Clare Montagu was the Chief Operating Officer (COO) of one of London’s largest hospice groups, Trinity Hospice. Before that, she was a UK government minister special advisor. Clare is now COO at Poppy’s, an independent funeral service.

We talk about the challenges and joys of running a hospice. Much of great hospice care is looking after people in their own homes and in the community. Hospice care goes beyond the medical. For instance, letting a patient die in the garden under a tree because that’s their wish. This is care a hospital can not give. The hospice is staffed 24/7, pets can come, family can stay. The hospice is part of the community. 

We chat about the importance of death admin. You don’t want to have your stash found by your parents or the state to take your inheritance estate. We speak on why Clare uses straight forward language about death and why we don’t talk about death enough.

Clare reflect on the challenges of COVID and gives her insights into how difficult running the hospice during the pandemic. She gives a sense of what being on the frontlines meant. How to find protective supplies, mortuary bags and and the lack of plans from the state.

We discuss the economics of a hospice. UK hospices are not state funded but mostly funded by charity. Clare had a GBP15m operating budget or closer to GBP10m for healthcare operations (excluding the costs of running charity shops etc) this looked after 2,500 - 3,000 people in a typical year. (In a year, in the UK about 9,000 people die for every 1 million of population; London has c. 9 million population and so 80,000 Londoners die very year).

We debate the difficulty of what funding a minimum service hospice would be like. 

We discuss the challenges of state capacity decisions in the light of swine flu and why governments will always tends to spend on a problem now rather than have insurance in stock piles.

Clare gives insights into the life of a special adviser, some of the highs and lows and the comedy moments, and some of the policy she is proud of (helping Children in care).

Clare suggests that while governments often get things very wrong, they are also have to deal with particularly conflicted issues and trade-offs such as security versus liberty. 

Clare has volunteered at a charity doing a manual warehouse job recently and she offers insights into that type of job and we discuss jobs that can have “purpose” and jobs where it is difficult to think you are on a “mission” 

Finally, Clare reflects on how to have a good death and her life advice:

“show up and do something about the stuff that you care about”.

PODCAST INFO

• Apple Podcasts: https://apple.co/3gJTSuo

• Spotify: https://sptfy.com/benyeoh

• Anchor: https://anchor.fm/benjamin-yeoh

Transcript (mostly automatics, typos expected)

Ben Yeoh (00:03): Hey, everyone. I'm super excited to be speaking with Clare Montagu. Recently Clare was the chief operating officer of one of London's largest hospice groups and formerly she was a UK government minister special advisor, which we call SPAD. Clare, welcome.

Clare Montagu (00:22): Thank you, Ben. Thank you for having me.

Ben Yeoh (00:24): So when running a hospice, why is cake important?

Clare Montagu (00:33): So I think this is one of the things that I've said sort of on LinkedIn, that actually cake is kind of what makes hospices go round. It's interesting. I think of cake as being, you can be very sort of flippant about it and say it's all just about sort of baked goods and increasing our waistlines, but we use cake a lot in the hospice to celebrate and to say goodbye to staff or to celebrate birthdays or to celebrate promotions. And it's a very good opportunity for people to come together. And we also use cake as a way of being able to talk informally about things that are often really difficult within a hospice context, but become easier over cake and tea. And the other reason that cake is really important is that a lot of the hospice patients and their family members kind of bring cake as a gift of gratitude to staff in the hospice. Whether it's the nursing staff or the porters or anyone who's helped out with them. And I think that idea of giving something; particularly something that's been homemade, although not always. Something that is sweet, something that is a gift of gratitude, it goes at the heart of what the hospice is about. It is about giving and it's giving to our patients, but it's giving to each other and it's about sharing too.

Ben Yeoh (01:53): And I've also found when speaking to people involved in the hospice world, you're very straightforward in your language. So you're using the language of death trying really not to over medicalize it, but essentially being, I guess, what consultants would call plain English, but to be more straightforward about it. And I think there's something about this dance around we have particularly in developed countries, about talking about death and the like. How intentional is this and do you think it's quite an important part about thinking about the world of hospice and the world of death?

Clare Montagu (02:31): Yeah, I think it is very intentional and I think it is critical. We're at the hospice, very clear that we do not talk about people passing, when you pass exams or you pass someone in the street, someone dies and we talk about death and we talk about dying. We don't talk about loss and we might talk about grief and loss, but we don't talk about having lost someone. Having said that, in a hospice environment, you also have to be very clear that you follow and support the way in which people talk about death themselves, particularly when they're grieving and they're at a point of very high emotion. So there's a sort of careful balancing out between being very clear and upfront and ramming it down someone's throat when they want to talk in euphemisms. But I think there's a broader point for many of us who work in hospices or in similar environments where we're very used to talking about death. It's so striking how in, as you said, in developed and Western countries, we don't talk about death at all. Very few people have actually seen a dead body and even within the medical environment, even within hospitals, you'll get mainstream doctors who are not great at dealing with death. They're very good at dealing with disease and how to kind of treat people. They're not great at preparing people for death. And so part of the hospice mission as experts in death is also to normalize and make clear that this is the one thing that's just going to happen to us, absolute dead [ ], irrespective of who you are and what you do.

Clare Montagu (03:59): And so actually the sooner we start talking about and breaking down some of those myths and actually call a bit of a spade a spade, it's more important. People start to understand what's going on and they start hopefully to become less fearful of it for themselves and for other people. But it's really important. I mean, other words, we don't talk about the deceased either. We talk about people who have died or someone who has died. And again, I think it's really important to be plain speaking, but to do it with a degree of love and respect. The deceased is someone who is a thing, someone who has died, was a person and it's important that we acknowledge that.

Ben Yeoh (04:36): Yeah, that makes a lot of sense because the joke is that what's inevitable is death and taxes, but actually as we've seen billionaires can avoid taxes. So it's not quite as inevitable as it might seem.

Clare Montagu (04:47): Even billionaires die.

Ben Yeoh (04:48): Yeah, exactly. So we're going to cover how your life was I guess, into pandemic, which is still going on, but particularly from the point of view of running a hospice, but I thought it might be useful to maybe give people a glimpse of what a pre pandemic kind of day in the life of a hospice or at least from your view [is]. Cause obviously you've got frontline workers, cleaners, staff, porters, care nurses, and then obviously you've got management and all of that, but maybe a little glimpse of what a hospice kind of functions like sort of pre COVID. Cause then we can sort of talk about then when the pandemic happened, how sort of dramatic a change and potentially the challenges in the gaps of state capacity that there might've been. So yeah, an ordinary pre 2019 day.

Clare Montagu (05:46): Pre 2019 day. Well, I think the first thing to say, which, I mean, it was a surprise to me when I started working at the hospice because I hadn't worked in that environment. Most people, I think, assumed that hospice is a building and it's a building where you come to die and I think the two sort of big myths that we start off with is that yes, we are a hospice building and we have beds, but actually the vast majority of the care that we gave to people was in their own homes because most people want to be looked after in their homes and can be supported to be looked after in their own homes. So the vast majority of our work was actually in the community. So we had nurses and doctors and physiotherapists and social workers and the full gamut of sort of health and care professionals and a large amount of our patients; they may have come into the hospice building either on an outpatient basis or into the beds, but actually many of them would never have come in at all and we were going to look after them in their own homes, if that's where they wanted to be looked after. And I think the other thing that people are really surprised about is that and people are very fearful often of hospices, because they do think that that's it, their days are up. Yes, people were coming into the building who were then going to die in the hospice, but again, even those who came into the beds, we had a 28 bedded unit at Trinity hospice. 40% of those patients would leave again because they would come in for some specialist care.

Clare Montagu (07:01): Maybe they had symptoms that couldn't be supported at home, they're in a lot of pain and they needed some specialist support that you would only get within a very clinical [setting] environmental or that a family couldn't cope with or they're a high degrees of anxiety and actually when we got them better support at that particular problem, we were then able to support them to go home again. And all of our patients had what we would call a life limiting condition, which means a condition from which they will eventually die. So they have a terminal diagnosis in layman's terms. But a lot of our patients were on our books for months and even years, and we wanted to get people involved in the hospice early, because the earlier we saw them, the more we could help. And so your involvement with the hospice-- If you were diagnosed with say a terminal cancer, a cancer that was not treatable, you wouldn't necessarily be days off death, you would come to us and one of the things that we might do is we might start talking to you about where, you know, if you're in a position to be able to do this and not everyone is, where do you want to start? We might start doing some care planning with you. How do you want to be looked after? Where do you want to die? We might be doing some kind of support with you, psychological support to help you come to terms with your diagnosis and the fact that your life is going to end. And also to provide some of that support to your family. We might help you do memory boxes for your kids. We would do quite a bit either on an outpatient basis or in people's homes to keep them fit and well.

Clare Montagu (08:21): So physiotherapy, occupational therapy, and one of the things I always used to say, if you think about the purpose of hospice, we were there to help people have the best life that they could have for as long as they've got left, we were to support them to have a good death in whatever way that meant for them and we were there to support the people who were left behind. So a lot of our work was with patients who maybe would have had months to live. And so we would provide an awful lot of sort of support and advice and that might be physical and that might be emotional and that might be practical to help them prepare themselves and their families until the point came when they were in their last few weeks, days. And then when they were getting to the point of which they were going to die, many, many people preferred to die at home and we would mostly be able to support them to do that. Or they wanted to come into the hospice for whatever reason. They didn't want to die at home. And again, that was a place they could come and then after that was all over, we would be working with families in providing grief and bereavement support. But I think one of the things that's completely-- I mean, hospice is weird because we were charity, independent, and we employ staff who are trained through the NHS, but the ethos of a hospice is very different from the NHS. The NHS is a brilliant institution, but it is by its nature, a Russian state service.

Clare Montagu (09:42): With the hospice, we're all about doing whatever it took for you to make the end of your life worth living. And so it meant we could go above and beyond for individuals. So for example, we had patients who wanted to renew wedding vows and we could arrange that for them within the hospice environment. We even were able to arrange at the last minute within 36 hours, a wedding for a young man who was by that stage only a week or so of dying. He wanted to marry his long-term partner and we were able to organize a cake and a registrar and we could sort of arrange the beds so that he could come to us and his family came in as fascinators or whatever. We had a lady who was a keen outdoors person and her thing was she wanted to die under a tree and she was in our beds and she didn't have anyone who-- any family around the place. So we made sure that we sat with her and that the point at which the nurses and doctors deemed that she was probably only a few hours of death, we wheeled her outside into the hospice gardens so that she could die under a tree. And that for me, sort of really epitomizes what the hospice is about because you can't do that within an NHS environment. They're just not the resources. And frankly, no one would have known or checked whether or not we were able to fulfill that lady's dying wish, but actually that was what was meaningful to her. So that was what we were about.

Clare Montagu (11:09): I think the other thing to say about hospices pre COVID is that because we very much believe in sort of busting the myths about death and dying we were very open to our community. So we had people coming and going all the time. We didn't have visiting hours. Families could come and stay. You could bring your pets. We were staffed 24/7, and you can come and go as you want. We had a cafe. We had a glorious two acre garden and we very much wanted to be seen as being part of the community and open 24/7, 365 days a year to our community, either for visiting or for spending time with people when they were dying. Obviously when COVID happened, all of that changed, but it was and remained the most extraordinary service when you are a part of that in terms of being able to go above and beyond for individuals to make the difference that they need.

Ben Yeoh (11:59): Those are some extraordinary stories, and it really strikes me. There's sort of two or three reflections I have immediately. One was how the sort of medicalization of health care through the sort of mainstream profession, because the NHS is all about not dying and actually strangely hospices are all about living a good death as it were not undying. Maybe we'd touch on the economics of a hospice just before going into COVID. In that, I was really astounded to find that particularly in a place like the UK, which believes in NHS and sort of state supported healthcare, that hospices are not supported really by the state at all. And to your points that actually hospice care gives people some of the best, most fulfilling moments of their life in a way which gives this total care, thinking about social and environment and other determinants of a good life or a good death, which NHS for its resources and its mission doesn't necessarily think about. So I don't know if you want to have a few comments about how hospice care is actually funded. I guess we're particularly talking in the UK or London and England about how maybe that might change or thinking about state capacity and therefore is this care actually very expensive if you wanted to do it some other way? I mean, is having a good death something which is kind of out of our reach and maybe that's why the state is having to do that? Obviously there's a big debate here in England about how to fund social care in general, but maybe touching about your thinking about whether this should be state supported, that good state capacity here would be that, and does this just cost an awful lot of money?

Clare Montagu (14:03): It does cost an awful lot of money. I think it's a really interesting debate. I mean, hospices in the UK, in England grew up sort of through a charitable route and in fact, we were called Royal Trinity Hospice. We grew up as an Anglican denomination. I mean, we'd been nondenominational for sort of 40 years, but very many hospices grew up through good works traditionally by the church, by nuns. So who were looking after the idea of people who were going to die and they weren't doing anything really other than providing loving care, because there wasn't a kind of palliative medicine in those times, in the sort of beginning of the late 19th century, beginning of 20th century. So, these sort of institutions grew up through a sort of charitable route and at the same time, there was also a kind of the development of palliative medicine within the UK. A sort of understanding about what it meant to palliative people, rather than just continue to treat and then have them die because they couldn't be treated anymore. There's this sort of difference. And I think it's been a sort of accident that therefore hospices have grown up primarily to be charitably funded with often with some state support, but not much. So pre COVID Trinity Hospice turned over about 15 million pounds and I would have said about three to four of that came from the NHS and the remainder of that, we had to either fundraise ourselves through donations, or we also had a string. I mean, we still do, had a very large number of charity shops in London, which brought in a significant amount of money for us.

Clare Montagu (15:43): And I think it's an ongoing issue that is probably not resolved, not part, because again, it goes back to at the heart that we don't really want to have a conversation about what we want for our death in this country, because actually the conundrum of hospices is a part of this much bigger picture, because on one level you say we had a clinical care service, all our staff were trained by the NHS, we had to pay NHS rates, we had a huge amount that looked like the NHS, and actually in this country, in the UK, we say that healthcare is state funded and is free at the point of view. So the hospice is certainly free at the point of view and therefore should be NHS funded. The NHS didn't fund anything like the actual costs. Having said all of that-- So, that was an ongoing beef for us, that we were providing essentially what was a kind of state health care service and we were regulated by the same regulator and all of that and that actually this was not recognized, but having said all of that, we also prided ourselves as I've described in being able to provide the kind of service that the NHS could never in a million years provided and you cannot provide in what is a rational healthcare service. I mean, the idea that you could take a health care system out of an NHS ward and get them to sit with a patient until they died, or until the point at which they nearly died in order to make sure that they died under a tree would just be for the birds within an NHS environment. And yet that kind of ethos, that this is what we're about is that we will go that extra mile is really, really important to Hospice.

Clare Montagu (17:11): I think it's very hard to sort of desegregate them. What is the state bit and what is the charity bit, because also we value hugely our independence to be able to say, these are the kinds of services that we want to provide, this is the kind of support that we want to provide and you can't do that when you're within a kind of state funded health care environment. I think certainly hospices are underfunded by the state compared to the service that they do provide. But I think until we as a society really step back and say, we think palliative care and preparing for death is something that we want to prioritize, we can't really unpack what the funding is because the funding is just a symptom of the kind of model and everyone just prefers to sort of leave it there. And it is also not something that is as politically salient, because most people don't come into contact with hospice. Most people don't have experience of either death and hospital, thankfully. It's not as politically salient as taking a kid to A&E or being on a very long waiting list while you're trying or not seeing your family doctor because of COVID. All of those things are going to be much more important in terms of political priorities for both voters and politicians. So, I think it's all part of our wider inability to deal with the death problem.

Ben Yeoh (18:30): And did I hear that correctly? You had an operating budget of about 50 million or was that 15?

Clare Montagu (18:35): 15. (Fifteen)

Ben Yeoh (18:37): 15 million and that would serve maybe a few thousand patients a year.

Clare Montagu (18:44): That's the other thing. Yeah, absolutely. And when you start looking at our kind of cost per patient, it was sort of astronomical. It really was and we were looking after two and a half to 3000 patients per year on that kind of operating budget. Now some of the operating 

budget, that 15 million, was actually also the operating costs of raising funds. So we also have-- 

Ben Yeoh (19:09): Yeah, exactly and your shops and things.

Clare Montagu (19:10): And shops and all of that. So actually, if you looked at the sort of hospice care bit it was probably-- if you knocked off the cost of generating funds, the fundraising department and the shops, it was probably more like 10 million pounds. But, you've still got 10 million pounds shared between sort of 3000 people. That's yeah, not a huge amount of-- That's quite a significant cost per person, but then equally, putting aside all the bells and whistles stuff and the lovely sort of visiting and the chefs on site and all those other bits, which make up a hospice, we were there to provide specialist care. In NHS terms we're what's called tertiary care. So you've got your primary care which is a family doctor, your secondary care which is a hospital. And when you go into a sort of specialist care, that's often called tertiary care. So it was something that was grafted over and above your standard hospital provision and that's why it was an expensive resource. And for example, doctors in hospices use morphine in a completely different way from doctors in hospitals and in primary care. Often primary care colleagues were very shocked at the levels of morphine that we used in a hospice environment. It's just a very different way of looking at things.

Ben Yeoh (20:22): And I think to be maybe radical on the other side for one second. As a nation state, which has decided on [free point of care] healthcare, I definitely think they should be funded. I guess on the other side of the coin, though, if this is going to be difficult, would a model where this was kind of somehow privately funded ever work or the sort of, I guess you would have free market people saying, well, if you want to pay for dying under a tree, then you should pay for it. I don't suspect that this will work, but is that something which could possibly work?

Clare Montagu (20:54): It's interesting. We had at various points because we had an ongoing sustainability issue. We had huge volatility within our income streams and basically a flat cash from the NHS, which basically means real terms cut in your budgets because obviously inflation and particularly healthcare inflation costs. So we're always debating what our kind of opportunities for new income streams are. I think one of the things that becomes very hard and it is again, it's like the mixed model of hospice provision when you say, what is the charity bit, what is the kind of bells and whistles and what is actually just the state health care staff. It becomes very hard to get people to want to insure themselves or to pay for all the bells and whistles when it's grafted as an integral part of what also resembles, I mean, we wouldn't say bowl cut standard health care but health care that is state funded. And I think one of the things that we struggled and also one of the things that we found is because of the myths around hospices, a lot of the time people of all sorts of stripes and backgrounds were very reluctant to come into a hospice because they thought they would be discharged from their oncologist and they'd be referred to hospice and they thought, oh my God, this is it, I don't want to engage with this. And actually nearly, always what people say is, I wish I'd known about this sooner. And it was important to us that we were able to see people sooner because we could do more to support them.

Clare Montagu (22:14): I think there would be real potential people not valuing hospices and therefore not choosing to pay for it because they didn't know enough about them in the first place and it's only after the event we realize how important it is. And of course, I think the other thing that's really important about the kind of care that we provide to people both up to and including their death is also the support that we gave to families afterwards. Because actually knowing that your loved one has planned for their death, has had a good death in whatever way that means for them and then getting the support to be able to deal with the grief, the inevitable grief that comes it which is what is going to enable you as a family member to move on from that the death of someone and we all know people who have never been able to move on from grief. And it's an integral part of being human, but it's also something that you can move on from and you can grow through, but not everyone can. You can get very stuck in it. But I think until you've been in that experience, it's very hard to say this is something I want to purchase.

Ben Yeoh (23:18): I can really see that and I hadn't heard that articulation before, cause I can now see it. The cost of administering a few weeks of generic morphine is something like a basic cost you could plan for, everything else very, very difficult to do. And it recall to me something that I read or paraphrased from a US doctor, Atul Gawande, and he's done some sort of studies into this and mortality. This idea that when you give up on the medicalization part, sort of when you stop trying to die so hard and actually start trying to just live out the last bit of your life, you actually find you live longer. All of the stats say that those who enter a sort of end of life hospice type of care, actually find that versus other controls they're living sometimes months or weeks longer than they would be expected to. Presumably because of all of this other care, which is around either the social determinants or some of these other things or the fact that actually in medicalization comes with a lot of side-effects which might not be providing any more benefits, but you're providing all of this other--

Clare Montagu (24:24): I think that's true. I think all of this stuff becomes very difficult to quantify, but without question, if you are-- There is absolutely something about treating and treating and treating and some of the kind of side effects that come with that or even palliating through a kind of traditional hospital environment. The other thing is that hospitals themselves are not very geared up to supporting people to die. I mean, I would always say to someone do try not to die in a hospital environment if you can avoid it, it is not a great place to die. And I think the kind of getting to an environment where both there is more comfort, there is more support and there is more psychological support for preparing yourself, you can sort of relax into if you like, and that in itself can help. Particularly if you're not physically suffering from the effects of treatment. I think the other thing to say with all of this is it's a very inexact science prognostication. I mean, all my medical colleagues would say, particularly with younger patients, you try and say you've got X months, people always want to know how long have they got left and the kind of palliative medicine community would talk about long months, short months, long weeks, short weeks. That was kind of about as good as you get and if you've got someone who is actually younger and physically healthier, that kind of prognosticating is often really challenging because you may have a condition that is going to take you on one trajectory, but if your underlying or constraint is quite good, that might take you much longer to die.

Clare Montagu (25:53): I think the other thing with all of this that is really tricky is a bit analogous to the debate about social care that's happening in England at the moment, which is none of us know how we're going to die, just as none of us know how we are going to deteriorate as we get older. I mean, we might be lucky enough to just die in our sleep, or we might be unlucky enough to have a terminal condition. In which case you'd be going through a sort of hospice pathway, or you might have that sort of middle road of sort of deterioration and possibly dementia and multiple comorbidities and being sort of sick and elderly for quite a long time. And so, I think there's this other thing about modern life where we plan and think we can control for so much in our lives and the one thing we cannot control or know is how we are going to deteriorate as we get sicker and how we are going to die. And so even when you think about things like insurance models, whether that's in a social care environment or in a death environment, it's very hard to know what, you know, do you stop putting aside significant amounts of money for an eventuality that may never materialize? And also what if you haven't put up enough money and suddenly you've become one of these people who is particularly when you're sick, physically sort of healthy but mentally declined and unable to look after yourself and in that state for prolonged periods. Because again, we all know people who've been sick and elderly for a very long time, but haven't actually died. It's a really difficult set of issues, I think

Ben Yeoh (27:20): I haven't quite appreciated that complexity. Well, that kind of brings me on to the pandemic and if it isn't too traumatic to relive that again, maybe you can offer some thoughts as to how it affected both the frontline of running your hospice and everything and some of the challenges that we saw, lack of state capacity I guess particularly in the early stage, but it seemed to run through. And just what your impressions were of running a hospice in London at the time of the pandemic happening.

Clare Montagu (27:56): Oh, I'm over it now, but it was really hard. It was really horrible. So, trying to group some of this stuff thematically, I think for all of us involved, I mean, you could see this wave of coronavirus coming, but no one really knew how it was going to land until actually, you were in it. And by that stage, it was all far too late and so we experienced what many health care facilities experience. So we had patients who were dying of COVID. And, yes, a lot of our patients will have died anyway, but actually you don't want people to die of COVID. Some of them died prematurely of COVID. So yes, they were on a trajectory, but that doesn't mean that they were going to die at that point. They might've had--

Ben Yeoh (28:41): Months or long months even.

Clare Montagu (28:44): Long months or whatever it is. It's not necessarily a way in which we would want people dying. It's not the way that we would choose people to die. So I think there was a sort of myth, some people that, well, they were all going to die anyway. Well, no. So we had patients dying of COVID for the first thing, and of course that was a wholly new sort of thing for us about how do you care for people who are dying of COVID and that was both people in the community and people in our hospice beds. And this all sort of happened at once. We also obviously had the thing where staff were themselves getting sick either from within the community or with it. Although, we don't think we have much transmitted within the hospice, but staff are getting sick. So we had operational problems with staff shortages. We had immediately real problems with access to PPE, particularly masks and I think one of the things that became really difficult quite quickly is that things were changing daily and trying to keep up with national guidance where you had to order PPE, from what PPE you were supposed to wear, how you were supposed to manage COVID, how you dealt with staff. Because at the time there was no testing. All of that sort of was changing quite quickly and so we had staff who were often very nervous, very scared, patients who were dying, no one really knew what was going on and no national guidance really that we could work towards. So there was this real sense of being completely out of control with a kind of wrestling with an octopus that you just had no idea when it was going to end and how it was going to end.

Clare Montagu (30:27): And there were sort of operational problems that came sort of thick and fast with COVID. So, I mean, obviously we have sort of the health care staff, we had PPE. We also had at the time that people were stockpiling in supermarkets, in the UK and in the US, for example, the death industry was also starting to stockpile and we had a mortuary at the hospice and suddenly you couldn't get body bags. And so I had to make decisions quite quickly about whether we start stockpiling body bags, for example, because actually, it's not really a way in which you want to go about things, but you had no idea what was going to-- We had a reasonable supply, but we had no idea what was going to unfold, whether we were going to start seeing waves and waves of sort of people who are dying. I mean, there was a personal thing for me in the first couple of weeks where I was working such ridiculous hours, that I couldn't get access to food. I had my 77 year old father who got his vulnerable early access to the supermarket to go and buy me food because I couldn't feed myself. Because every time I went to a supermarket, it was completely out of fresh food because of the hours I was working and everything was sort of stockpiling. But it's really hard to sort of describe in a way that makes sense, but there was this sense of things coming just thick and fast and no one knowing what there was to do. And so therefore we felt normally there is someone you can rang, or there's a website you can search or this national guidance or someone knows something, or you can kind of work out a problem.

Clare Montagu (32:02): I mean, that's the nature of operations and there was just none of that. And so it felt very much like I was on my own. And there was one day at the end of March when we had been promised a drop of PPE, we were running low on masks and we had two days where the PPE hadn't come and we had less than 24 hour supply of masks. And we just didn't know what to do because we were going to run out and we had patients with COVID and at one stage, I mean, it's laughable now, we were Googling what you could do with incontinence pants and masking tape. And actually what we did was we rang around our local dentists, all of whom were closed at the time and blessed them. But luckily for us, because we're a hospice and there was a huge amount of support for health care, we got a donation of a thousand masks, which kept us going. But even then, once we got that, I didn't know when the next drop was coming. And so there was this constant hand by mouth existence. On the same day funeral directors were not picking people up from our mortuary and the mortuary was full. So I started to ring around, does anyone know what the kind of London resilience plan, because this fundamentally is a sort of public health issue and there must be, I don't know, the army gets involved or something because you can't have people who are dead not being managed through a sort of [Inaudible:00:33:20] system. And again, everyone I spoke to in the NHS or funeral directors, no one seemed to know what were the arrangements for managing people who were dead.

Clare Montagu (33:30): I mean, a lot, from whatever reason in a kind of emergency and also on the same day, 70% of our income had dropped overnight because we had stopped all our fundraising and our shops closed. So very quickly our charitable money dried up and on the same day, my [finance person] came and said, we can't make payroll. A lot of this stuff sort of resolved itself eventually. We had some savings and we have some reserves, so we launched an emergency appeal. So we were eventually able to get some money and we were able to make payroll and eventually the PPE did start coming. I mean, I did make a decision to hire a temporary mortuary to sit in the car park because, I couldn't bear the idea that we didn't have any answer to the problem of people who were dying, who were dead and that not being dealt with. But those were sort of quite a traumatic sort of set of events and I mean, that was the worst sort of example of it, but there were days where those things kept coming thick and fast and you just had to sort it out yourself because no one else was helping. And in the meantime, the government was getting upon the television and saying there's quite enough PPE to go around. And of course, in between all of this, as a leader I had a lot of staff who were very scared and I couldn't make it okay. And that's fundamentally when you've got staff who are scared and they're looking to you and all I can say is we're doing the best I can, you're doing amazingly, I'm really sorry, let's just keep going day by day. And that was grim.

Ben Yeoh (35:01): It seems extraordinary. Maybe not so much down in hindsight, but the lack of, or even the wrong direction that state capacity went into. I think a lot of us, I certainly had assumed that in this area there was state capacity or there was going to be state capacity and then speaking to you and you realize, okay, there is no state capacity or there's no organization, and there is no plan and you eventually got somewhere, but even there, it seemed that it kind of cobbled together ground up because people realize, okay, we need to put in place something and it traveled that way. So when the answers did eventually come, did it actually even come in a joined up fashion? I'm assuming not because that was my impression, but for someone working on the ground, is that really--?

Clare Montagu (35:58): I think everyone was cobbling something together and I mean, I think everyone was cobbling something together, whether you were in your local NHS, or you were kind of NHS central, or you were in a local authority, wherever. I think everyone was trying to adopt and that will be true for businesses who are at the last minute trying to send everyone home who didn't have enough bandwidth or didn't have enough Microsoft licenses or no one had ever got teams working. Everyone I think was having to kind of cobble this together because it came so quickly. I think it felt very acute on the frontline in healthcare and you did just sort of have to sort of-- I mean, there are some interesting reflections, like we had a whole load of business continuity plans and a COO, it's my job to make sure that we sort of occasionally ran major incidents, but they were all geared towards major incidents. That there's a bomb or that there's something going off and that we now need to provide capacity within the NHS. There was nothing that was really geared to a kind of prolonged national sort of disaster. I'm very conflicted. I mean, the government had a pandemic plan, but they were all planning for flu and you can sit there with hindsight and say, well, you should have been planning for every other kind of pandemic. I think there is a genuine problem that I remember from my government says about the more money you put into planning, stockpiling, capacity, resilience is money that you have, a fixed amount of money and that can either go directly to the frontline to services now, or it can go into the never-never--

Clare Montagu (37:33): I mean, it's your basic insurance problem that you have. The more money you put into capacity for a possible eventuality that may never materialize is money that is forgone that could otherwise be spent on the front line. And I do think those decisions are quite hard for politicians. I think the real issue for the health service, particularly social care and particularly local authorities is that the state had been engineered it for the last 10 plus years and when you are asked to take cut after cut after cut you have no capacity at all of any description. And I think one of the things, I mean, I would say this, wouldn't I given my political background, but actually surely coronavirus shows us that the only guarantor really of safety and security and services is the state. And actually, unless you fund those services properly, they are not able to respond. There's just no capacity in them.

Ben Yeoh (38:27): Your articulation about putting oneself in the place of the decision-maker or the politician I hadn't heard before and it actually makes a lot more sense as in what we saw in hindsight, I think you had this in the US, they had ventilator contracts, but they canceled them two or three years in because they're very costly and well, these ventilators are sitting around doing nothing and we know we would get a return now, because essentially we're underfunded. Well, you can always hire another diabetic nurse and you're going to do some good with that cause you've got an almost infinite demand for where you are in healthcare. And I could see why we would necessarily stockpile 10 million masks in a country when most of the time seemingly you wouldn't even on a seven to 14 year cycle. Like you say, that's an insurance problem. Maybe that brings me to the thinking about where we are now as politicians kind of always like to say, and looking forward to the future there has been a lot of talk about being more prepared for either future pandemics or other of these kinds of global coordination or country coordination type of problems. And a lot of people have said, well, we should look at some more of this insurance or state capacity and I think it's a good idea, but I recall, although it wasn't as severe, we had a swine flu pandemic of not the order of magnitude and a lot of this was talked about, and we ended up in similar problems. Arguably part of Asia, which had a much worse experience of original SAR or SAR- MERS, which had a [worse historic experience] had some planning, but it overall talks to the difficulties we have of state [capacity] within healthcare thinking.

Ben Yeoh (40:17): I think actually the UK's got a very specific problem cause it's spent so much less on health as a percent of GDP as versus a lot of OECD countries, even excluding the US which is unusually high, but maybe from a more operations maybe policy background or even thought, what would your reflections about now what we should be doing or thinking, maybe through the lens of hospice care? I mean, part of it seems to me, hospice care should definitely get more state funding. That's [-] an obvious win-win. Part of the mission of a country like ours in Britain, which supports that may be harder in some other countries which might not have that support, but certainly here, but aside from that, I'd be interested in your thinking.

Clare Montagu (41:07): … I think this is almost impossible to answer because I think almost by definition you end up fighting the last war. I wonder whether and actually, I wonder whether there is something about what [you said on] the swine flu [ ] is really interesting because I was in the department of health as a special advisor around the time both that we were preparing for a flu pandemic and also when swine flu started, this is in 2008. And actually, there'd been this lot of chat about kind of the pandemic being over the hill and flu being a really big thing. This would've been in sort of 2007 when I first went to [DoH]. Actually it arrived in the beginning of 09, I think, sorry. And so, there were a lot of kind of COBRA meetings and buying a lot of Tamiflu [an anti viral flu drug]. But then we had vast amounts of Tamiflu that we had acquired. And I mean, as was typical, there was then a huge amount of kind of backlash for the amount of wasted money that we'd spend sort of buying up Tamiflu from GSK when it turned out to be not a big deal in the first place. And that's just one drug against one strain of one kind of condition. I don't know how you begin to-- I don't know enough about the epidemiology about how you begin to prepare for multiple types of, you know, the next one might be a flute pandemic. It might be a coronavirus pandemic, it might be some other kind of virus altogether and I don't know how you begin to, you know, masks of the surgical variety may not be the kind of thing that you need at all. Maybe you'll need kind of the bigger N95 masks and that will be the next problem.

Clare Montagu (42:45): And again, I do think you've got this kind of money versus money spent kind of problem. I wonder whether there is a much broader understanding of public health that came out of particularly the east Asian countries after SARS. So for example, things like mainstream mask wearing, and that there were certain sort of lessons about how you manage epidemiology, how you manage public health that isn't necessarily about pandemic but it's about, for example, if you've got a cold, in the old days we would all stagger into work. You don't go into work with a cold and it doesn't matter whether you've got COVID or, you know, it's nothing to do with whether you've got COVID, it's just that you don't go into work with a cold because actually you'd be spreading around a lurgies or that you, as a matter of course, if you are feeling unwell, you wear a mask on [transport]. Now, I think there is a real difficulty because we haven't had that kind of culture and leadership, but we've seen over the last 20 years that for example, mainstream mask wearing pre COVID pandemic was much more mainstream within east Asian countries than it has ever been here. I mean, if I'd turned up with a surgical mask as a white British woman on a London [train station] people would've looked at me like I was bonkers, whereas actually that's been much more mainstream in east Asian countries.

Clare Montagu (43:59): So actually maybe we start thinking about how we handle public health differently as a result of this, that would just be applicable to a range of different potential lurgies in public health situation, rather than trying to kind of bet on what the next one might be, because then you end up sort of stockpiling for the next coronavirus thing. And maybe you do then end up destroying millions and millions of pounds worth of kits and that's millions of pounds worth of kit that could be given to diabetic nurse, sick children, hospices, insert your favorite kind of political [cause]

Ben Yeoh (44:35): I hadn't heard that articulation either and I think that's quite wise. I do think it raises some quite questions about, I guess, process, culture and leadership that we could learn from if we could do it. [-]  Speak, if we could actually execute on it. But for instance, clear messaging would've been great. It still would be great and would be great in the future. So if there was even just a little, I guess it's a Comms department but someone who could do this kind of very clear messaging infographics, almost like a community-- It's a social science skill, I guess. And then to put some of your points, I don't even know whether it needs that much money, but someone, some state capacity, which can make decisions very quickly realize when it needs to put some of these processes in place and then hit go on the processes where they can cut through some of the checks and balances that you definitely want in normal times. You probably want to speed up during pandemic time. And we saw this, actually. We kind of did it with vaccines, right? The usual length of safety testing, you could tackle a different risk reward because people are kind of dying on you now, which actually it is a different situation to be, and you have to change your mindset, particularly if you have, I guess, an exponential disaster unfolding which actually some of these infectious diseases could well be, then you need to handle that very differently. Deliberating checks and balances for three to six months is not going to help you and so--

[Crosstalk].

Clare Montagu (46:08): I think that's right and I would hope that this has now come about, but I think that the public health bit of-- the surveillance bit of PHE with the Public Health England bit prior to COVID was a bit sort of ropey and a bit-- It was a sort of bit of a backwater over there and never got any kind of political attention at all and the hope is that actually there is now much greater understanding and also genomic sequencing, which we've been doing in this country incredibly successfully and has been integral to some of the ways in which we've been tackling the virus. You'd hope that some of that would continue. I do think a lot of this though starts with political leadership. I mean, one of the reasons the Comms messaging has been so unclear throughout the pandemic and remains unclear is because the leadership is unclear and there is not a strategy. And I think that's also partly, and again, I am partisan, but I think this is also observable and this isn't just the criticism. This government, this is ideologically quite libertarian and not into what would be seen as a kind of nanny state messaging. So that for example, restrictions are left and we do not maintain a mask mandate. I was in France last week where masks are emphatically [deployed] and while you still get on the tube and you see a person with the Metro with a mask around the chin, by and large the kind of compliance is 95%.

Clare Montagu (47:31): Now, I'm not saying that's necessarily right but actually there is something about very, very clear leadership, about what we expect as a society in terms of our obligations to each other in a public health crisis and in an ongoing public health context and unless that is set from the top, it's just going to kind of fizzle out because if it's set from the top, then money and kind of enforcement follows. And for as long as the prime minister sits in a room with Joe Biden, when everyone else is wearing masks and he doesn't, I mean, it becomes very difficult to sort of enforce this sort of stuff. That is the point, but I do think there is something about actually the government needs to say there is a step change now in public health practice in this country, and this is now what we expect.

Ben Yeoh (48:18): And I would say that some very, what I would call, I guess, smart libertarians who are all for masks and this type of thing. Alex Tabarrok who's a George Mason university libertarian and professor and some others like him would say, well, there are limits to libertarianism, right? And you can argue that a pandemic is exactly the one where you want state capacity and you want these because you have a greater good for doing it. They would be a small state for many, many things, but this is one area which they would do. So even amongst a libertarian philosophy, I don't think they even applied their own economic thinking in a consistent manner. Maybe this brings us onto your former life as a special advisor and maybe it's worth just touching on a couple of things. One is again, maybe a day in the life. I think a lot of people I guess here in the UK, we've had Thick of It and in the US you have [Veep] and everyone has this kind of imagination about what it is. And I guess, particularly in this country because of the outsized role let's say media attention that Dominic Cummings has had. We have a particular impression of special advisors or SpAd which I'm not sure is correct, but I mean, maybe it is. So, maybe you'd like to say what is it that actually SpAd did and do and has it-- I know you're kind of quite distant from that world now, but in your impression, has that evolved and what good do you think SpAd can do and what do they do well and what to do badly? But what is it that SpAds are brought in to do and what is it that a good SpAd in your thinking should be doing?

Clare Montagu (50:07): Okay. So, I used to prefer as my television reference the west wing but actually it has to be said that quite often my life was like the The Thick of it…. [The Show] was extremely well informed, I have to say within the UK context. So SpAd is a shortening for special advisor and within a UK context there are very few of them and they're basically personal political as in partisan advisors to a cabinet minister. And obviously within the UK, we have an executive cabinet that is slightly different from a US cabinet and also within the UK, as you know, the civil servants are permanent and they're nonpartisan. So you are attached to a particular minister and in my case it was a [minister] called Alan Johnson, who was a lovely cabinet minister in the late sort of two thousands. And you are effectively his or her presence on earth and you act both as a transmitter of his view or advice or view of the world to the department, to the wider sort of stakeholders, to other people within white hall and beyond. And you also provide him or her with personal advice and generally you have one who kind of focuses on communications and that's classically like the spin doctor and then you have one who focuses on kind of policy development and that was my role. So my role was very much about within the departments that I was working in with Alan was about working directly with civil servants, with other state orders, people in number 10, whoever to develop policy. And that was both ensuring that the policy that was being developed reflected Alan Johnson's priorities and it was also advising him on what we should do on various different policy objectives was essentially what it was.

Clare Montagu (51:53): And then a kind of day in the life was, I mean, it was literally anything from the West Wing to the Thick of It. I mean, you have this-- You know, at any one point in time, you are kind of progressing good long term strategy development, which is your west wing bit and that's kind of like-- And some of the stuff-- I was a special advisor for Alan between 2006 and 2010 when labor lost the general election and there was very few things that I worked on still left, but one of the things that I was involved in in 2006 in part for education was children in care, green paper and white paper and children in care legislation and that was all about improving life chances for children in, so children who are looked after by the state either permanently or for a period of time, because their parents can't, and they have really poor educational outcomes, really poor health outcomes. I mean, they're a really disadvantaged group of children and young people and I did a lot of work with a team of civil servants about developing policy in that area. And a lot of that is still kicking around today. So there is a bursary, for example, that children in care can get access to enable them to access higher education, for example. And that was something that we developed back in 2006. So there was some really things that you can get kind of-- you can feel quite heroic about and that was something that was really important personally to Alan, because he himself was orphaned when he was very young and was brought up by his elder sister and in another context, would've been sent to a Bernardo's home and put into the care system himself.

Clare Montagu (53:23): So it was something-- as well as something that we all felt was very important was also something that was personally very important to him and something he championed. So you can get involved in kind of policy development that will outlast you and outlast your administration and that's the sort of most heroic bit, working with a group of people to kind of develop a strategy, put some money behind it, put some legislation in and really transform something. And then other bits are kind of comedically horrendous sort of things that are coming at you thick and fast that you need to kind of deal with either as they're coming up in the media, or because you're having a bum fight with a stakeholder, or you've decided to make a policy change and someone thinks it's a really bad idea and if you're not careful, you're going to kind of get egg on your face. And that's the sort of [Think of It] type stuff. And then there might be just in the middle of that a day to day-- I mean, certainly as a special advisor, you're working across as a policy special advisor. I was working across the sort of full gamut of government policy within my department. So within health, for example, I might be dealing with hospitals or I might be dealing with embryology and abortion and some of the kind of very controversial issues associated with that. I might be dealing with child obesity and tobacco and some of those public health issues. I might be doing sexual health and some of it is just genuinely nonsense. Sexual health was one of my favorites where there was a group that-- I can't remember which junior minister it was putting together a group of people to develop some sexual health strategy and she put together a group of stakeholders and it was going to be called the sexual health advisory group.

Clare Montagu (54:56): I kind of got wind of this and went in and said, "You do realize that that spells shag, don't you?" And that's your classic sort of the Thick of It type thing and there is a lot of that kind of stuff that does the rounds. Alan had a similar thing before my arrival, I think when Tony Blair, after the 2005 general election created the department of trade and industry, and he [ I can’t recall the exact name]  wanted to name the department….the department of productivity, energy and industrial strategy or something like that and Alan was appointed as the new secretary of state and he went to see Tony Blair and said, "You do realize that that spells penis?" And Blair hadn't really twigged. So he had to be going back to the department of trade and industry. And so there's a fair amount of that kind of nonsense that kind of trots around the place and a lot of it is just about trying to kind of balance very real-- I mean, I think the other thing that no one really realizes is that governments, although they mostly often get things very wrong, they're dealing with the kind of sticky issues they're like of which that most people cannot begin to get their heads around. So one of my last departments at the home office, which is the same as an interior ministry in another country and the home office just deals with the most intractable--

Clare Montagu (56:23): I mean, the first duty of a state is to provide security to its citizens, but you are constantly kind of trading off security versus Liberty and it's an area where you've got a kind of set of policy dynamics, you've got a very, very strong political and quite often your parliamentary party has very strong sets of views. You've got where the media are at and very strong sort of media campaigns running, very emotive public issues, and often some very difficult legal ones as well. And trying to come to a decision about sex offenders or about immigration or national security or whether or not you keep people's details on a DNA database, which is both a kind of individual Liberty versus a national sort of security issue. None of these things are very straightforward and so you are trying to model through as best you can.

Ben Yeoh (57:16): Well, I for one am really glad that it has very smart and clever and committed people like you behind the scenes. I guess, well, with either side of the houses we'd say in this country, but that a lot of people are dedicated to try and work on this and like you say, on those problems, cause the standard financial economic tool is a kind of opportunity cost benefit analysis and that can work where you can readily convert things into monetary values at sort of moderate estimates that you think you're getting right. But actually the amount of policy which fits into that mold is not as large as you would thought, because then, like you say, if you get into issues of security or policy, you are doing a cost benefit analysis or a trade off, but for things which you can't possibly put into monetary value and are not time stationary and vary on all of these different stakeholders. So I can really see, and you're sort of using that same tool, right? Because you are trading off different or opposing sets of view and you are kind of trying to, I guess, maximize as many stakeholders in whichever thing that is to make them more happy, but you are not going to make everyone happy and you may well get the calculus because who knows how big the weight of those various arguments actually in reality are. And actually you might have even got it right at that point in time and then one or two years later, like on the privacy thing, it completely changes because technology has changed on incident or something has happened. So yes, I get that.

Ben Yeoh (58:47): Maybe then pivoting completely to another job that I know you've done for a little bit was volunteering in essentially warehouse working. So you've done high powered CEO role advised the highest politicians in the land and you've done essentially what would be associated with a working class job as stacking things in a warehouse. So, in your reflections about what's that like, I guess a lot of people assume that it's not a very nice job, but if you look at, for instance, conglomerate reports about people who work in Amazon warehouses and yes, it is quite hard and it's not the most glamorous job net on average people actually do surprisingly well of it. And maybe that's part because actually minimum wage for warehouse stacking because of digital and where we've all gone is actually quite close to where living wages are or it's actually above-- I mean, actually you get now more in warehousing than you do say burger flipping, but that aside that is kind of an intriguing force, but yeah, what's it like working in a warehouse

Clare Montagu (01:00:02): So I should probably just explain what I was doing. So I gave up my job in March and [have been on a sabbatical until the] end of September, and one of the things I decided to do was volunteer one day a week for a charity called City Harvest and it comes from an American brand, actually. I think the City Harvest in New York, possibly in other cities, which is about redistributing surplus food from restaurants and kind of retailers to food banks and hostiles and refuges and charities that need it. And so the work I was doing was basically in a warehouse sort of sorting fruit and vegetables or sorting or stacking kind of dry goods or pantry goods to go to charities and it was manual labor. It was quite hard. It was surprisingly hard actually. I didn't feel like I needed to go to the gym afterwards and I really enjoyed it. I think one of the things to start off with is that I was coming at it as a previously quite senior person working in a job that was using my brain, actively wanting to do something that was completely different and actively choosing to do something with my time. And I think there is something very different when you step into something as a volunteer than when you are paid to do it and it is hard work. I mean, I was doing one day a week. I think doing that 40 hours a week or the 35 to 37 hours a week would be quite tough going.

Clare Montagu (01:01:33): One of the things I found was I had to not put my COO hat on when I went to the warehouse. One thing I loved about it was that I could clock on, be told what to do and as long as I worked hard, I could just clock off again and I really like not having that sense of--

Ben Yeoh (01:01:48): [X percent more efficient if you change this process though.]

Clare Montagu (01:01:51): But equally it was really hard not to sort of look at it and think, how would I do this? Definitely and I've not run a logistics business, which is essentially what it is. You've got goods in, which is being donated by people, which you have to process quite quickly and you put in freezers or in fridges and then kind of get it out again quite quickly before it spoils [ ]. One of the things I was thinking, I do remember sort of thinking about though, and I was thinking about how you would lead a team within a warehouse environment; is that warehouse work is hard work and although I think the cause was great, it is nevertheless, I mean, it's kind of a sh*t job type work. It's not a career job. And I think one of the things I was sort of thinking about was how would it feel to be doing this sort of 37 hours a week? And I was thinking that in part, because how would I lead this team? Because I thought I saw some behaviors that I should [maybe call out and  I thought the management should be a bit all over, but actually I think when you've got jobs where people are coming in to do pretty relentless tasks, I think you have to be realistic about what you can expect of them in terms of their engagement with their work. Certainly, I think that what I observed was that people who were being paid to do the job, I think their enjoyment and their fulfillment depended hugely on their colleagues.

Clare Montagu (01:03:16): And that was the first thing that I thought was really interesting compared to working within a graduate environment or working with a bunch of healthcare professionals where actually your colleagues matter but so do does the exercise and the skill in which you have trained and you don't have that when you're in warehouse work and warehouse work may well be kind of substituted for driving work or for any other kind of not great job paid at probably minimum wage/living wage, just. And so actually what is going to keep you there? The cause is not enough. The usual stuff that you use within a charity environment is quite often dependent on people who are very committed to the cause or the key workers who really want to help up with X cause and you don't have that with warehouse work to the same extent, even though it's for a good cause. And so one of the things I sort of really observed was it's a substitutable job for any other sort of stuff you might do. You could go off and work for DPD and you'd probably get paid the same amount. It's sort of slightly less hard. It's less hard work, physically hard work, but you are doing it on your own. [ ], what is it that you want from a job in a short period of time?

Ben Yeoh (01:04:26): I've always been slightly suspicious of [strong purpose in low paid jobs] n— So, I'm thinking about purpose and mission led, which is great. It's all fine for us in healthcare job; you're saving life or you're helping people's pensions and you are dealing with technology and you're inventing a really great product, but yeah, if you are cleaning floors or stacking and shelves, there is a sort of, I think it might even be apocryphal, but you get this. There is this story about-- I think it might have even been the US white house and the president asks the janitor, "What are you doing? And they're saying, "Oh, I'm helping put a man on the moon."

Clare Montagu (01:04:59): Put a man on the moon.

Ben Yeoh (01:05:00): I actually suspect the story's made up because actually people don't feel like that because the job isn't very good and to have that sense of purpose, even when it's more direct. So cleaning in a hospital, you probably are really saving lives because you are killing bugs and those bugs don't get-- and that's actually quite direct, but I don't know really-- I've only spoken to a couple of cleaners and janitors and they don't feel that, half the time it's outsourced. So I do wonder whether we do need to think about it now, but again with--

Clare Montagu (01:05:32): What's interesting, I think there is that thing about direct cause and I think certainly my observation within hospice was we had outsource cleaners as well, but they were superb, but we had outsource cleaners who had been with us for 10 plus years. And in fact, we treated them as employees when we came to give them long service awards and that was in part and they weren't being paid well. I mean, they were being paid London living wage because we paid London living wage, but they weren't, you know, it was still cleaning within our kind of hospice environment. But I think that was two things. I think they had good employers who treated them well with respect and nice colleagues. But I also think in a hospice environment, you get to see the patients and I think there is something that's re-- What was really easy or easier for me leading a team within a hospice building and the analogy was actually our retail colleagues who were spread out in shops was one of the things that was always much harder for them, because if you're in a shop in wherever, you only come to the hospital maybe two, three times a year, it feels much further removed the cause. And so you've got to keep them ticking over for some other purpose because the cause is not enough to keep you going if you don't get much exposure to it and if it feels that further removed, whereas when you're physically in the building and you can see patients and you can see family members, there is much more a sense of purpose.

Clare Montagu (01:06:50): I think that the janitor who puts the man on the moon, the janitor, the cleaner in the hospice would absolutely have said, I'm here to look after patients. I think everyone in that building, whether they were a finance assistant or cleaner or a Porter or a doctor knew why they were there and it's not for everyone, but that was what gave them purpose and I think you can do purpose in that environment. I think it is really hard when you're further removed and you are basically doing a job that is much more indirect.

Ben Yeoh (01:07:18): Yeah. That mission led. When you can see the mission in front of you, I think that's definitely a thing. Great. Maybe that brings me to the final two questions. So, one would be how should I have a good death or maybe you could think about it maybe in your context as well if you prefer it's easier? So I've written a will, I haven't done any of what I should have done as a letter thing or stuff like that. Thankfully, I don't really have a porn stash or anything, which means that I wouldn't want my mom to look through my stuff, although I should probably say, I've got notebooks and things and some of it probably people wouldn't realize if it's important to me or not. I've now taken on board your notice that I should try very hard not to die in a hospital and I think obviously dying at home is probably good. I'm probably not quite as prepared as I should be on some of the things, but I feel having a will and some things is probably slightly above where the average person sits. I'm trying to think about, well, I haven't developed how my funeral service would work or even any songs or readings or things like that, which I'm actually working on that thinking about what I should do, but any thoughts or tips or advice on how someone, or maybe someone like me should think about having a good death.

Clare Montagu (01:08:38): So I think you are well ahead of most people is the answer. So there's a kind of basic stuff about [death admin], right? So that's your kind of will and there's the admin you need to put in place. So absolutely, particularly if you own property and particularly if you have kids, you need to have a will and there's just no two ways about it. The number of people who still don't have wills despite earning property and having children is still sort of extraordinary, actually. And you can get a will off the internet. You don't need to spend squillions with this.

Ben Yeoh (01:09:06): 10 pounds or whatever. Yeah.

Clare Montagu (01:09:07): Yeah. I mean, it's really straightforward and that's because the grief involved in [death] and if you have any complexity at all in your family arrangements and, or you are not married, you're partner, but not married, certainly in this country, in the England that will create all sorts of problems.

Ben Yeoh (01:09:24): Some of it goes to the state or the queen [I].

Clare Montagu (01:09:26): Some of it will go to the states and if you are not married in England, but you are partners, your common law partner does not have a right to your estate. So I mean, you do not want to die into state. So I think there's some basic [admin] about sorting will, which is a good start. And actually, I think also the other thing that I think is really important for everyone at whatever age and this stuff is a lot easier when death is not on the horizon, it becomes a lot harder when people get older and or when they're diagnosed with a life limiting illness, is actually to talk to your partner or your next to kin or whoever about what you want for your death, but also for your care and also what they want too. So one of the things that always is particularly if you were unfortunate enough that something bad happened unexpectedly, and you kind of pitched up in hospital, do you want to be treated at whatever cost? I mean, people will say, well, I don't want to be a vegetable. Well, that's not sort of massively helpful. If you were diagnosed with a life limiting condition, would you want to continue to have treatment? Would you still want to continue to receive antibiotics? And some of that will change according to what happens, but actually it is surprising the number of people who haven't talked to their partners or their next of kin or their parents or whoever it is about what their wishes are in respect of death, or if they found themselves in a very serious condition.

Clare Montagu (01:10:52): I think certainly for, I mean, one thing I always say and I'm very delighted to hear you don't have stashes of porn around the place, although it's totally your bag if you do. But one things I also say to people is, think about, do you have something that you don't want your parents to see if you were to find, you know, because actually it would be no bad thing to go and talk to a friend and say top of my cupboard, there's a little bag with some stuff and can you just remove it before my mom starts clearing stuff out. Whether that's porn or sex toys or whatever, but just thinking through some of the kind of practicalities. I think funeral stuff is great because I think the more that you are able to think and talk about it, the better that is for the family and for those who are left behind. I mean, one of the sort of classic things you get is that a family member turns up to-- no one's talked about a funeral and what's wanted, and it turn up to a funeral director often having had no sleep and the height of grief and the funeral director says, what do you want for the funeral and they haven't got a clue. And the next thing the funeral director often says to try and help is, oh, well, what was their favorite song? And then you can't think about their favorite song and then you go off on one that you've spent 30 years with this person, and you don't know what their favorite song is and actually that's all nonsense. But I think that thinking about your arrangements now helps someone for the future. But I think the other thing is that what we want changes over time, right? And it would change again once you become older and sicker, but starting to normalize these conversations means that you can flex over time.

Clare Montagu (01:12:18): So for example, I have always thought that I would be cremated just because 80% of people are kind of cremated in this country and I have no faith and I'm not interested in the burial, but actually the more I look into it, the more I think actually I'd quite like a natural burial because actually if you think about the emissions involved in cremation, that that's pretty kind of grim. And then you get a whole load of sort of ashes that are basically inert and in this country, there isn't yet what there is in the US, in some states in the US a natural organic reduction where you can kind of basically compost someone and produce soil, which I think is amazing. But in this country, in the UK, you're only allowed to bury or cremate someone. So I would want to be now buried in a natural burial ground because I think that's more environmentally friendly than kind of going off into a kind of cremation. So I think you just sort of change some of these things over time, but the more you can start thinking and talking about these things and some of it may be really basic. So I have written down on my wishes, like one thing that would drive me absolutely nuts is if I were unable to communicate or semi-conscious and someone were putting heart FM or something radio on in the background. I mean, that would set my teeth on edge. But if I were unable to communicate that that would drive me nuts. But if someone's just going to put a gentle radio three or radio four, that's fine but there are some things that I just, you know-- One of the things I've put in my wishes, for example, in case I-- this is sort of in case I got knocked down or something is I'm really shortsighted. So I wear contact lenses, but if I got taken to hospital and then I had to be taken into hospital for an extended period of time, someone's going to need to remember that I've got glasses.

Clare Montagu (01:13:57): You might have a dog, you might want to kind of write down somewhere that actually your dog, you know, you want your dog to be looked after and maybe you want to think about who your dog should be looked after in your absence. So that's a bit about care and a bit about death, but I think the more one starts thinking through if I were knocked down or I ended up suddenly in hospital, cause that's sort of a bit easier to get your head around than suddenly having a kind of awful diagnosis, what would I want people to know both in terms of my care, but then potentially if I were to die and actually just to talk to people about it. Start normalizing those conversations, and then it becomes easier at the point at which you really do need to have them.

Ben Yeoh (01:14:32): That's fascinating. I think we should all think about death more often and I think I should think about it a little bit more. So the final question then is, do you have any thoughts or advice for people? I guess I'm thinking more young people, maybe people who are interested in politics or public policy or generally interested in the kind of things that you've learned over your career or life.

Clare Montagu (01:15:00): Oh, goodness me, my life advice. I think if you're interested in politics and public policy, I think that's fantastic. I think one of the things that I have learnt is that there are many different ways to do that and actually you can make a difference in mainstream politics in the way that I did. So I had, long engagement in the labor party and I was that kid that was running a general election while doing my GCSG for the labor party and all of that kind of stuff. And that is one route through a political party and through Westminster or through local government. But actually there are many other ways to make a difference and activism matters too, matters hugely. And in fact, sometimes activism matters more and one of things I've learned through doing operations is that actually it's not all about this kind of highfalutin stuff that happens in Westminster and white hall or in Washington or wherever the seat of government is. I mean, self-evidently because for most people life goes on irrespective of what's going on in government. But I think when you are committed to making a difference in a public policy field it's quite easy to be drawn to thinking that that's all that matters and it it's fantastic and you can make a difference, but there are heaps of other ways that you can do it. And I think the older I get the more I think about both either directly involved in operations or activism. There's so many ways to skin that cat and I think the main thing is to show up and do something about the stuff that you care about.

Ben Yeoh (01:16:21): Great, show up and do something. So I'd like to thank you. I don't know if anyone's really done it before, but you've had enormous public service and an enormous service to family and people all around London and next chapter in your life and everything. But I think you've had an extraordinary life already. So Clare, thank you very much.

Clare Montagu (01:16:42): Thank you, Ben. That's very kind. Bye-Bye.