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The National Health Executive Podcast is the perfect place to garner insights from across all aspects of healthcare, as we get into the crucial ‘whys’ behind the stories and how they can impact all of us to improve our work, our lives and the care and services we provide as an industry.
Tune in, discover more about our diverse and talented health sector and it may well spark the solution to help you see a problem or challenge in a new light.
Why should it be the case? That because you are a child growing up in one community, that your healthy life expectancy could be 20 or 25 years less than a kid growing up three or four miles down the road. This must be a proper wake up moment for us as a nation where we don't allow this to continue anymore where this is just our moment in time. It's, it's our epoch moment. That is so much link between stigmatisation and inequality and inequity.
This is the National Health executive podcast bringing you views, insights and conversation from leaders across the health sector, presented by Louis Morris.
Today I'm delighted to be joined by Durka Dougal, the chair of the Health creation Alliance and Andy Knox, who is a GP and Associate Medical Director for Lancashire and South Cumbria NHS population health and also leads their population health leadership academy, how is your work led you to be interested in population health, population health management, public health, health creation, etc.
So I grew up in the city of Coventry, in the West Midlands, the glory days, the West Midlands, and then went and studied medicine at Manchester. So two cities where there's quite a lot of significant inequality, actually, I'm growing up very aware of that. And then I've done quite a lot of work in Sub Saharan Africa. So I've worked in South Africa, Kenya, Uganda, Sierra Leone. And so I have a real kind of core sense of social justice, and really, really care about the issues of inequality. And I did some training back in 2010, with a group called The Art of hosting, that began to kind of make me think differently about what leadership is and what the role is of leaders in communities. So I think, often in medical school, we're taught that we are the fixers, whether we're the heroes, we kind of ride in and help people. And we're that we're the ones who sought out people's problems. And yet, I was beginning to realise, in my work, that that way of trying to fix people wasn't really kind of getting into some of the wider issues I was seeing in the communities that I was trying to serve. So I did this training. And I had a bit of an awakening, really, that leadership is more about hospitality than it is about heroism. And I'm really glad I did that training, because I moved with my family from Manchester, to more convey in 2012. And within a year got really, really close to burnout. I had a moment as a GP, where, after one day, I was just so utterly exhausted by the number of people, we were seeing the complexity of the issues we were facing, that I kind of just put my head onto my onto my desk at the end of one day and just wept with this sense of I'm so exhausted and overwhelmed with the tide of people coming through our doors, and not really knowing how we can carry on working in this way. And I kind of had a little bit of an epiphany, I suppose in that moment, which made me join up my thinking around different kinds of leadership. And also, it began to make me ask a different question about what is it that my community are really facing that's causing people to come through the doors of our practice in such huge numbers, with problems that it feels that we can never really solve? And what that led to, for me was a step outside of the doors of my surgery into my community to have a different kind of conversation. So initially, we had about 30 people come to a conversation in which I wanted to ask them, the question was this if Carnforth, which is a town hall I work in became the healthiest town in England? What would it be like? What would it be like to live here if we were truly healthy? And well, if we experienced health as a, you know, a daily good thing in our lives, what would happen and in that conversation, I kind of shared with the people at turn up some of the exasperation and the overwhelm I was experiencing as a GP, but then also really wanted to hear some of the experiences of my community and the lord mayor of the town happened to be in that conversation. And he loved that conversation. And he invited me to host a breakfast with him. And 150 people in the town turned up. And then 300 people turned up to the next conversation, and within about six weeks 1000 people in the town was suddenly in a conversation about how life might be different if we chose to think about health and care differently. And I think that was my real introduction about 1213 years ago. Can't do maths 1011 years ago, into kind of a different way of working which is what I which is the way of population health. So rather than being reactive and Sitting on waiting for people to come to us how do we take a proactive step into community really understand what is the data showing us about what this community is, is experiencing? What are the community themselves telling us about what the data says and what they are experiencing? How do we join those things up to work with our communities differently, and build better health and well being in our communities, but also tackle the root causes of inequity and inequality in our society. So for me, that was kind of my convoluted journey and a deep care and passion about social justice, some training that changed my view about what leadership is and how it functions as an experience of overwhelm, and exhaustion, that led me to begin to work with my community differently, and which has now spread into much wider work across a bigger geography. Darker, what about you?
So I guess, for me that word epiphany probably is the right one. When I look back on it now, being a Sri Lankan woman growing up in England, I think I probably always have been aware of these terms instinctively. And I think that's probably what drove me towards a career in medicine, and wanting to make a difference to people's lives. Even from a fairly young age. I started training as a surgeon, and as, as in my surgical career, I absolutely loved my role. But I loved the kind of interactions with the public the stories, the lives, the people I was working with, and what I was doing in terms of the work, but I saw so many opportunities where things could be done differently, to better serve the people that that I was coming across. So yes, being a skilled surgeon can help treat a condition at that time. But there are so many steps in the community that I could spot that I was hearing from people that I was talking to, that meant that that surgery may not have been needed at all, or may have been effective, earlier or could have been delayed. So I became interested in prevention, earlier detection and care, transition out of hospital support in the community, and began to realise that that's the language of public health. So I trained in public health as a specialist, a brilliant profession, and I gained so many skills. But I also began to be interested in workforce and systems development, and the sheer power of people. So communities and staff to bring about that change themselves. By working together across systems, so this notion of more than thinking about population health. So since then, for the last 10 years or so, I've worked for various local and national organisations, leading efforts to deliver this change to bring about a new model of care that's focused much more on population health, public health, tackling health inequalities, but not just about creating the conditions or you know, for it to be an aspiration, but how to really implement it and deliver improvements for people's lives on the ground and with people. And I guess, I've never really stopped being amazed at what I see happening as a result. So people are incredible. There is such an untapped potential in terms of transformation that's possible. And I guess I've begun to increasingly realise over that journey, it's about using the right approach, providing the right support, bringing people together in the right way, with others, using the evidence base, but helping people to figure out their own solutions to co create their own solutions and to lead the change themselves. And then incredible transformation can result feels like we've started on that journey. But it feels like there's actually so much more to do.
And the next thing I'd like to ask is to get your insight on I've done this with a few other definitions, most notably what digital and what digital actually means the NHS, because there's quite a lot of ambiguity I found around that. What are these terms public health, population, health, population, health management, etc? How would you actually characterise those terms? And how do they all tie together?
Yeah. And I think that's a really great question. Thank you. And one that I'm often asked because there are terms that are often used interchangeably. And sometimes people get stuck on the debate about what they are, where actually, I think there's also a need to accept that there is a difference in understanding or use sometimes. And maybe it's about moving on from that debate to actually utilise the terms agree what you mean, to actually bring about the change for the public Well, as you get stuck in that debate, but roughly speaking, these are four terms, all really important, key concepts and actually critical to the bringing about of a new model of health and care. I think they're relatively poorly understood. Overall, though, it's brilliant that they're getting increasing attention An interest and increasing recognition about just how important they are. So public health, this is my profession. I'm a doctor in public health medicine now. So a public health specialist, and I'm on the specialist register as a practitioner. So there are two ways of looking at it. And really the true way of looking at it, in some health systems is actually quite overlapping with population health. But the problem is, often public health is seen for the other bit of it, which is, it's a workforce, it is a highly specialised, invaluable workforce for any efforts in this space. So my key message there is, please understand who your public health teams are, and connect with them. Because you cannot do this without public health teams. Then in terms of health creation, I'd see that as the underpinning principle, and probably out of all these terms, I'd say the least well understood. And that's why I'm so proud to be the chair of the Health creation Alliance, because it feels like there is humongous potential in terms of even just getting that right. So health creation is the process through which individuals and communities gain a sense of purpose of hope, of mastery and control over their own lives, and their immediate environment. And when this happens, their health and well being can be enhanced. So it's that underpinning principle of enabling health. And then very quickly, the notion of population health is then an approach that can be taken at any level, to really think about a defined population, and how partners can work across organisations, and importantly, with the people that they are serving, to understand what local needs are, and to get improvements in health and care, and importantly, to tackle health inequalities, because we know that health is not an equally accessible opportunity for all. And that focus is needed, therefore, to really tackle health inequalities proactively, and we can go into that. And then that last segment being population health management, and that is a tool. So it's a data driven tool, which can help with population health approaches. But it's really important to understand that data in itself is not enough. It is one part of the picture. And for a population health approach, which has health creation, at its very core, and has the involvement and support of public health teams. That is probably the best way of describing how they tie in together and actually looks like a healthy future for health and care. Andy, from your VISTA. How do you see that? And do you agree?
I do agree. And I think we're actually in a bit of a stage of recovery. And it's not really a criticism, I think it's it's a consequence of public health teams being kind of pulled out of the NHS and put into local government. And there was some actually really, really good thinking about why and how that happened. Because a lot of what we call the wider social determinants of health, the stuff that actually makes people more unwell for issues like poverty, access to education, clean water, good sewage systems, but also access to green spaces, and good quality work and all those kinds of stuff. A lot of that sits in the work of local government. And so it really makes a lot of sense for public health teams to be there. But then there became like this weird separation that happened between public health teams and NHS teams. And I was in a really great conversation with Ivan Brown, who's just a brilliant public health leader in London worked for Sadiq Khan. And I was just with the NHS Assembly last week. And we were talking together about kind of this interface and the need for better integration between public health and population health and actually how it's it can sometimes become a real competitive minefield rather than a place of brilliant integration, joined up experience and expertise, where teams are just doing the best they can and serving the needs of the community whilst bringing their different bits of expertise, or even the different bits of their organisations together to really make a difference. And he was just talking about how he's so welcoming of anyone who will come and play on the field with him, because actually, it's felt quite lonely in public health for the last number of years. And they've and there's been huge budget cuts to local councils that have made the work of public health even more complex. So the fact that we're now talking in integrated systems about having better join up between public health teams and NHS teams, but also inviting other really key colleagues from community voluntary faith sector, from schools from from all kinds of different partnerships into the mix. See, that actually becomes a place of really exciting possibility, integrated partnerships to improve the health of the whole population. And so I think what we need to be careful of is that we don't get caught in semantics and name, almost like finger pointing or name calling are your public health, your population of your this, we're integrated teams trying to work together to serve the population. And we will work for different organisations who have different kinds of priorities or different measurement things that they're going to be interested in. So the NHS has some population health and health inequality measures that the NHS needs to answer. Public Health hasn't stuff that local government really wanted to focus in. But actually, what matters on the ground in our teams in communities is that we become organizationally agnostic, that it doesn't really matter which bit of the system you work for. But together, we are serving the needs of the population to improve the health of the population to create better health, to prevent ill health, and to tackle health inequalities and inequities. And I think if we can get into that space together, that's where the magic happens. That's where the fireworks are. That's where the realm of possibility lies, that we're no longer in competition, we're not worrying about whose bid is better, or we train onto the toes that we stop being a little bit precious with each other. And we think about how do we best use our skills and our gifts to really, really do this very, very important work.
You've both mentioned health inequalities. The next question I'd like to ask is, why are all these terms these approaches, philosophies, however, you want to characterise them? Why are they so integral to flight and health inequalities for the NHS?
That's a big question. I mean, it's huge. I mean, when when you consider the health inequalities and inequities at work across the UK, before we even talk about the global picture, which we won't get into today, because it's just absolutely colossal, you realise that we are facing an incredible uphill battle, and one that we have not managed to make any real difference on since 1948. With the conception of the NHS, we just haven't, you know, health inequality gaps between our richest and poorest communities still remain incredibly wide. Actually, women are now dying earlier, in our most disadvantaged communities. For the first time, since the inception of the NHS, women's life expectancy is falling, which is appalling. And and why should it be the case? That because you are a child growing up in one community, that your healthy life expectancy could be 20 or 25 years less than a kid growing up three or four miles down the road? And why should you be expected to die 1517 years earlier than that, then that same child growing up in a household literally three, four miles down the road, and that is the story of Britain right now. We have massive inequality and inequity in this country when it comes to health when it comes to what actually right across society. And there are two people who have nailed the issue for me. One is the economist Mariana mazzucato. And the other is the sociologist Dr escapes and they look at it from completely different angles, but their conclusion is the same. Society is a manifestation of our values, and what we value. So if we want to understand why we see such inequality and inequity across this country, we need to understand that we have built our society on particular values, and a set of values. And it shows us who we value and what we value. And so fundamentally, at the heart, I think of the work of population health is a deep challenge to us to reconfigure or reassess our values, our value system and work out how we build a kinder, more socially, just more inclusive, more equitable society, in which it wouldn't really matter where you were born, or which ethnic backgrounds you came from, or what sex you were, or whatever. Because we've created a society together, which in which people can flourish, and people can live well and prosper and really love life. Right now, we don't have that. That's a lot about what I write about in my upcoming book six society. Just a little plug. But I think that there is huge work for us to do. And it really, really deeply matters because right now, the experience of so many of our communities is is huge social injustice, and it's unacceptable.
I completely completely agree. It is unacceptable, and it's really, really upsetting. Anytime I look at the statistics, and I guess, you know, even through my Public Health Training, the thing that is possibly most upsetting other than the individual patients that I've seen, is also seeing policy document after policy document articulating the presence of health inequalities. decade after decade, and yet seeing just how powerfully people like. So Michael Marmot articulate that picture. And 10 years later his report, so he did a report in 2010. And then again, another one in 2020 10 years on just that things have not hugely changed. And even since his 2020 report, just to see the predicted trends, the trajectories and to know that, that these are unfair and avoidable differences in and within groups, and if we think about those words, that's really it's it's just the injustice that the fact that it that's not on. And whilst I really am proud to see things like tackling health inequalities as being one of the top four priorities for integrated care systems, and I'm really so kind of, you know, I'm in admiration of work like bola so Professor bola, or Willoughby in NHS England in core 20 Plus five or the health inequalities academies. So the one in West Yorkshire and Harrogate or actually Andy, your your work in the population health and equity Academy in Lancashire and South Cumbria, these are steps forward, but they're one still in pockets, to if I'm honest, there's still a big risk that it will be dropped off the agenda. Because even if you look at the huge review, recently, of integrated care systems, while it is there, as one of the top four priorities, the government response was actually quite underwhelming in terms of health inequalities, instead, placing more focus on things which are much more reactive to the pressures of now, I think there's not enough understanding that the pressures of now are because in a large element of insufficient focus on things like this previously, right. And I guess, for me, a few things are missing, in a way. So I think that understanding about the how to do this, maybe that the willingness to work in a complex system, and these are complex issues, that, you know, we're going to need to stick with and persevere with and prioritise to get right. And again, like I said, there is so much potential that we've seen through our work. But that notion of when you speak to people from communities who are sometimes labelled as hard to reach, we repeatedly hear, you know, and rightly so they're not hard to reach, it's just about finding the right approach to reach them. And then you find that these are not vulnerable communities, they are powerful individuals and collectives, who often know what matters to them, and how powerful solutions can be formed. And our job as health and care providers, or people working in the space is to go out to the communities, work with the communities enable them, where, where they can do things themselves, to kind of ask them, you know, how we can help. We don't even need to help for some of the things because they are amazing, but where we can help we enable we lend our power, we can, you know, magnify their voice? And where there are things that services need to step in? That's when services step in. And those are some of the core principles of health creation. Yeah, and I know that's been some of the bedrock of the work. We've done Andy with Lancashire, South Cumbria colleagues. Absolutely.
Yeah, I think it just made me think that how much if COVID hasn't woken us up to how important it is to really take public health and population health seriously, then I don't know what else? Well, I mean, we've had all these papers on health inequalities. For years, we've known that this is an issue, but because of the short term political cycles and people wanting to focus on things that maybe win votes in the here and now like my a&e Waiting time, or how quickly I can book an appointment to see your GP or so we keep pumping money and funding into the short term initiatives. But we're not thinking about that longer arc or how do we actually fundamentally change the way that we create health and well being within society. And that takes bravery from leadership to be able to do that it takes bravery to shift funding and funding formula to make sure that we're actually putting resources into the communities that are most struggling. It takes bravery to choose what you're going to measure differently so that you're not always measuring In the short term gains that can grab the headlines, but you're actually looking at the arc of history and bending it towards social justice as Martin Luther King would implore us to do. And I think the problem is that we have not allowed this to be number one priority. And so it never gets to be, it always gets pushed back again and again. But COVID must surely have woken us up to why this is so important. Partly because as the reviews are showing, at the moment, we simply weren't prepared we had the opportunity to be but when you slash public health funding, and when actually you slash funding into health and social care, and all of the surrounding, kind of things for for a decade or more, then you you are not able to be prepared for this kind of thing. But also, we can see from the vaccination programme, for example, what same difference it does make when we get into communities, and we work with them differently. And we can promote health. But if you look at the data, and Michael Marmot has has shown this so sadly, and so powerfully that it was people in our most disadvantaged communities who had the worst outcomes, because their housing was so poor, because their health was already so poor, because the opportunity to go and work with them differently, we're so poor, this must be a proper wake up moment for us as a nation, where we don't allow this to continue anymore. Where this is just our moment in time. It's it's our epoch moment, where we absolutely, fundamentally now have to do things differently. And that is going to take leadership bravery to do that. But it's also going to take hard nosed determination from all of us within communities that we just say enough is enough, we're simply not going to continue to just jump through the same hoops we always have. Because if we do, we're going to keep getting the same answers we always have. And this is a time for genuine fundamental change within our nation.
You both mentioned the working with communities, and how integral is work with communities and patients because I've seen a bit of a trend on off you guys. But I've seen a bit of a trend say like patient initiated follow ups shared decision making, this seems to be a concerted effort to work with patients Puneet is more. How integral is that to properly leverage the benefits for this, though people want to do it involving them every step of the way.
I think that it is essential. And I think fundamentally, it cannot be done without this, I think it's going to require humility, because that may be that the single biggest missing piece in terms of the health and care system, because it's right now done in pockets. Whereas I think if we look at the NHS constitution, just the NHS segment alone, actually, even that came from a place of humility, and well meaning actually, and there was a whole first half of it, which was about health creation, about enabling health. But for some reason, we've had a slippage over time, to become much more focused on ill health. And this is an opportunity, even the 75th anniversary of the NHS and social care. So we mustn't forget that it was twins born 75 years ago, in a policy sense. And there is something about now's the opportunity to bring it back to the core of what it was and stop that kind of over focus on just ill health. Because whilst that might be the seeming issue for now, it's like plugging the holes in a ship that's leaky, it kind of needs a fundamental look. And actually, the approach needs to be health creation. And yes, also management of ill health, but that's one part of it. And seeing that means we cannot do this without partnership, equal partnership, if not leadership, with communities. And I know that at the Health creation Alliance, we talk about the three C's that people need to be well, so meaningful and constructive contact between people and communities, which increases their sense of confidence, which leads to a much greater sense of control over their lives. And really having that power to have control over our lives as well as the factors that you said, which is the adequate income homes, occupation, all the wider determinants, the real environments that enable health means that they can enhance health and well being and people can cope well with health conditions, disability and ageing, too.
Yeah. So I totally agree. I mean, working with communities deeply and genuinely, is for me the foundation stone of how we work. So I think we have to build social movements for change, and we have to fundamentally work with communities differently. And I think Doug has hit the nail on the head. With the word humility, I think it also takes massive curiosity. I think it takes deep kindness. And it takes a real commitment to inclusivity. So, you know, we often think that, oh, yeah, making every contact count, we'll just tell people more, we'll just tell people more things that they can do to in those moments will just tell people the answers. But actually, we're talking about something fundamentally different. Here, we're talking about deep listening, we're talking about how in a conversation with our communities, we ourselves should be the ones that change that as we listen to, for example, as I am at the moment, a bunch of parents who are massively struggling to get their kids with autism, or ADHD, or mental health issues, the kind of help that they really need, as families. As I listened to them, I realised it's not them who need to understand the system better, and just be patient. I need us in our teams, to have the humility to fundamentally be willing to change the way that we work together with them, and ask them to help us redesign the services that we are providing, but currently are failing to meet their needs. I think this, you know, this struck home for me so powerfully over the last few years, particularly with my work with the Gypsy traveller community here in like Lancaster and morcom. And actually, it started through two separate encounters. One was through a patient of mine, who, basically she knocked Well, my one of my admin team knocked on the door of my clinic. late one evening, as I had finished all my work and said, Andy, can you please see this lady who's come to see us today? She seems in a lot of pain. And I went out to see her. And she was actually hoping to see a female doctor, I wasn't female. And so I offered to make her an appointment the following day, but she said, No, no, no, she'd come. And she would be seen now, though, with the help of, well, I brought her into my room, and we had a conversation. And it turned out that she had a lump in her breast. And, and was in a huge amount of pain with it. And she waited a very, very long time to come and see us. And I could tell that she was incredibly nervous about being there. And I said to her, let's call her Mary Jo, Mary Jo, why is it that you have waited so long to come and see me as a doctor and with this problem, and very sadly, she told me that she'd been to the doctor when she was nine years old. And she'd been sexually assaulted by a doctor on the couch, whilst being examined behind the curtain, and her parents knew nothing about it. And she kept it secret, but she'd never seen a doctor again all that time. But she came to see me that day, because because the pain it just got so bad. And so I explained to her that I was going to have to examine her breast and that that would feel like a really potentially very vulnerable and scary thing for her. And with the help of one of our nurses, we managed to help her relax and to lie down and together, we examined her breasts. And as soon as we peel back the blanket, we could see that she had a massive fungating tumour that was already breaking through the skin, and had already spread to the nodes under her armpit. And actually, when we did the scans, she had widespread what we call metastatic disease, the cancer has spread everywhere. And very, very sadly, she died within about four months, but through my interaction with Mary Jo, and also then through some work that we've done with what's called the poverty Truth Commission, I started encountering the Gypsy traveller community. And when we looked at the data, we realised that women from that community are dying 20 years earlier than other women in Lancaster and more come district from from breast and cervical cancer, but very few of them come for their screening. Now, the data has told us this for a long time we've known it and we keep on sending out leaflets and saying come to your clinics, and when they don't attend, we say did not attend patient declines or whatever. So we can still claim our funding, but it's made no difference to them as a community. But through the relationships that we built, I was invited to go and sit with women in the community and we went and listened to them. And what I realised through listening through actually having the desire to be humble, and to be curious, and to find out what's going on here, we heard some pretty distressing things. So we thought that there were only 1000 gypsy Roma travellers in Lancaster morcom gypsy travellers sorry, they're more gypsy travellers and gypsy Roma travels. And they told us actually there's there's not 1000 There's 10,000 9000 of the community pretty much just never admit to being gypsy travellers anymore because they experienced so much racist abuse. And actually the data suggest to us that gypsy travellers are the most racially abused community in this country. But they experience it at the doors of the NHS. When they come and book in and they tick the box that says gypsy traveller, they get little smiles or little funny comments made or a bit of eye rolling, or a little giggle or a sarcastic comment may to one of their colleagues at the desk. And then so they they've stopped admitting to their own beautiful cultural heritage, which is shocking. There's also massively higher literacy rates amongst gypsy traveller women, so 80%. So when we're sending out our leaflets saying, come for your breast screening, they can't read it, but they're too ashamed to tell us what didn't realise also within a very patriarchal culture that actually they won't talk about breast or Guinee issues in front of their husband, who often accompany them to the appointment. And they certainly won't talk to a male clinician, nine times out of 10. So we need to totally redesign our service, we needed to completely work with this community differently. We didn't just need to put on more clinics and send out more leaflets and tell them why or blame them for their own health inequality. We needed to have the humility and the curiosity to sit with them to include them in the decisions about their own health care and how we were providing clinics. And then we needed to have the kindness to then change our service to make sure it actually work together with them. And that is the difference between what we call internal and external gaze within communities. So sociologist, Jenny postepay, talks about this really well and propel tambor and has a huge work on this as well, and they're doing amazing work. And it kind of chimes really beautifully with the work Cormac Russell's doing so Cormac Russell talks about the power, the innate power of communities to drive their own change, right. And that is asset based community development. It's about listening to communities and saying, what is the power? You already have to change this? And how do we work with you alongside you to partner with you in driving that change. But the other part of it is, actually, we mustn't just or as Jenny popiah, and Paul tambor say that that's, that's internal gates that's helping communities change the stuff that they themselves have power to change. But we also need to listen to communities about external gaze, looking at the issues of deep systemic social injustice that actually holds them prisoner holds them in that place of inequity and inequality that they cannot break out of, and how then together with them, we challenge those systems of injustice and create different ones so that together we create a fairer society.
So and not only do I entirely agree with you, I know that we've talked about the story of let's call her Mary, Jo, for now. But yes, and each time I hear it hits me hard. So it's to acknowledge that and then I'm thinking in my own clinical practice, just, you know, this is not an isolated event that there are so many people like that at the moment. I guess the missing piece for me also, is that this applies to the workforce as well. So I think it is a complete delusion. To think that actually, health inequalities is just about the community and the community is that thing out there. I am a board member of two NHS Trusts, and I love the fact that our trust gets this And increasingly, there is recognition. But the people working for health and care, they are people as well. They are probably members of maybe the local community may be other communities and inequalities that happens externally. There's something about organisations looking internally as well. And there's at the moment, this notion, mistakenly almost that inequalities is an external to an organisation thing. And diversity inclusion is the internal thing, right? I think that's entirely wrong. The two are absolutely intertwined. and the E DNI agenda, for example, just even looking at ethnic inequality is just one facet. That tends to focus on understanding lived experience, creating cultural awareness, sensitivity, agility, adaptation, and, you know, really trying to bring that into the heart of efforts. Actually, that's almost the missing bit for the inequalities agenda. People can easily think it's just a data exercise, but it's not it's about going out and speaking to people and understanding and equally the understanding that the health inequalities but applies within organisations. And I think that's really, really important because that's part of the kind of getting the understanding and humility. And I think the other bit for me is the work that I do constantly with the system says, we're leaving it to chance at the moment. This is not supported. These are not skills. I mean, we can say them and and go well that's that's part of being a good person is to want to listen, when you create space to go you know what, this isn't easy. It might sound easy, but actually it can feel quite frightening. I might go and have come conversations and then go, Well, what do I do with this? And creating those spaces to let people connect? And yeah, bring that together as workforce, I think it's just really important.
I do too. And I think there are two things to say off the back of that are just a riff off the bat what you said, which is one, we actually can apply improvement thinking to this work. So I actually prefer increasingly I like the word population in population health improvement, rather than population health management, when we think about specific projects in specific places, because we can apply the great improvement work of people like David filling them into the way that we think about how we do this work, there is methodology to be done here isn't your right, it's not leaving it to chance there are there are tools that we can apply to how we go and listen to and work with communities that change us. But then we think about them together with our communities, how do we improve this situation? And there, there are ways that we can work that I think, really are tried and tested. I think the other thing that this really takes is, is self reflection. So Durkee you and I have worked a little bit with Ellie McNeil who's Chief Exec of YMCA together in Liverpool, and she's an extraordinary leader. She's She's wonderful. And there's a reason why her charity is considered the best charity in the country to work for, from kind of all, all of its workforce surveys and everything. And that is because she has introduced a model of leadership within her organisation based on cognitive analytical therapy or Compassionate Leadership and cheek but basically, she gets her staff to be curious about why it is that they hold certain biases or why it is that they treat certain people differently to others or why it is that they might have a reaction to one member of staff in a way that they don't about others. And I think we have to own the fact that there is so much link between stigmatisation and inequality and inequity. So we stigmatise communities, it's easy to look at the Gypsy Roma traveller community have an awful narrative about them often based in comedy based in you know, racism. And we we hold conscious and unconscious bias about the Gypsy Roma traveller community, and therefore we treat them in a particular specific way. But if we have the humility to be curious about why do I hold that belief? Where does that come from? Why do I treat someone who's gypsy different to someone who's classically white British, when they come through the doors of my surgery? Why is it that we don't change the way that we work with the South Asian community in Burnley? Why do we continue to expect them to behave in certain ways? Why have we allowed ourselves to develop a narrative around? Who are the deserving poor? And who are the undeserving poor, and the narrative that has a lot come through the press or through particular ways of thinking maybe politically, and we need to challenge our thinking and do our own internal work so that we ourselves don't actually perpetuate inequality and inequity? We ourselves must take responsibility, we must do our own work.
So under you mentioned earlier, is working with patients to challenge the system is this sort of devolution of power, the future the NHS is the future of health systems generally, in a wider regard,
personal perspective, I think devolution or devolution or you set is is absolutely integral to this work. I think that there is some stuff that we need to look at nationally about whether the funding formula fair, because if we're going to really tackle inequality, I'm gonna say this as a northerner, we have to think about whether or not we are spending our money or putting our resources in the right places, and understand it in the context of how local government is funded alongside the NHS. So it's actually about holistic packages into places. Let me give you an example why I say that. So Blackpool is officially the poorest town in England. Okay. And we have the worst health inequalities in the whole of England in Blackpool. And yet, the public health cut that happened through this last 12 years has been deepest and hardest were in Blackpool. How crazy is that? And so when we're thinking about tackling inequalities in inequity, we got to work out are we putting the right resources in the right places. So when we're talking about devolution, I sometimes feel a little bit anxious that it can be yes, go be responsible for all of this, but you're not actually going to get a fair funding formula to actually then help you in the work that you're doing. So I think there is a conversation to be had about that. But I think we have to put our back into the hands of local people. And we need a much more participatory and participative society where people can actually own what goes on in their own neighbourhoods and communities and they come together with the services that serve them. determine what's the real priorities and how they want to move things forward. And And we've got to meet communities where they're at. So, but actually, there's a lot of mistrust. And there's a lot of things that communities think are more important than what we think are important. So as a doctor, I know, in my community, people are dying, really early of cardiovascular disease, and what's really important is that we get their blood pressure controlled, we get them on statins to control their cholesterol, we get we check their pulses, and make sure that they're not in atrial fibrillation, and we, you know, do some work of them around smoking, I know those things are gonna make a massive difference to their overall health and well being. But my community don't care about that. If their streets are still full of dog poo, if there's nowhere for them to sing together, if they don't have a sense of youth provision, if they're not getting out, if elderly people are feeling isolated, not getting help with their shopping, we've got to meet communities where they're at. And that's why we need to devolve power. It's why we need to devolve resources, we need to meet communities where they're at. And we need local people working together with local services to drive local change. And that is the best way to population health can really make a difference. And that is absolutely some of the model that we have talked about in our Population Health Equity Leadership Academy here in LAX and South Cumbria.
I'll tell you what darker, I'm gonna give you the final word. With everything that's been said so far on this podcast, considering all of that what structures legislation guidance action measures, however you want to determine it? Do you want to see in support of all this from the health question, Alliance perspective, maybe?
Yeah, and just the bit about devolving power to add my bit to that as well, if that's all right, I completely agree with Andy unsurprisingly. So I guess my only caveat is that there are two ends of that spectrum, right. So there's something about doing unto and not devolving that power, and that that, you know, is one end. And I think that's closer to where we are in a lot of the country at the moment. On the other side of it is actually just letting go. So national bodies just letting go and just or local bodies, or kind of an almost dumping on or draining community resources. Just to say that I think what Andy, you're talking about is that bit in the middle, which is very much about staying connected, but in an enabling, listening, humble, partnership approach. And I think that's what's key. So it needs to move a lot, you know, towards the other side from where it is now, but but not fully to the extent of letting go because that also is not going to be helpful in my No, you're totally right. So I guess in terms of the legislation, goodness me, there's a bit of me that thinks that there is so much that could be done. And if you just look at the recommendations from Sir Michael Marmot in the Institute of Health Equity, they've given six policy recommendations. Some have been factored in more, but we're nowhere near there yet fully. But for me, and certainly Andy's talked about public health grants when you know, we've got such tight public health grants, and they're at risk, can we really say that we care about all of this, I'd argue that those are some of the metrics, we've clearly got kind of, you know, aspirations laid out in integrated care systems and strategies, public health outcomes, frameworks, and more. My thinking is actually so those to some extent, and they're not there where they could be. But the things that do exist have moved in the right direction. It's about implementing that change. It's about implementing actual meaningful change in terms of population health, and health inequalities, together across partners, for and with, led by communities, and those who are actively involved in enabling them and supporting them. So there are people closer to the ground, then many statutory organisations, so respecting that actually, those networks of networks exist, and mobilising those as well. So there's a whole we could talk about for a lot longer in terms of complex systems and systems thinking. But those are some of the core principles in that. So for me, it's about the implementation, and about the making it stick about really, really kind of, you know, letting this day for the long term. In terms of health creation. I am so proud to be the chair of an organisation which is actually the leading national cross sector social movement for addressing health inequalities and working from almost the ground up to bring this about. And there's so much available. So I'd say to anyone wanting to move more and more further across into the, you know, bringing about a healthier, better future. For all please remember that you're not alone. Please remember that there's so much available to support you and people working in this space. There's so much by way of Insights, resources frameworks evidence base. And please also remember that kind of organisations like the health creation alliance can not only provide some of those resources and opportunities to connect with others, but also practical support on the ground to do this. So if anyone is interested, just just get in touch with our team and we'll do our best to help you. But more than anything, remember that we're all in this together, and I genuinely believe that it's by working together that we stand the best chance of really making a difference.
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