a cost to that and I saw that as well, so there's a lot of evaluation of you, you're judged, you might be excluded because you're not really adhering to what other people's expectations are. Of course, the guilt of being a working mother and so she always made it a point to never miss a sports day or our performances so there is a cost to it. She has been a role model and an inspiration and what I have tried to do is be thoughtful and intentional about the trade-offs that I need to make. It can't be that I want to be a working mother but also then be able to do everything that somebody else who wasn't working is doing. I have to give up on some things that I might like to do.

Also, what are the positives I can offer to my children because I'm working, otherwise you can feel that they're just missing out on their mother being around. I saw how she handled that so key thread is how she navigated her career and her sense of mission with expectations of different roles.

Other inspiration for my leadership journey is really seeing what roles and I'm still figuring it out and I will continue to do that as I go forward. What roles and what platforms will be the best for me to make the biggest difference? One of the attractions of the NHS role is the scale is incredible because I was asked will you not miss having a global impact and this is a national role, but actually, health care and climate change are the two biggest challenges facing our planet and to be involved in an endeavour, and I call it an endeavour and an idea at the NHS because there's very few words that can encapsulate the amazingness of the NHS.

Yes, it is a mission and to be engaged in that scale and be able to make a difference, that inspires me and that informs my leadership journey. I don't think of my leadership journey as a snapshot or episodic kind of thought, it really is an arc. It went very differently from where I thought it would go. If you had asked me 20 years ago if I would be doing this role in the UK, I would say not really. 20 years ago I was in India, and I was head of HR in Unilever, for a large part of the sales organisation and I always thought one day I am going to be in public service but I just wasn't specific about it.

One more thing I'll say before I hand back to you is when I started giving voice to how I wanted to make the world better and when I first said it, I thought who am I to make the world better? The world? That's huge. Over the years I have come to the conclusion who am I not to make the world a better place, and then I discovered this amazing poem by Marianne Williamson which is Nelson Mandela’s, one of his favourite poems, and she says who are you not to shine.

Then I started giving voice to my vision and my dream and I thought what if somebody laughs at it and says you're too big for your boots to think about changing the world, that's fine, but when I give voice to it I realised actually I have a role, I have my part to play and I want to carve out space where I can do that every single day. Not in my spare time. That's when I changed, and also my daughter, when she was three, she just asked me what is it that you do, mama, that's more important than me. She had moved on from the you don't pick me up from school, she went to the heart of the issue. I said actually I don't do anything that's more important than you at that point I was working in the private sector in Unilever which is a wonderful company, but I thought this is the time that I should really bring my values and my everyday work much closer together.

Another point that that I want to share is at times when my values have been incongruent with my workplace or with the values of the workplace, has been one of the most difficult times of my career. First to recognise that there's an incongruence and a dissonance between my values and the values of the workplace, then to see what do I want to do about it and then to do something, there's usually a cost when you do, to be ready to take that cost and then to either move on or change the values of the workplace. I've had several experiences of doing that, so I think leadership without risk is not really leadership and you need to have your support around you as well and allies who believe in the direction in which you want to take the organisation.

First of all, I'll say the grown-ups don't know everything so don't imagine that your views are less important or less informed or less valuable than people who've been running things for a long time, so you have equal validity for your mission and vision. In fact, more because you are inheriting this planet and this world so that's one.

The second is talk about your dream as much as you possibly can. Make it real, tell lots of people about it. Then you'll find that actually there are loads of people that want the same thing. They want to join and want to collaborate with you and have ideas that can help you make your vision a reality. I think each person with a dream has to have a bit of an activist inside, and we do but we just shouldn't silent activist. If at first, you feel people aren't supportive or actually are trying to shut you down, expect it because you're trying to make a change and for some people, that might be scary, so how can you bring them along? How can you refine your message in a way that includes people?

Then also there are lots of older people who have a vision and a mission and have energy and their activists so search them out because they have the experience of what worked and what didn't and they're looking for people who have that energy that young people bring.