Density vs. Distance: What They Can Learn from Each Other

We can't think of a better guest to conclude the Great Divide Series than Peter Bradley. A leader who’s had a rare vantage point across two vastly different ambulance systems i.e. London Ambulance Service and Hato Hone St John.

From urban congestion to remote access, scale to spread, this conversation explores the real trade‑offs between metro and regional service delivery, and the lessons each system can take from the other.

Brought to you by Corvanta and the CAA.

Transcript

SPEAKER_00 0:00

There were so much perverse incentives to try and deliver performance targets became quite a toxic situation. There's a bit of naivety at times about how many calls can be handled through other means other than sending an ambulance. There's a bouncer strike.

SPEAKER_03 0:12

I remember somebody, a manager coming to the station to thank me once because I'd met all my response targets. And I remember asking them and saying, that's great, but that patient actually died.

SPEAKER_00 0:22

To achieve those targets, the scrutiny was absolutely intense. And people did lose their job because they weren't able to achieve targets which became increasingly impossible to achieve.

SPEAKER_01 0:31

Increasingly, the move is to move that measure of an ambulance of success away from those priority lights and sirens response times to more patient outcomes. What does that look like in a New Zealand context? Welcome to the final episode of the Great Divide series. I'm Hanwe Lee.

SPEAKER_03 0:51

And I'm Lindsay Mackay. And we are joined today by Peter Bradley, the CEO of Hattahon St. John. So I am going to read a bit of your bio here. I give a little bit of your age away here, Peter. So Peter's career in ambulance service spans more than three decades. He began on the front line in New Zealand, went on to lead one of the world's busiest ambulance services as chief executive of the London Ambulance Service, and later returned home to lead Hattahon St. John through some of the most challenging periods in its history. You today respond to almost 700,000 emergency calls, cover around 90% of the population and nearly the entire geography of New Zealand, and does so through a really mixed funding and workforce model. Across Peter's career, he has led through major incidents, public scrutiny, and fundamentally different system designs, offering a rare perspective on what that really sits behind the so-called Great Divide in the ambulance services. So, Peter, welcome to Ambulance Insights.

SPEAKER_01 1:49

Peter, Lindy's talked about some of your leadership in ambulance services across the globe. Leadership in ambulance is often shaped less by titles and more by moments. You've led your crews and your people through some really extraordinary mass casualty events. The London Olympic Games and later events like the Fakhari White Island disaster here in New Zealand. When you look back across your career, is there an event or a moment that changed the way you think about leadership? And why has that moment stayed with you?

SPEAKER_00 2:23

I think what's important is that when you um I mean le leadership and you you you know you have to earn respect and credibility and have credibility, right? And and going from New Zealand to to work in England, there's an assumption that because you worked in an ambulance service that you you know you you you've you've got to earn it. Moving across to England was probably the biggest life-changing experience. I'll be back to England to to in the end run run the London ambulance service was a big, big thing for me, and that sort of shaped my leadership, I guess, because you had to go from running what was the smaller ambulance, smallest ambulance service in Auckland to running a you know a very, very large ambulance service. And so I guess a bit you know that that really shaped me uh through through a yeah. It was a it was a really difficult first three or four years there. Where you really had to, you know, it didn't matter how well respected you were in your previous role, it was like starting from scratch. So that for me was my leadership. Having to really be on top form and really prove myself even though I was a my mid-career senior manager. I had I had to really that was that first three or four years back in London. Yeah.

SPEAKER_01 3:22

Yeah, sure. So what were you CEO of St. John New Zealand in the U.S.?

SPEAKER_00 3:28

No, I wasn't. I wasn't I was I was sort of the I was sort of the what's called chief ambulance officer for Auckland the Auckland Northland region. So I was I was in charge of a an ambulance service because we had separate ambulance services then. Oh so I was in I was a sort of senior person and then that's partly why I left because there was nowhere else to go really in in New Zealand. So yeah, so I was in charge there and then went down to university for a while.

SPEAKER_01 3:50

Yeah, I guess uh I guess going from a smallish region um like Auckland into I guess one of the busiest ambulance services in the world would have been quite the uh quite the contrast.

SPEAKER_00 4:04

It was, and I think it's a it's a it's a good test, isn't it? Because it makes you defensive for people who apply for roles who've been in small organizations, a bit like even Jordan going from Jordan Nemera going from Tasmania to Ambulance Victoria. There's something, oh well, you know, can someone, you know, I mean leadership's leadership, so um it can be scaled up. So I I think I really had to prove myself because I was from Little Old New Zealand, so what would you know about? You know, so so I think it's about you know recognizing that you've got to be prepared to take a few steps back in terms of humility and but also really make the effort to just to show that you are capable and suitable for the role. So that's a good thing.

SPEAKER_03 4:37

I think it really talks to, you know, Nat around that transferable skills as a leader. And I think in paramedicine it's something that we notice that as paramedics, we you know, being three paramedics, we're not the best at that. Like where we actually realise we don't have to be in the same system where, you know, we can take our skills and transfer them elsewhere and elsewhere.

SPEAKER_00 4:55

Yeah, exactly. No, I think that's right. And I think increasingly there's a recognition that people can, you know, move move around and and and I I think it's very hard to, you know, I mean I mean the sort of going back a few decades, there was always a desire to try and try and have an ambulance person, as it were, in charge of ambulance services in the UK at least. And of course, by and large, when I was over there that was the case. But now increasingly they just don't have the people, you know, then that's the whole story in itself. That's a close and planning and making those roles attractive for people who are you know paramedics by background, who you know, who w want to have these roles because these are great jobs.

SPEAKER_02 5:26

Yeah.

SPEAKER_00 5:27

You know, they're they're they're challenging, but they're also really rewarding. So we want to encourage more and more senior managers in the ambulance service who've got ambulance background to be able to, you know, aspire to those roles.

SPEAKER_03 5:36

Yeah, definitely. And you know, one of the things I find with ambulance services is especially from, you know, I've worked in ambulance and across health, is that um ambulance has so much scrutiny, you know, more than I think within health. And but sometimes we're compared to health at the same time. When I think to some of the big events that you've managed in those moments, what do you think about being leading in those spaces in an ambulance service compared to what maybe leaders have learned in the health system? Like do you think there's a difference being a leader in that space?

SPEAKER_00 6:06

And of course you've got a mobile you know, workforce that are that are out in the field working shift working for you um from from very many different locations, and therefore you haven't got the benefit of seeing being a in a healthcare system where, say, it's all in hospital, it's all in one location or two locations. That does present a lot of challenges in terms of you know maintaining a connection. And I think it is very different. Um there is, as you say, quite a lot of scrutiny, uh, uh and certainly from a a target perspective, um less so in in New Zealand, but certainly in the UK, the the the requirement to hit response time targets and to achieve, you know, to achieve those targets, whether the scrutiny when I was there was absolutely intense and people did lose their job because they weren't able to achieve targets which um which became increasingly impossible to do to achieve anyway. So I I think an ambulance service scrutiny is different, you know, the health system has a lot of different parts to it, but the ambulance, you know, we are schizophrenic, right? We're part of the health system, but we're an emergency service, and try to maintain maintain both those a foot in both camps, I think is important, you know. Yeah. And and sometimes the pendulum swings too far, you know, you'd become part of the health system, but people want to be s you still want to be seen as an emergency ambulance service.

SPEAKER_03 7:10

Such a balancing act.

SPEAKER_00 7:11

It is a balancing act, yeah.

SPEAKER_03 7:13

Do you uh just out of curiosity? In New Zealand, so I find in when I was in England, you know, I couldn't have necessarily even told you who my CEOs were. They weren't in the media very often. I came to Australia when I when I arrived and they were in the media all the time. I know as being an executive, I was in the media all the time. Is it like that here in New Zealand or No, it's very different.

SPEAKER_00 7:33

And I I think, you know, and my and you know, you you've worked in it, but I think my reflection is that the the sort of state-run ambulance service, the political the closeness to the pol to politics is much different in the UK and in here. You just don't have that, even in the UK, it's not the same. Uh you know, the ambulance services are by and large left alone. They aren't sort of a political, they aren't, you know, so we don't have that at all here.

SPEAKER_03 7:57

Yeah, interesting. I wasn't sure.

SPEAKER_01 7:58

Just going back to the the scrutiny on on ambulance services and the KPIs, we recently had a panel discussion with Jordan, Emery, Nick, and and Jason from from London and increasingly the the move is to, you know, we're trying to move that measure of an ambulance service success away from those priority lights and sirens response times to more patient outcomes. What does that look like in a New Zealand context? Are you having success with sort of saying to government it's not just how fast we get there, but you know, how how how we manage, you know, the right care for the right patient at the right time.

SPEAKER_03 8:38

Put an outcome as a full piece.

SPEAKER_00 8:39

Yeah, yeah. I mean I mean the yeah, it's it's a it's an interesting conversation in its own right, I guess that the whole thing around response times and what ambience services should be responding to. And um, I've always had a view that you can't stop people calling 000 or 1999. You've got to accept they're gonna call, which is what you do with the call when it when they ran. I d I think in New Zealand there's no real you know, for for the for good reason, I think there's no real strong scrutiny on time, but there's there's no getting away from it. You look at all the patient experience surveys, satisfaction surveys, speed is always the always number one. From the ambulance survey, speed, number two, speed. What do you want? Number three. There's an assumption that when you get there you provide good care. So the trust and confidence comes from speed, and that that will always be the case. Um so I think there's no getting away from that. I do think that I've made some mistakes over in my career, because I I I did a review of the ambulance services in England, a national review, and we looked at response times and we we changed it to try and make it. There's a lot of gaming going on, a lot of lack of transparency over, you know, and there was so much per so much perverse incentives to try and deliver performance tags, it's become quite a toxic situation. Ambulance uh, you know, ambulance managers were under intense scrutiny. It wasn't unusual for me to check uh performance 50, 60, 70 times a day on my phone, uh seven days a week for twelve years. So I think the move's been good. I think there's there has to be a recognition, there's a bit of naivety at times about how many how many calls can be handled through other means other than sending an ambulance.

SPEAKER_02 9:55

Yeah.

SPEAKER_00 9:55

Uh or so there's a bouncer strike, right? And the and the system, the health system and what's available in the system plays a big role in actually how much, how far you can go down the sort of alternative route for that. But yeah, I mean by and large, I think response times are always a there's a need for trust and confidence and speed for some calls, small numbers, uh, but you still have to have an outlying time for for you know for some sort of response or care at least.

SPEAKER_01 10:18

Yeah. Interesting. Uh just I guess following on from that London millions of incidents a year to St. John, where you've got I think it was 700,000 emergency calls, um, one of your busiest years on records. What does the uh difference in expectations look like for you, say, your scrutiny in London ambulance? Scrutiny from government and public in London ambulance versus um here in St.

SPEAKER_00 10:43

John? It's like night and day, I mean. It's like absolute night and day, I think there's uh there's no real comparison. Yeah, the media interest, the political interest, the health. In fact, the the in in the UK it was more around the the ha the health system expectation rather than the politicians. I think you know there's a there's a wide uh the national health, the NHS has got its sort of superstructure of management and you're accountable through that structure. Uh through a through a management structure really, rather than directly to government. I think here it's it's just very different. Um there's an ex you know, I think New Zealand cultures are different as well. Yeah, the public expects, you know, that they they want a good health system, but you know, we pay lower taxes and there's an expect people in rural areas expect to wait longer. So so I think I think the public here are a lot more discerning or or understanding. Whereas you tend in the UK you tend to get lumped into the the NHS as a mess and you know it's not working. So I think it's very hard for ambulance services then to become a separate entity in terms of their own uh how they're viewed at times. Yeah, it's just the difference is yeah, profound. Yeah. Um, you know, we well by and large we get left alone. And I think I think the problem the the problem would be in the you know, I've always had this view that you can have I I didn't I don't mind the idea of high accountability with proper funding. What you don't want is look high accountability with no funding. And I think in New Zealand what what I had what I experienced when I joined was no accountability and no funding. So it's sort of so no one had to get left. I'd rather have high accountability and you know, so so so I I'm absolutely all for accountability. You've got to be accountable, you know, it's public money, right? Uh and the public don't know in New Zealand, so you're even more accountable. But with that comes an expectation that you'll get the funding you need to deliver a safe service.

SPEAKER_03 12:17

I think that really um, you know, we I mean we've only been in New Zealand for uh 24 hours and we met some of your teams yesterday. And I think it goes to that that Kiwi attitude like you talked about. And I think because we definitely experienced that the welcome and the you know sharing of information and talking about the service. Your teams are so positive. Like that's what we noticed. Like the culture was lovely to witness, and people were so friendly. So yeah, I just had to call that out. I think it was nice. And I think St. John's obviously is big in the community and it has a brand in itself. And you obviously you have a large volunteer workforce still in New Zealand, coming from like if you think about it with the London model to then coming to Australia, Australia, sorry, New Zealand as uh the CEO. And then really, how do you kind of balance making decisions? Because I can imagine it's different when you've got the kind of public money in the UK, and then here you've got to balance the public money, the community, the responders. Like, how do you do that in a kind of forward planning risk way? Like it seems to me like so many uh competing factors for you to make decisions, is it? It's complex as that.

SPEAKER_00 13:22

It's comp it's it's quite a comp I mean uh we we are quite a complex organization, uh, you know, we are uh you know, and it it's a it's a strength, but it's also a challenge at times, or has been in the past. So we're in an we're in an emergency ambulance service, which is our main activity in terms of funding and turnover and people, but we've also got this uh community charitable service with thousands of volunteers providing community programs. So I so I think managing that as a as a as a as a as an entity in totality uh has been over the years quite challenging. So I think that from an ambulance service only perspective, we've got like 2,000 plus frontline staff paid, and then we've got you know a couple of thousand volunteers. So so it's about it's about making sure the model's right and you've got the right workforce mix and skills for for the different areas that you operate in them. And that's that's been a bit of a challenge as well, in terms of trying to make sure you've got the right people in the right place at the right time. Right. Um particularly in rural areas where you've got a large volunteer workforce. So we we rely on our volunteers and it it's it's a good model. We've got uh incredible volunteers putting a huge amount of time and effort, and our expectation of them has increased over the years in terms of their training. So you know, we're trying to do a lot more and get your government support to support their volunteers as well because uh you know it's a public good, and and that volunteer contribution is worth over a hundred million dollars a year. So you know, if you you know we had some independent research done to say what would the, you know, what's what's the business case to justify investing in volunteers, which the workforce is is you know provides for for a couple of million dollars, a hundred million dollars worth of value. So it's really important. That's uh it's incredibly important.

SPEAKER_01 14:45

Yeah, exactly. Yeah. Peter, throughout this series, we've we've talked about the Great Divide. Often people assume that's urban versus rural or density versus distance. From your perspective, having uh gone from one of the most urbanized ambulance services in the world to quite a uh dispersed urban rural mix. What's the most challenging aspect of of the Great Divide? Is it funding, is it system design, is it expectations, or is it the geography itself?

SPEAKER_00 15:18

I think it's probably a bit of all those, isn't it, inevitably, isn't it? That I think um in an urban service uh well, like London, for example, you've got a small geography, you know, high density of traffic in people. And I think that the the the the the benefit is you've got everything contained within a thousand square kilometres, and therefore you can and you've got you've got more access to pathways, more access to different uh opportunities for patients to be to be given the right care at the right place, more hospitals. So so so so the system design even though it's got some shortcomings over there, is much more contained and manageable. And and even just moving workforce around, they just the the the area so it's much simpler in that sense. It's notwithstanding the challenges of you know of the workload. And uh and but also the you know 180 ethic you know, ethnic minorities or you need in England and in London, I mean, the where that that brings its own challenges to try to make sure you're providing the right service to the right people and that you're culturally culturally aware and culturally sensitive. So that increasingly became an issue to work through and there'd be some a lot of work done over the years in that area. I think here, I think in a a a rural, urban, remote setting where you've got volunteers and paid staff, it's trying to get the the the the the challenge there is really distance, but also um often the people in some of the rural calls are some of the most challenging calls. Uh and therefore you've got distance to deal with uh and getting resources there quickly, but also making sure you've got the right the right support for the people who are often a look at the lower train level of people in our rural areas. So getting that getting that response model right is more difficult in a rural setting.

SPEAKER_01 16:49

In that rural setting, is there a place for technology in those sort of different systems? And yeah, like so digital tools and data were probably abundant really in in LAS versus the connectivity gaps you might have here in New Zealand. What does that look like?

SPEAKER_00 17:07

I think there's a lot of work being done in from a technology well from a from a um sort of national infrastructure resilience perspective in terms of the so the government's investing one and a half billion dollars in a a new communications network for police fire and ambulance in in in New Zealand. So it's called next generation critical communications system. That's that's big because often the ambulance services don't get what there's always been, you know, whenever I've worked, there's always well ambulance have got poorer communication. Yeah, yeah, yeah. Or they've got they can always contact you know what so this is this is big, this is a sort of 10-year program. So that that's that's really gonna you know, say we're a satellite, digital that's gonna make a big difference, and it's making a big difference for uh for connectivity. So I I think that will really be a game changer for our rural people. It'll improve connectivity, improve uh ability to you know connect and communicate, but also will mean we can use more tools, you know, we can use more um, you know, uh telehealth, more you know, video. Uh so so I think that's uh an area to to work on, uh, but recognizing that our volunteers have got a time making sure that they're well equipped to deal with you know the technology we give them is is going to be really important going forward. Uh but fantastic opportunities and it's it's it's an absolute requirement to do that, right? We can't leave it, we can't leave ourselves behind in that area.

SPEAKER_03 18:16

So and I think it goes to what you were um you know, earlier you were talking about performance times and and I read that you know, under your leadership, but ultimately you've always met your performance times and um which is amazing. I don't think there's many leaders that can say that.

SPEAKER_00 18:30

Um it depends on the target, right?

unknown 18:32

Yeah.

SPEAKER_00 18:33

I mean we've got we've updated the answer to the the other team, you know, we've got we've got a really good leadership, you know, ambulance leadership team and um people who really were done a lot of work over the years. We've got a really good uh management information and and business intelligence stuff to really make sure we're you know focusing on putting the right people in the right place. It's it's a it's a you know a big team effort, right? As always.

SPEAKER_03 18:52

Yeah, absolutely. And um and I think the other thing that um I that struck me was not just to be meeting to performance targets that we all have agreed, it's not always potentially the best metrics, but you also, you know, have been a leader and as one of the most trusted charities I read as well. Yeah. Which is that's outstanding that you've been able to balance both of those.

SPEAKER_00 19:10

Yeah, and and then hence why people want to want to donate. I mean, you know, yeah, it's it's a very special model, I think, in New Zealand where and and obviously I'm English by birth, so and returning back to New Zealand, it was a good reminder for me that not only we've got an amazing volunteering sort of ethos in the country uh and in in the in the Hatteroni St. John, but also people's generosity too difficult to give. It's just absolutely astounding, you know. Millions and millions a year get given to St. John to to um help run the ambulance service.

SPEAKER_03 19:37

And it seems like the public trust is very high. So high which is fantastic.

SPEAKER_01 19:42

No, it's extraordinarily high. Yeah. I think it was just it was we all remarked, I I knew there was some level of community donations for vehicles, but uh what really struck us yesterday when we were talking to your people was that every single vehicle is essentially publicly donated, which is bothering coming from Australia. Yeah.

SPEAKER_00 20:03

Yeah, yeah. And I think it's a deb it's an ongoing debate around getting the model right in terms of charity, you know, because you know, it's an old conversation itself around are you a government zone or are you an NGO and you know there's arguments for both, right? I don't you know, and I'm agnostic about the right, you know, model for who runs an ambulance service, but because I haven't worked in a government run and a charitable run. I think that you know, as long as you've got the right funding and the right infrastructure and the right people and the right leadership, then it doesn't really matter. But it's but but either way is getting the right model, right? And I think we've been we've been in a position where we've relied too much on fundraising to run an emergency ambulance service, so now's the time to finally get that right once and for all and say, listen, we can we can get ambulances donated, uh, but the government needs to pitch up here and pay its fair share.

SPEAKER_03 20:44

And we can see obviously with the you know changing demographic of the communities that is happening and what's coming our way, and we think we've talked about in some of the other podcasts, you know, it's about then keeping that pace as well with the forward thinking as well. I can imagine is something quite complex in this situation as well.

SPEAKER_00 21:00

Yeah, no, it can be it is it is complex. And um, yeah, we want to we want to innovate and do keep doing the right thing. But as we said, you've got to do the basics well too. And I think the big focus of the team, the the the operational leadership team really has been to you get to get to get the basics, do the basics well.

unknown 21:14

Yeah.

SPEAKER_00 21:15

It's already it's all well focused on the nice shiny things, but you've got to make sure have you got ambulances, have you got uniforms, have you got people, have you got build good buildings? So all the basics, because that's what ambulance staff want, right? You know, I'm getting a break.

SPEAKER_01 21:24

It's the most important thing.

SPEAKER_00 21:25

Yeah, am I getting a break, am I finishing on time? Do I know what I'm working next? Am I getting paid or right? You know, have I got the equipment I need? So it's you know, it's that's the old Maslow thing, isn't it? Doing the doing the basics well. Yeah. That's a big that's been a big focus.

SPEAKER_01 21:35

Like we said, you began your career in New Zealand, built senior leadership experience both here and in the UK. And then you've returned home uh to lead St. John. How's that sort of full circle journey shaped how you think about leadership and stewardship?

SPEAKER_00 21:52

Yeah, it's an interesting question, right? I mean it's this quite you know, I I've been just been really fortunate I I don't know how to answer the question directly. I guess I've been fortunate to have had a really good I'm getting towards the end of my career, obviously, uh not not too long to go, to to before I finish a year, I guess. But but I've been fortunate to be to play senior leadership roles in England and in New Zealand, which is reasonably reasonably unique, I guess. And to run two two ambulance services. I think I've always stuck to some uh some fundamental principles. I I only got into management in the ambulance service because I was a paramedic and I I saw things that weren't happening that should have been happening, and I thought, well, there's no point winching about it, Peter, yeah, then do something yourself. So put yourself in a position where you can make some changes, right? And that's that's how it all started for me. So I've always had the basics, you do the basics well in management, not just in having the so so for me it's always been about being accountable, transparent, uh responsive. You know, it's it's this basic stuff, you know, answering emails, following things up, getting back to people, making sure you know that, you know. So I think, you know, but also I've also learned that you don't you've got to not do it at the expense of other people. It's very easy in these senior leadership roles. When I when I went to London, I went out on the ambulance stations and, you know, took some post-it notes and wrote down the things that they were telling me and what needs to do in this, need sorting. And then you go back and sort it all out. Oh, that Bradley's a good bloke, isn't he? Wow, he gets everything sorted out. But but you don't you don't want to be doing that because you want to empower the managers underneath you, you know, you don't need the credit. And I'm at a stage where I don't need the credit, right? In my career, but but you want to make sure the people uh in the in the important roles. Because the other insight for me has been that in senior leadership, people want thanks from their manager, line manager, not from Peter Bradley, or from the chief executive, they want it from the people. That's the most important thing, because that's their connecting point, that's the person they deal with the most. So I've I've learned that that and a lot of my role is thanking people, by the way. I'm the chief thank you officer. I say that's my job, you know? Because it's an important part of what you do, right? So showing gratitude. So I've always held on to some some principles which have always seen me through, and that's there's no magic to get into senior roles, it's about you've got to have some competency, right? And some brains, but it is about just doing the basics and people thinking, wow, he you know, he he does what he says and he gets stuff done. And it's there's no magic to it. It's not often it's not mysterious.

SPEAKER_01 23:54

Um, I I think you know, all the sort of the values you've you've espoused could be core values in in many organisations. And I think you've just sort of highlighted the importance of all those basic tenets of leadership in terms of keeping your people happy, yeah. Um, thank them, yeah, clothe them, yeah, water them, feed them. It's yeah, it's yeah, it's really important.

SPEAKER_03 24:18

Yeah, it is for sure. And I think you did make it, you know, it's not obvious that you're coming to the end of your career. You said obvious.

SPEAKER_00 24:25

I'm very mindful of that. You know, you know, I said to someone the other week, 'cause I'm I'm a bit too open about with the feedback, but sometimes when when you when you when you start your career, I I got I got promoted quite s quite young. And so quite a senior real quite young, and I always had this thing around being too young and whether I have credibility in front of all these other older men. And then and um and I was in the ambulance service, which wasn't quite the same as a policeman far back in the day, and think, oh well so you had to work extra hard to feel it was a bit of an imposter syndrome thing. And then you get towards the end of your career, you think, oh shit, that must have been too old now. So you'd still have to prove yourself. Can't we? So the important thing is that there can never be complacency. You know, I'm I'm as hungry now or as keen now as I was from, you know, I've I've been 27 years, the ship executive. So you've you've got to you've got to be that's for me, it's I I've got to make I've got to make sure I can satisfy myself that every day, said to my wife yesterday morning, am I adding value? Am I am I making a difference? Or if I because I I I can't just I can't just coast, I've got to be doing something which is adding value and people and that people think is adding value. And that having no complacency is absolutely crucial because once that crews in, it's time to go. Yeah, so and and I'll that's been really important to me. Keep learning and keep making sure that you're on top of your game.

SPEAKER_03 25:31

I think so much what you're saying definitely is resonating with me. I was very young when I got quite senior. I mean, I'm heading into my third decade in ambulance, and sometimes I think what's next, and I'm not even sure. And um, so yeah, it's interesting. So yeah, I feel like I could talk to you for ages about that. But it is a really exposing career. It's tiring. You talked earlier about, you know, I remember I know exactly what you're talking about. I used to have two phones in my pocket, I used to have to bring one out. I'd be checking that screen. My husband used to ask, What was I doing? Get off my phone, like it was a little bit of contention. So I can I can hear you. But what kept you here, like an ambulance?

SPEAKER_00 26:04

I didn't intend to go. I mean, I when I I when I finished, when I before I went to England, I didn't intend to stay in the ambulance service. I was I was I was mid-30s and I I went and did an MBA down at the university, I went full-time, which was a big thing because I actually left, I actually uh resigned from my job with my family and moved to the other end of New Zealand and and with no with no prospects of a job. And I and and so I and I, you know, so that was a looking back, that's probably the biggest thing I did. Sorry, the most courageous. Uh I had this sense that I wasn't qualified. You you you you you spend your time as a clinician doing more and more training and keeping yourself proficient and learning more skills and being going through continuous education, then you become a manager and that you don't you're a manager now, it's an athletes. There's no there's no requirement to be a you know, it doesn't cop so there's I I've always had a view that as as you advance your skills and a as a clinician, there's a requirement to advance your skills as a manager.

SPEAKER_02 26:50

Yeah.

SPEAKER_00 26:51

And so I I I felt ill quali I felt ill-equipped. I wasn't, but I felt ill-equipped and without having a management qualification. So that was the only reason I did it, just for my for my self-worth. And uh in a sense that I didn't know what I didn't know. So yeah, so so that's what gave me in the ambulance was that I went there, did it, did the degree, finished, and I thought I'd return back to Auckland and and do something else in health. But then I got approached to completely out of the blue about going to England for a job, which I never expected to get. So and and when I you know I I never expect to get the job, never to get to to be offered the job. So yeah, so that that's why I stayed in the ambulance. Yeah, really.

SPEAKER_01 27:23

Peter, we've sort of talked about the focus on KPIs, but I guess as we know that demand's increasing on ambulance services, we've got aging populations, we've got workforce pressures with with people not like you and and us being career Rambos, but maybe being in the sim system five, six, seven years at the most. And constraint funding as well. Which we've definitely seen post-COVID. What worries you uh most about the next decade and what gives you confidence?

SPEAKER_00 27:55

You touch on the workforce as a big issue, right? Because people tend to, you know, people are increasingly sort of more mobile with their careers. I think it's probably a bit of a red herring to think that everyone's gonna leave and become an extended care paramedic and you know, working in the sort of outside of the health system at small numbers, right? But at the same time, I think as the you know, the parade registration, increased clinical pathways, a desire to get more people working in the wider health system and primary care. I think there's there's an issue around workforce support, workforce management and workforce planning. Planning longer term, right? For for for the workforce and what the workforce should look like in the future. I think we've been pretty good at that overall. How do you retain a workforce who you know join at 20 and then by the time of 27 wanna want to change? Uh so that that that concerns me about what's the what's the answer there. You know, because it's you know, peop you you you're you're in a constant, you know, people leave, recruit, people leave, recruit, it's all a constant cycle. So you gotta you've got to manage that and and and keep pick people pe people join this job for for the because they we've got a purpose, right? Uh, you know, and they enjoy what they do. So it's about making sure that you look after your workforce the best you can. So but but that will remain a challenge. No matter how good an employer you are, people still want to, you know, get the 27, 28, be it. Want to move on. But then off and return. So so what's the how how's that managed and how how does that how do we connect that with a wider workforce planning of the health system, I guess, is a challenge. Technology is is a is exciting because there's so so much, so much opportunity there uh for technology. So much more in the com centre. I've I've always thought the comm centre was the most important part, you know, that's where the investment needs. The clinical leadership needs to be in there, the investment needs to be in there. Because that's the the decisions that are made in there and the leadership and the clinical have a massive downstream impact. So I think uh we really need to see a lot more investment in in in com centres around technology but also around clinical support and leadership in those centres as it increasingly as we because the risk, you know, we carry the risk, right? We we carry the risk for all you know, we we we sort of talk about you know 50% of patients we attend, 50% of calls we don't get an ambulance. Well great, but who's who's bearing the risk for that? We're bearing the risk. And as the pressure comes on to do more and more of that, then the risk increases, right? Uh so managing that risk, managing that the clinical governance aspects of that is really important going forward. I always I sometimes joke that actually if you're doing a really good job, then 100% of the people you try the people, 100% of the people that you attend get go to hospital because everyone, you don't go to those that need to go to hospital, right? Yeah. Um so you get to a position where there's nowhere else to go with that. And I think in New Zealand there are limited, you know, compared to England, there are far fewer pathways for patients. We're a small population, five million people in the coming in there. So so that that's a challenge. So maximising pathways, maximizing the use of data to for integration purposes to get patients, the patient flow right. You know, we are small enough in New Zealand and innovative enough to be able to really put a good package together for innovation and data management technology. So yeah.

SPEAKER_03 30:44

I think you're really speaking to the heart of uh Hanwe and I coming from ComCentre backgrounds. I think I always talk about it being the kind of heart of the ambulance service. And I think people don't always realise that. But if we get it right and we invest well, it has that ripple effect to help every sector of the ambulance service. It's yeah, it's a really missed link of you. And leaders in across ambulance, they're so focused on the fleet and the movement of those paramedics, which is trucks. Yeah, which is so important. But if we can get that background in the the engine room of the ambulance service working well.

SPEAKER_00 31:16

And it needs to be seen as a profession in its own right, right? It needs to be something that people aspire to. Oh, I'm gonna get towards the end of my career, I'll go back to the concept. You know, no, actually, it's actually a career choice, and it's actually a great career, exciting. So prospects are good. And and using technology to best effect is a big is a fantastic opportunity. Um yeah, so I I think we need to really put put our money where our mouth is there, so to speak.

SPEAKER_01 31:36

Yeah, I think we have seen that that sort of change in focus with uh the increased spending on secondary triage, certainly, certainly in in New Zealand and very much in Victoria. You know, we always say uh you when I started in there there was a single paramount taking all the secondary triage calls for for MAS as it was then. Yeah. And now there's 300 plus. Yeah, 100 plus. Taking what, 30% of triple zero calling.

SPEAKER_00 32:03

Yeah, it's fantastic. Yeah. So there's a big change.

SPEAKER_03 32:07

It goes right back to your comment there about seeing it as a professional pathway. I think that was the big thing I noticed when I started working in those environments. People used to describe themselves to me as that was a dumping ground. They said, Oh, I just came here because I was dumped here.

SPEAKER_01 32:18

You've got to sort back. Yeah, yeah.

SPEAKER_03 32:21

So it was one of the big things I can say that was really that was successful at EV at Ambulance Victoria was the fact that actually people saw it as a career choice and they chose. And if you actually didn't want to be there, we'll help you find something that you do want to do, but it's not a dumping ground. No, no, no. Because it's such a highly skilled role.

SPEAKER_00 32:35

It is high school, yeah. And I think you know, getting the prior as getting the prioritization system sort of once and for all the primary triage, that's long overdue, long, long overdue. I mean, talk about it, you're getting getting out of IMP DSF Pro QA, that that's you know, there's not there's not been enough appetite to to really do something like that. Yeah. It's gotta happen.

SPEAKER_03 32:54

It does have to happen, yeah. There's and there's a big push around in that at Victoria as well. So yeah. You know, you've mentioned quite a few things, but if you had to, you know, have that um if you had to challenge the global ambulance sector as being a global leader, um, to rethink kind of one assumption it kind of holds about ambulance services to kind of progress it to that next generation, what would you is there one thing that you could think? Do you think there's one thing holding us back?

SPEAKER_00 33:19

Not necessarily. I th I I do think Yeah, I think I think there's a bit about what we've talked about. There is definitely a bit about the primary triage piece and and and the opportunity there to really do something different around how calls you know, the the discretion that calls the c you know, the front you know, call takers are you know, call the call taker profession, not a profession not necessarily in uh in s in some people's eyes, how do we really get that primary triage? It's alright given the secondary triage, but what about the primary triage? So so that that's where the big focus, that's where the the sieve, that's where the calls come in. So we've got there's got to be a really big give some really really serious thoughts of how do we how do we deal with that? How do we bat you know? So you know, there's a big school of thought in in parts of New Zealand with some of the funders of the ambulance service that you shouldn't even be receiving those calls. Well, you know, well well you know, you shouldn't be responding to those calls. You know, you only respond to the you know high acuity, well what what about the other four or five hundred thousand? What do you expect to do with them? Yeah so you know we're we're you know so so that's that's that's a big focus. And I think the integrated workforce uh in rural in rural areas needs a lot more work. Um, you know, there's there's not enough justification to have a a primary care, you know, ECP type person in a rural area in New Zealand, there's just not enough work for them. But the mixed model of working on an ambulance, responding to a call, sorry, when there's an ambulance call, as it were, but also working the GP surgery or looking at Ursul sent, doing both. We've got some great examples of that.

SPEAKER_02 34:40

Yeah.

SPEAKER_00 34:40

And there needs to be more of that because we're too too small and then and uh the the workforce is too small to have this separate this siloed workforce. So it needs to be a bit more open openness about that and less uh sort of you know because that's a constraint at times. Oh, well, you know, I'm not employing them, they're employing them, you know, they'll work for me. You know, they can't do you know so just be you know, we're too we are too small to be able to have that divide.

SPEAKER_03 34:59

So yeah, you need to be more fluid, don't you? Yeah, and I think that would give such good, you know, professional development.

SPEAKER_00 35:04

Oh, and and people want a brick, if people want a brick, right? You know, spend 10 years on an ambulance and say, well, actually, if I can work in a GP suit, then I might return for a while. You know, it's like having people who are in a single response cars for year after year after year. At the end, it gets them, you know, they get it gets to them, you know, they need a break.

SPEAKER_03 35:17

And it goes back to a little bit of the conversation earlier when you talked about, you know, we talked about the performance targets. And it, you know, the thing that has always sat with me since I was young was that we I remember somebody, a manager coming to the station to thank me once because I'd met all my response targets. And I remember asking them and saying, that's great, but that patient actually died. And and I said, and I said, but I saved the next one that you just told me I didn't need to be. And it's always resonating with me. Like I was just young and thinking, why are you congratulating me on a time when a patient died? Like, and I think when we get the primary triage right, we focus on actually right care, right time. I think that is that's where we'll get real value, is it? Is that service?

SPEAKER_00 35:57

I agree. I I think the other reflection I've got, and I've mentioned to the team a few months ago, that that we've the pendulum swung up uh, you know, we've gone from being seen as lights and hard and you know, big car, you know, fight by the public, you know, car accidents and all the major trauma stuff to sort of the more of the primary care and the secondary tree aspect, which is all good, all well and good, but we still do that. The stem is the strokes, the major trauma. And and so I've just been saying to the team, we need to make sure that we don't that we've the p pendulum has swung a bit too far the other way now. So, you know, what we brought in a national STEMI pathway, national trauma, you know. So how do we make sure that there's a focus on that still? And because that's where the patient outcome evidence can be more profound, right? Even with small numbers. So I think we've got to be extra get that balance right and make sure we remind our remind the politician and our purchasers that we've still got a very important role to play, stemistroke, major trauma, spinal cord, you know, in those areas. And and I think also for in New Zealand at least, what's the next step for us in terms of those areas to try and make make more of a difference, I think.

SPEAKER_03 36:55

Yeah, so important. If you had to give young Pete when he's starting his starting his journey, is there um to where you are today, is it something you wish you told yourself or thought about back then? Some advice you'd give yourself, I should say?

SPEAKER_00 37:08

Well, it's the usual thing, isn't it? Uh I'm a bit of a people pleaser. I think you you know you it's the old thing you can't please all the people all the time. And you have to be prepared to make tough calls and and and well a well-informed tough call. Uh and uh uh so so for me just being prepared, accept that you can't can't be everyone happy and do the right thing at the right time for the right reason, uh, and then then get get behind it and take your same with you. Yeah.

SPEAKER_03 37:31

I think it's so important in Ambience actually to be said because I think one of the challenges, um, you know, I've obviously moved countries, I've worked in different states around Australia. Yeah. And um but a lot of the services I go to with the leaders that I meet, they have started when they're young and they're working their way up that kind of ladder as they see it. And then they're suddenly now having to tell their friends what to do, and that's a really hard balance. And so I think it goes back to your core, which you talked about, your values is actually just being a nice person, actually.

SPEAKER_00 37:58

Being a nice person helps, yeah, and and being being personal and being downloaded, right? People got you've got to be connect with them. And I and and I think that's a really important this is a really important point, actually. Uh I think what I see one of the most important skills an ambulance leader can have is and it sounds obvious, but changing your tone, changing your language, changing your la how you approach conversations with different groups of people.

unknown 38:19

Yeah.

SPEAKER_00 38:21

And there's no point talking about management speak to frontline staff. Not because they are not because they're thick, but but because it's not interesting to them. No, it's not interest. You've got to say, what is it uh what am what how am I gonna change my my communication style to to to to work for them? Not for me, for them. Uh and also a final point would be that uh um when I but just about the honesty thing and people connect with people connect with that. You wanna, you know, so when I when I became chief executive of London Ambulance Service, it was a it was quite a difficult it was a difficult place to work and we we were really struggling. And we'd never been honest with the pri with the media about that. And I went on TV and said, asked me a question and said, we're struggling. And that that that that's really res really resonated with our people from our staff. At last someone's prepared to be honest.

SPEAKER_01 39:04

Yeah.

SPEAKER_00 39:04

Um, you know. Don't blame anyone else, just saying we're struggling. And that being vulnerable and showing that was really important.

SPEAKER_01 39:10

That's great. I think that's pretty powerful. Look, as we close this is the final episode of the Great Divide series, what really stands out to me is that you know, we've been exploring that divide, and that it's not really about distance, density, geography, or or or distance. It's really about people leadership and the systems we choose to build. And and Peter, I I think your really fundamental core values of leadership, being a decent human being has really resonated with certainly the way I lead and I know the way Lindsay leads as well. And we've heard that it's actually a similar theme from leaders right across the series. That you're all facing very similar pressures and it's those uh remarkably human decisions in moments that matter. And you can't always please everybody, as you've just said. I think, yeah, if there's one takeaway, it's uh learning across the systems isn't just possible, it's really essential. So really just want to thank everyone who has joined us throughout this series, and a really special thank you to Peter for sharing decades of experience across the globe. We hope these conversations have uh sparked reflection for everybody, challenged assumptions, and really encourage you to keep asking better questions about the future of ambulance services. And thanks again for joining us, Peter. Thanks for the invite, really appreciate it.

SPEAKER_00 40:37

Yeah, thanks, Peter. Thank you.