Professor Kiran Patel: Apply social value judgements to tackle inequalities

 

Matthew Taylor

Hello. After two long years, the pandemic seems finally to be fading away. Unless there are new and worse variants, covid will simply join the list of unpleasant but not generally life-threatening viruses that we have to cope with.

And then the NHS can turn its attention to its many other priorities. But how do these fit together? On the one hand, in the short term, reducing the elective backlog is the government’s and the public's number one priority.

On the other, with the creation of integrated care systems, there's a longer-term commitment to focus on population health, to reducing health inequalities, to moving resources upstream to prevention and community-based care. It can often feel like the immediate demands pull in a different direction to those long-term goals. But could they fit together?

Today on Health on the Line, I’m speaking to someone who not only believes that they can, but has started to show how.

I'm delighted to be joined by a good friend of the NHS Confederation, Professor Kiran Patel, who is chief medical officer and deputy CEO and cardiologist at the University Hospitals of Coventry and Warwickshire. So Kiran, welcome to the show and how are you?

Kiran Patel

I'm fine thanks, Matthew. It's a pleasure to be here.

Matthew Taylor

Well, I just discovered something about you Kiran that I hadn't realised. We, of course, share an affliction you and I; we both support the same underwhelming football team, West Bromwich Albion. And I shall look for you next time I go to the Hawthorns.

But what I didn't know Kiran until we were chatting just before we came to start recording, is that you've got a broader involvement in the world of football. Tell us about that.

Kiran Patel

Matthew, yes, I am an avid West Bromwich Albion season ticket holder I'm afraid, so I’ll look out for you as well. But yes, I've been involved in football. I've combined my passion of cardiology and sport, so I do sit on the FA cardiac panel as one of the cardiac experts, and I've also just started chairing the Premier League Clinical Governance Group.

Matthew Taylor

So, I want to start on the issue of health inequalities because that's how I first came to know you Kiran and know your work, I think at a conversation about health inequalities at the Confederation. It's something you feel passionately about. Where did that passion start from?

Kiran Patel

Matthew, I grew up in a place called West Bromwich and Sandwell in a two up two down terraced house, and what I experienced growing up was just normal.

But then as I grew up and went to university at Cambridge and subsequently started working, I suppose I personally experienced social mobility. But then I always wanted to go back and do something for the communities I came from.

So, I did two things. One was setting up a charity which works on health inequalities, which embraces the philanthropy of a lot of healthcare professionals. And secondly, I always wanted to go back and work in Sandwell, which I did as a consultant. I had a fantastic opportunity and I spent seven years going back to help the community.

But then I subsequently worked in areas which are a bit more affluent as well. So, I've seen the entire spectrum of socio-economic enterprise and population health, and I think we often forget that there are very vulnerable people out there who need our help and leadership, and they need us to be their advocates. And unless we are their advocates, we will continue to see health inequality.

Matthew Taylor

And what are the principles that you bring to your work on health inequality? Because it's something   that we are aware of. And I remember studying sociology at university 40 years ago now and people talking about the inverse care law. So, what are the principles that you bring to this work?

Kiran Patel

Everything and anything that we do should have an equality impact assessment, as well as a quality impact assessment.

And that shines a lens on making sure that we think at the outset, by default, designing our services around the needs of the entire population. I think too often we do the equality and equality impact assessments as an afterthought.

But if you do it at the outset, we design services based upon whether they're appropriate, whether they're accessible, whether populations are aware, and fundamentally whether they are required. And I think we forget those forays when we drive services to target health inequality.

Matthew Taylor

And do you think there's been a shift in awareness of and commitment to doing something about health inequalities? And do you think that the experience of the pandemic has contributed to that kind of raising of awareness?

Kiran Patel

Yeah, I'm really pleased to say that I think we are much more aware now of health inequalities. It’s featuring as a mantra in a lot of policy that comes out in health, which I think is fantastic. Covid clearly shone a spotlight on health inequality. When I looked at our intensive care units and our wards at the height of the pandemic, there was clearly a disproportionate level of patients from the lower socioeconomic groups in our hospitals, and I was involved with the South Asian Health Foundation writing one of the reports early on where we looked at the causes of why those patients were disproportionately affected by covid.

So, we really started to look at health inequality. And whereas traditionally we've always thought it was a long-term game to influence health inequality, with covid of course, we did that very quickly. We looked at the socioeconomic determinants of adverse outcomes, whether they’d be increased exposure or occupation and protection. So, we could do something quite quickly, and that was to restore services, of course, it becomes even more important because the evidence tells us that if you simply focus on waiting times to restore services, we can widen health inequality and we absolutely must guard against that.

Matthew Taylor

I want to get on to your work on the elective recovery in a minute. But just while we're on this question of covid, one of the starkest statistics around covid is the difference in mortality amongst BME staff in the NHS and then on BME colleagues. I think, you know, is it over 90 per cent of people who died in the health service have been from BME communities? Do you have an explanation for why that disparity has been so stark?

Kiran Patel

Yeah, I mean, Matthew, it has been extensively studied and published, of course, but I think fundamentally it's a multifactorial issue, as one might guess. But there are some specifics. One is the levels of exposure are disproportionate simply by the fact that a lot of our BME communities work in frontline facing services. So, we look at the gradient of BME representation across the workforce. You know, sadly, it falls as you climb the pyramid. And then, of course, the levels of exposure driven by work in the frontline. Professions of nursing and medicine and HPC is disproportionate. And then, of course, there are socioeconomic factors. Multi-generational households being one factor.

So, all these things actually combine to increase levels of exposure and reduce levels of protection. And then add to that some of the issues around vaccine hesitancy in BME groups, we then end up with the perfect storm in terms of increased risk from covid.

Matthew Taylor

I think the concern for many people who share your commitment to tackling health inequalities is that elective recovery goes in the opposite direction, or a focus on it as the number one priority, goes in opposite direction to the direction we want to go in. In the sense that on the one hand, what we want to do is to have a health service which really focuses on need not just on expressed demand and elective care is expressed demand. We know that there are millions of people who ought to be on waiting lists and aren't.

But that's not what the government is encouraging us to focus on, they’re encouraging us to focus on the people who are on the list. And then secondly, a focus on elective probably means a focus on putting more resources into acute.

And the second thing we want to do over the long term to address population health is actually to try to shift resources out of acute; the proportion, not the absolute number, but the proportion and more into prevention, public health, primary community care.

Now, I think you're determined that the approach that should be taken to the elected backlog is not one which flies in the face of that focus on population health and health inequalities but goes together with it. So, explain how you're trying to do that?

Kiran Patel

Yes, Matthew. It's been an interesting exercise with our teams. I appointed deputies in public health and primary care, so I have a GP and a public health consultant who have been a fantastic resource as we’ve designed recovery here.

And I would say that elective recovery and health inequalities can be great bedfellows. They're not antagonistic if we're smart. And the first thing I would say is that everybody deserves their constitutional rights. So, everybody in the population will get treated within the two weeks or the 18-week metric that we use.

But within that, we can be a bit more sophisticated. So, my first mantra is that if waiting lists swell with appropriate people needing health care, then we should absolutely value that and recognise it.

So, I don't have an issue with waiting lists increasing if we are proactively finding people who need healthcare because otherwise, they present at a much later stage and they need more and they suffer more with adverse outcome. And we saw this during the pandemic, when we told people to protect the NHS and stay away from hospitals, they did stay away, and they presented with much more significant disease later on and we're still seeing people now presenting with late cancer symptoms. And of course, we don't want that. We want to proactively get out there and use our population health management to find individuals.

And secondly, once we found them, we need to make sure they take up services and they get the best outcomes. And if we use evidence to drive scheduling and prioritisation within our waiting lists with good sophisticated clinical prioritisation, then we get best outcomes for everybody. And we've done some incredible work building an online tool that helps scheduling, building in those clinical prioritisation factors which are objective.

Because traditionally, of course, what happens when people get frustrated about waits? Well, those with good health seeking behaviour just continuously badger their GP or call the consultant secretary and eventually they get a service. But of course, we want to make it much more objective. We want people who don't have that level of health seeking behaviour or awareness to get the care they need as well. So, we've built a tool that is evidence based and clinically prioritises within that. And our driver here is making sure that everybody gets the best outcomes from a clinical perspective. And to do that, we need to treat people disproportionately sometimes.

And the second area that is quite fascinating when it comes to health inequalities. Of course, we don't just talk about clinical outcomes, we have to talk about social value judgements. So, I'm going to be provocative and ask if you had a bus driver who is on the waiting list who's about to lose his job for want of a hip operation. Should his care be prioritised above somebody who may not have the socioeconomic benefit from an intervention but the same clinical benefit? So, we're building in our ability to say we'll look at occupation and income benefits, we will look at potential educational disbenefit from delays in care, and we'll use those factors to apply social value judgements of interventions as well. And as we do that, of course, you start to reduce health inequalities as you recover. So, I'm really pleased to say that through this sophisticated methodology, we have the ability to address elective care recovery, but within the clinical prioritisation groups, we are starting to look at socio economic factors in reducing health inequality.

And the final factor, I would say, is that at every stage of that wait, we must use a process which I call active weighting and equalisation. So, application of prevention. Because we know that if we tell people to stop smoking, lose weight and do all the good stuff that we should be doing, we improve their clinical outcomes and that must start to the point of referral and be applied throughout the pathway.

Matthew Taylor

I think that is inspiring what you describe, but in a way, it maybe goes beyond what the public think that clinicians should be doing because you're making these kinds of social judgements.

And I've looked at polling, for example, which suggests that the public say that elective care long waits are an absolute priority. But when they're asked about health inequalities, they don't seem to care nearly as much about that. So, I think you've been doing some thinking and work around the kind of public attitude to these issues. And what's your sense of, if the public in Coventry and Warwickshire knew that you were using these kinds of socioeconomic criteria sometimes to make these judgements, would they think it was legitimate for you to be doing that?

Kiran Patel

It's an absolutely valid point, Matthew, and because of that, we've coupled what we're doing with some ongoing interaction with the public and with people working in services. So, we're doing some work with Ipsos Mori to gauge public opinion on what we're doing.

And as I said, fundamentally at the outset, what we're telling everybody is that they will get their constitutional rights to the two-week and 18-week standards. And of course, we can do this in Coventry because we are starting recovery at a fairly good stage relative to many of our peers across the country because we continued a lot of elective work during the pandemic. And therefore, we're going into this with very few one- or four-week waiters and a 52-week wait trajectory, which we will recover within a few months. So, we're at a good starting point whereby we could do this.

But the Ipsos Mori work will be really interesting, and the early outputs of that are telling us that actually people recognise that those most in need probably should get healthcare as a priority.

Matthew Taylor

There's one bit of your story, which I find worrying, I guess.

I'm a great supporter of the NHS and care bill, system working. We are the membership organisation for ICSs. I think we need this to work. And so, when I saw that you decided to step down as ICS clinical lead, and that in a sense this reflected some scepticism on your part about ICSs and what they're able to do. That worried me. So, tell me, why is it you've decided to step away from the ICSs? And does that reflect a broader concern you've got about their likelihood of making a difference in the areas that you really care about?

Kiran Patel

Yeah, thank you for asking that, Matthew. It's a really good question. The first thing I would say is that integrated care, I think, is absolutely the right direction of travel. And I absolutely welcome that approach because it's about time we started working together and reducing barriers across health and social care.

For me personally, I've held the clinical leadership role for about two years. We're now at a juncture whereby we are making formal appointments to the leadership roles within integrated care systems. And so, for me, it was a choice.

Do I want to step out of my acute sectors and chief medical officer and deputy CEO role to do the integrated care role or do I want to stay where I am? And to me, I don't think it matters because my contribution will remain the same. I won't be formally in that leadership role, but I'll step back, and it was a choice between one or the other. And I think being in the acute setting gives me a really strong footing to continue what I'm doing.

I guess one of my concerns I've had is that we have decided as a system to make these roles substantive and, in many systems, saying that they need to be independent of organisational sovereignty in a system. And whilst I think that's a great principle, I guess in a mature system, I would challenge why the rules need to be independent of organisational sovereignty rather than drawing upon the expertise that we have within systems.

So, I guess as ICSs emerge, it would be really interesting to look at the individuals who make up the ICS boards and whether they are from within the system or whether they're appointed independently within it.

Matthew Taylor

Yes, that's absolutely right. I've just been writing a blog about the kind of layers of complex ambiguity about ICSs - the relationship between the ICB and the ICP, the relationship between the ICB and providers, particularly if those providers join up into collaboratives and even more acutely all the providers within a system become part of one collaborative, or the relationship between systems and places. It is a complex picture.

What about a kind of collaboration? Because I've actually been an admirer for many years of the leadership in Coventry, for example. People don't realise this as much as they should, but Coventry really has turned itself around in many ways with strong civic leadership, the strong role that the university has played in the city. I actually used to be a councillor in Warwickshire as well, so I've got a commitment to Warwickshire. I’d have thought one of the things that would be attractive about system working in your neck of the woods is that capacity to collaborate with local government?

Kiran Patel

Yes, it's absolutely critical, isn't it, Matthew? Health outcomes are only 10 to 15 per cent impacted by the health services we provide, so the majority of health outcomes are impacted by socio-economic factors and social determinants, and therefore that link into local authorities is absolutely critical.

And here in Coventry, as you know, we work very closely with our councils, our leaders, our local authorities, and in fact, the public health consultant who's one of my deputies is a 50/50 split role with the local authority. So, we need to integrate our planning as well as our delivery. I think it comes back to working together. We've got to put the incentives in the right place to encourage collaborative working. And if we go back to the pandemic again, I guess one of the things we learnt is when we took out perverse incentives and irrational barriers, we could work much better together.

And during recovery, we can continue to do that. So, an example I'll give you is in the West Midlands. We're seeing that our waits in cardiac surgery are really worrying and significant. So, we're working together as tertiary centres across the Midlands to say, let's think about having a single waiting list that's shared between us. How do we prioritise within that to get the best outcomes for that wider population?

So, we've got to do a lot of this integrated planning as well as coordinated delivery and then divided responsibility. And to do that, you've got to integrate thinking at the outset.

Matthew Taylor

So, it sounds like your kind of view of systems is that they need to weave themselves into the existing architecture and to add capacity to the architecture in terms of collaboration, rather than seeing themselves, as it were, as an extra layer and trying to suck the kind of energy up to their layer. Would that be a reasonable interpretation of your view here?

Kiran Patel

Yes, I think that's a reasonable interpretation. What we need to avoid is just adding in another layer of bureaucracy. What we need to do is have a really short transmission belt between planning and delivery, and that's what will make us more efficient and much more capable of delivering at scale and rapidly, which is what we need to do over the next couple of years.

Matthew Taylor

And how much of that is about the centre and regions rethinking the way in which they operate? You're not the only one to decide to step away from Coventry and Warwickshire ICS, because Chris Ham, of course, stepped away as chair. And he's just completed a piece of work for us, which is looking at the role of the centre in a world of systems. And one of the things he argues, and this is not a phrase he uses, but I'm summarising his argument, is that the centre needs to lose an empire and find a role. It needs to behave in a different way. It needs to set broad strategic objectives, to have a smaller more expert staff, to not micromanage, to really let systems determine not only local priorities but how they're going to go about achieving those.

Do you think it's important to the success of the system working that the centre and regions do operate in a different way?

Kiran Patel

I mean, it was great working with Chris, and I think he did a fantastic job for us. We had some really good intellectual banter over the last couple of years, and I think he's right. I think we need to find a balance between localism and nationalism. And if we swing too far in one direction, we lose the ability to draw upon the value and the intellectual capability and capacity of the other.

Having worked with an NHS England, of course, I realise how difficult it is to shape and develop policy. And the temptation is that centrally we can design exactly what needs to be done and then we just expect it to happen.

So, when we want to design something, I guess we have to find a balance between saying, let's let a thousand flowers bloom to saying, let's provide a framework and a strategy for how we deliver. And I guess I'm a strategist at heart. So, I think behind every initiative, policy and ambition, there probably needs to be some level of framework and guidance to drive delivery into the system.

So, I think we've got to be really mindful of the fact that while ICSs and ICBs want to have a high degree of autonomy, we've got to say, well, what is it that we are here to deliver? Let's define clearly what it is we're striving for. Let's define where the responsibilities and the corporate accountabilities lie, and let's use that to then design where we want to be. So, we've got to be objective in that design. And if there are lessons for the central, I guess we're continuously learning. We need to be objective, we need to engage and we need to be very clear about what it is we're trying to achieve.

Matthew Taylor

Yes, and I think the centre has to ask itself the same question that your analysis suggests systems need to ask, which is what is the value they are adding by existing? What is it that they need to do? It sometimes feels to me as though the centre has a kind of implicit view, which is unless they tell people to do things, nothing will ever happen. And that really isn't the case. Leaders like yourself, leaders I speak to, are perfectly capable and spend their time trying to prioritise the various tasks that they're trying to do.

So that question for every tier it seems to me of management, what is the value that we are adding is the question we always need to ask ourselves, isn't it?

Kiran Patel

Yes. One of the things I've learnt in leadership is that you've always got to listen, and you've got to hear as well. So, at every tier, we've got to make sure that we're listening to the people that we're trying to tell something to. It’s very easy to sit in an ivory tower and say, I want this to be done and let's make it happen. But actually, we need to engage and listen to our staff as well. And our workforce across the NHS is quite an intelligent workforce. They will tell you what's achievable and what's appropriate. So, we need to listen to that in order to help guide what we're trying to design.

Matthew Taylor

Kiran, because you're so thoughtful and you've got such experience, I want to ask you a final question, which is something which is just kind of fermenting at the back of my mind. And I'm a keen to get a kind of sense of whether you think it's got any credibility to it.

If you look at the health service from its very founding days, it's really been obsessed by one question above all else. And that question is how do we deal with the gap between the capacity we've got and the demand that exists for our services?

And in a way, the whole of the NHS discourse at the moment revolves around that question. And it feels that is an eternal question. But the question I've got is this… in the future where it could be that through the kind of diagnostic revolution, people are regularly monitoring their health, we become better at supporting people to make interventions earlier, to manage their own health. We disintermediate to an extent so that actually people can use apps and other methods to be able to determine whether they need secondary care themselves, for example.

In that world, do you think that the fundamental question for the NHS might shift? Instead of being how do we meet overwhelming demand with the capacity, the actual issue is how do we preserve the egalitarian principles of the NHS in a world where actually we are empowering every individual much more to manage their own health?

Kiran Patel

It's a really great question, Matthew, and I think we are really privileged to be in a system that delivers universal health care at the outset. So, the founding principles of the NHS were fantastic and they still apply today.

I guess today with that mismatch between supply and demand, if your glass is half empty, you see this as a huge problem. I sit here and I think actually we're at a really exciting stage. My glass is half full saying this is absolutely the catalyst that that if we're smart, we start to challenge ourselves into some really exciting territory.

So, you talked about digital delivery, and again, we've flourished over the last two years in terms of how we've embraced digital capability and also started to address digital illiteracy and access, so we can use that. I think we're at an exciting juncture where we can really transform healthcare. So, we need to remove the transactional barriers that prevent us doing this.

But I'll give you an example. So, I think the days of a patient sitting at home, getting a symptom, then seeing their GP and then waiting to see a consultant, having a few tests, going back and then starting treatment, I think those days are numbered now. Why can't Matthew Taylor sit at home and think I've got this symptom, I'll look online. Actually, this is the test I need. Why can't Matthew just go out and get that test directly without seeing a healthcare professional? Get the result and that result automatically trigger what you need in terms of your healthcare delivery or intervention?

And I think we need to be smart and think outside the box. So, let's use the digital capability we have to create a revolution whereby patients can get the diagnostics they need on their doorstep if possible, and that then triggers healthcare that they need in terms of intervention. And when we start thinking along those lines, we'll start to use our most scarce resource, which is workforce much more appropriately. So, I'd like to sit in my cardiology clinic and start seeing patients who come in with their diagnosis rather than having to make that diagnosis, if possible.

And the breadth of stuff out there now in terms of diagnostics is fantastic, so let's embrace it and use it. But again, let’s guard against that, just incurring the huge cost pressure into the NHS. Fundamentally everything we have to do has to sit within a cost envelope and be affordable.

So, getting organisations like NICE to be part of this innovation and forward-thinking approach is absolutely critical, and I think our clinicians are really up for this.

Matthew Taylor

That's a brilliant answer, Kiran, and it makes me feel I want to take this idea further and it would be great. We must involve you in further conversations about it because I think you've talked about it in relation to cardiology. But another example would be mental health, where we have an enormous number of people waiting for mental health interventions.

And actually, there are a lot of apps that can be used by young people that can help with anxiety or insomnia or whatever it might be. But we have a kind of crazy system where people have to wait to see a GP, have to be referred by the GP, in order to be told about an app, which they ought to really just be able to access.

So, I think this question of how we reimagine access to the health service is going to be a really big one in the next few years. Kiran, it's been absolutely brilliant talking to you. It's rare to talk to a West Brom fan who says that their glass is half full and there is only one way for us to end our conversation, which nobody else outside the West Brom fraternity would understand. Professor Kiran Patel, Boing boing!

Kiran Patel

Absolutely, Matthew! Boing boing! Let's go up there.