Does the NHS have a listening problem?

Matthew Taylor

Hello and welcome to Health on the Line. Later, we're going to have a fascinating conversation with Sir Norman Lamb and Matthew Bolton from Citizens UK. We'll be talking particularly around community engagement, where they've done some fantastic work in south London. 

But before that, I'm delighted to be joined by Sally Gainsbury, NHS policy and finance analyst at the Nuffield Trust think tank, former Financial Times and HSJ journalist. 

The reason we've asked Sally to join us for this edition of Health on the Line is because in a few days’ time we're going to be publishing a major comprehensive survey of the financial challenges facing NHS leaders this year. So, Sally, welcome to Health on the Line. 

Sally Gainsbury 

Hi there, thank you for having me. 

Matthew Taylor

Now, you've been a very close watcher of NHS finances for the last 15, 20 years and you're renowned for getting under the skin of the arcane and opaque world of NHS financial management. Your Twitter threads are fascinating insights into that world. So I'm really looking forward to hearing your thoughts. So let me start with this survey that we're about to publish. 

What leaders are telling us is that they are experiencing the tightest financial challenge in years, many expecting to have to make or already making cuts in clinical and non-clinical posts and some services. We seem to be trapped again in another kind of cycle of short-termism. So I guess, Sally, first question is, what's your assessment of the financial outlook for the NHS in 2024/25? 

Sally Gainsbury 

Yeah, I'm afraid it's a pessimistic outlook. The financial settlement for the Department of Health and Social Care this year, as you all know, is a real-terms reduction compared to last year. And whilst the DHSC has tried to sort of send more money towards NHS England, NHS England is facing a historically very small real terms increase in its funding, although we should probably have a bit of a chat about inflation at some point because this week we've obviously had some exciting headline inflation measures, but these are not the headline inflation measures against which the government measures its own spending plans. 

So if we were to compare NHS England's budget this new financial year compared to the CPI measure of inflation that's come out this week, then NHS England is actually also going to experience a real-terms cut in funding this year, which matters. The CPI measure, of course, will matter to NHS England because that is what the workforce will be looking to in terms of pay increases this year. 

Matthew Taylor

And it's worth reminding people that, broadly speaking, health economists argue that with population ageing, rising expectations, costs of technology medicines that you kind of need 3, 3.5 per cent real terms increase to be able to sustain things. So, you know, a real terms cut then is pretty substantial. That means that many of our members are facing efficiency targets of 6 per cent, some even higher. 

Sally, how realistic do you think that these kinds of efficiency savings are given what the NHS has been able to deliver in recent decades? 

Sally Gainsbury 

Yeah, again, apologies for deep pessimism. These figures, I doubt anybody can really believe that they're achievable. If we go back to the early period of what was called the Nicholson Challenge in 2010, providers for a brief few years were achieving around about a 4 per cent efficiency target, but they very quickly ran out of road on that level of efficiency saving. And what we saw was a sort of tail-chasing efficiency, whereas actually we had short-term one-off efficiency savings that just had to be recovered the following year. 

And the thing that I think is really worrying about this sort of 6 per cent efficiency target, and to be clear, that's in the region of £8 billion on the provider sector. I mean, it's a huge amount of money. It's almost the entire temporary staffing bill, just to put it in context in terms of one of the key areas where providers would be looking to make this saving. 

One of the worrying things about that is you might sort of start to try and be optimistic if there was a sense of some real low-hanging fruit. But we know that in the last financial year that just ended, the NHS already made really quite substantial reductions in its agency staff spend. So I think it's going to be a very difficult year. Realistically, I think 6 per cent is not going to be achievable. And we are going to be looking at another year where the Department of Health and Social Care, NHS England, will be needing to go back to the Treasury and ask for further top-ups to funding.

Matthew Taylor

Which takes me to my next question. Most of the leaders we spoke to felt that it was inevitable they'll be top-up funding later in the year. Now, they have to plan their budgets on the basis that there won't be top-up funding, but they believe deep down that there probably will be. And that's hardly surprising because it has happened year after year after year.

Sally, is it inevitable that we continually find ourselves in this position of having one financial situation at the beginning of the year, but nobody really thinking it's going to apply until the end of the year? 

Sally Gainsbury 

Yeah, it's so dysfunctional, this entire, I don't know how anybody runs a business when… this financial year providers do not have coverage for £8 billion worth of their cost base. I mean, it's almost inconceivable how you would try and run an organisation on that basis. And yet that has been, the reality in the NHS for much of the past decade with the two years of the pandemic being a sort of a strange exception to that - when the NHS experienced much more comfortable levels of funding, although obviously, you know, really great operational pressures. We can't even call it the elephant in the room anymore. But one of the reasons this year why we've got this situation, apart from there obviously being an election, is obviously the productivity issue. 

I think the DHSC and NHS England were in a very difficult position in terms of negotiating the budget for this financial year in the face of what looks like relatively low outputs on, I mean, it's probably a separate discussion, but all of your listeners will be well aware that on the outputs that are measured, which tend to be in the acute sector, we know that the NHS has had a significant slowdown in those outputs, but of course, spending - and particularly staff costs - have risen, which I think has probably contributed to a lack of willingness on behalf of the government and politicians. It's notable politicians probably on both sides of the parliament not feeling particularly willing to increase NHS spending this financial year. 

Matthew Taylor

Yeah, well that productivity issue is a huge one and will be a continuing kind of debate. I've just noticed in the last few days, for example, disagreement about the level of acuity of people going into emergency departments, for example. So we don't really understand the nature of demand, which is obviously an important component of this productivity debate. But just to finish, we're talking here about revenue funding. But clearly, one of the reasons why productivity increases are so difficult in the NHS is the capital situation. I know I won't reveal my sources, but I know a major think tank has done some research which shows some pretty impressive improvements in elective productivity if you have an elective hub.

But you only have an elective hub, a fully equipped elective hub, if you've got some capital investment to put into it. So the other really big issue, of course, for any incoming government and right now is that if we do want the health service to be more efficient, to be more productive, we are going to have to invest more in capital spending, aren't we? 

Sally Gainsbury 

Yeah. And of course, that has been very problematic over the last year because we saw over a billion pounds transferred out of the Department of Health's capital budget and into the revenue budget. Partly to fund the additional costs by industrial action, but also because of course last year we had a similar situation where funding levels were below where anyone would realistically predict they needed to be for the year and thus that transpired and one of the ways of filling the gap was through raiding the capital budget, which of course is counterproductive, as you've just suggested, to addressing the productivity challenge that the NHS currently experiences.

Matthew Taylor

Well, Sally, thank you for joining me. You've said a couple of times that you're sorry to be slightly pessimistic or downbeat, but actually, you know, and I'm speaking to you now, everyone is predicting that the general election will be called in the next hour. If you're listening to this, you'll know what the prime minister has done. But it is one of our jobs to be honest with people about the reality and try to make sure that the debate that takes place between political parties is based on the facts and not magical thinking or mythology. 

So, Sally Gainsbury, thank you so much for joining us on Health and the Line. 

Sally Gainsbury 

Thanks for having me. 

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Matthew Taylor

And now over to the fascinating conversation I recently held with Sir Norman Lamb and Matthew Bolton. 

Today, we're tackling a critique that is sometimes levelled at parts of the NHS that, well, we have a bit of a listening problem. We talk a good game when it comes to community engagement. Well, we don't always, in fact, we don't often follow through. Now, I've seen firsthand examples that challenge this perspective. But this question of whether we need to be better at listening, better at engagement, is one that we really do need to discuss. Particularly as we work through new structures like integrated care systems and place bodies. 

In fact, how could we go one step further than just listening and consulting but instead roar on communities' insights, their assets, their knowledge to create a better approach to health and care? That's certainly the way we in the Confed are thinking about a new project we're doing on integrated neighbourhood teams. Anyway, to delve into the issue with me, I'm delighted to be joined by a fascinating combination - a highly experienced health leader, politician, and one of our country's most high-profile activists.

So I'm being joined by Sir Norman Lamb and by Matthew Bolton. So Matthew, Matthew Bolton has 15 years’ experience as an organiser, is now director at Citizens UK. He's pioneered community organising as a force for social change and democratic renewal. And he was the lead organiser for the UK Living Wage Campaign by Citizens UK. He's also an author, author of How to Resist, a book on organising and campaigning, but which includes a set of principles to enact lasting change in communities and Matthew coaches community organisers all across the country. 

Now Sir Norman Lamb will be known to many Health on the Line listeners. Indeed, this isn't actually his first time on an NHS Confederation podcast. Sir Norman is chair of South London and Maudsley NHS Foundation Trusts - SLAM as it's often known - and task force co-chair for South London Listens a community partnership project between south London schools, faith groups and community organisations. Norman was an MP between 2001 and 2019, served as Minister of State for Care and Support from 2012 to 2015. And as a health minister, Norman worked to reform the care system and led the drive to integrate health and social care and always has put a great emphasis on prevention and, of course, is passionate about mental health. So Matthew, Sir Norman, welcome.

Norman Lamb

Good to be here, Matthew. 

Matthew Bolton

Good to be here. Thanks for the invite. 

Matthew Taylor

So Matthew, I'm going to start with you. Just tell us, I mean, I know a lot about Citizens UK, but just in case anybody doesn't really understand what you are, what you do, just tell us a bit about Citizens UK. 

Matthew Bolton

Thanks, Matthew. Yeah. So we bring communities together to make change. It's worth thinking about us in terms of the method. So we're fortunate to have this method of community organising that we've been practicing here for 30 years. We've kind of inherited and drawn on from various organising traditions. 

So there is a real set of principles and practices that enable us to build diverse community alliances and train effective citizens and effective community leaders to make partnerships and make change. 

And also thinking of us as a kind of membership. And so we have a dues paying membership like the NHS Confederation. Our membership is a civil society of organisations ranging from small Somali Women's Association to the large university or health trust, primarily faith, education and voluntary sector organisations. And they're brought together in diverse alliances in 18 towns and cities. 

And the great majority of the work happens at a very local neighbourhood level around a zebra crossing outside a primary school. But up to, as you mentioned, larger campaigns and initiatives like the Living Wage. 

Matthew Taylor

Fantastic. And Norman, just to bring you into the conversation, tell us how things are today. Whenever I talk to health service leaders, I always want to get a sit rep. So how do things feel for you right now? 

Norman Lamb

Incredibly stressed. I mean, the financial position is really difficult. I mean, south east London, particularly difficult. We have King's Hospital, which has a very substantial deficit. But that has implications for all of the trusts within south east London. So we're expected to make very substantial efficiency savings larger than the NHS has ever achieved. 

At the same time as facing extraordinary levels of demand. I mean, every morning we have perhaps 30 people in A&E departments across south east London. The decision has been made that they are in need of a mental health bed, but there are no beds available. So then people get sent out of area 

which is a dreadful practice, or get stuck in A&E for long periods of time, which is also appalling because it's not a therapeutic place to be. 

So we're grappling with a system that feels pretty dysfunctional. I mean, it's another conversation, Matthew, but we're about to trial a new model of care in Lewisham, a population with a lot of deprivation, with a very diverse community, but a model of care that's more based on working in the community, supporting people earlier, focusing, you mentioned prevention in your introduction, but looking much more to prevent people falling into crisis in the first place. 

And NHS England is now encouraging mental health trusts across the country to put forward expressions of interest in trialling models of care of this sort. So I think that's quite an exciting opportunity because I feel that the current model is frankly broken.

Matthew Taylor

Yeah, well, I mean, there's a lot to talk about, but we're going to focus on the kind of community engagement side of this. But I can give you one bit of good news, Norm, which is that I have just been at a meeting and Julian Kelly, who is the chief operating officer, and Amanda Pritchard were there and they were both asserting their commitment to the mental health investment standard. So in your arguments with the system, they are reinforcing the importance of that standard. 

Now, I guess in the face of the kinds of challenges, the day-to-day challenges, that sense of managing crisis that you described, many people might say, well, I've got to community engagement… I haven't got time for that. We've got to focus on just keeping the show on the road. But I think you're both going to argue to me that the community engagement is an absolutely mainstream part of how is we deal with the kind of gap between capacity and demand. So Matthew, I'll start with you. 

Tell us a bit about South London Listens and your engagement in that? 

Matthew Bolton

Yeah, I will. And to make that connection, we work with, as I say, schools, Baltic Academy trusts, churches, different organisations who have hundreds or thousands of people in their everyday air and relationship. And those people are experiencing housing problems, they're experiencing low pay and insecure work, they're experiencing mental health concerns.

And the argument that we're making to that range of civil society organisations is that it may be really hard to keep your show on the road and, you know, working with schools through the pandemic. You can imagine it's hard just to kind of fight the fires that are arriving, but as civil society organisations, we do need to try and lift our sights up and build those creative partnerships because part of the challenge facing the NHS is if we are in a broken society where people are experiencing overcrowded housing, insecure work, then it can't all fall to the NHS to pick up the pieces. 

And if we can build partnerships between communities and health organisations, we can help release energy and assets in communities to act for wellbeing, but we can also together address some of those underlying social determinants of health that lead to health inequalities and lead to further pressure on the system.

Matthew Taylor

Matthew, how do you measure the effectiveness of this work? I mean, obviously, working with the messy business of working with communities, really responding to their agendas, and that's a big part of this, isn't it? When we have to engage communities, we have to start from where they are. But nevertheless, anyone in the health service who are obsessed with the issue of productivity right now will want to feel that things that they do can be linked to outcomes. So what do you see as being the outcomes of this work? What evidence have you got of it succeeding?

Matthew Bolton

So there's a range of types of activity that arise from South London Listens and we can kind of go back a few steps in a second and as to kind of how it began and the listening process. But what really struck me coming out of the South London Listens partnership and the listing that we did together with SLAL and with the south London health system and our community membership in that area was the range of initiatives that include, for example, the Be Well hubs where you have local communities in south London saying, actually, we want to be better at helping and looking after people in our community, signposting them to the right services, prioritising relationships and listening, helping to connect to people who are struggling and work on that prevention as communities and to co-design that kind of training with health professionals. 

There were also activities around sort of innovative co-design of new ways of working. So we work with SLAM on pioneering virtual waiting room for CAMHS where people on that list could have a bit more certainty about where they were on the list and also access support while waiting. And then also activities, as I say, addressing some of the underlying social determinants and working together on the living wage to really roll out the living wage across the health system, benefiting thousands of workers and therefore benefiting entities in terms of health outcomes. 

So those different sorts of activities need different sorts of evaluations. And we've got an evaluation in place with King's College London, looking at the Be Well hubs, looking at the service innovation and, with the living wage, we've got a whole series of evaluations around that, but it is essential that we do evaluate, but also that we are courageous to begin new things where the evaluations might not fit into this sort of very established standards of measurement that the NHS has. 

Matthew Taylor

So Norman, turning to you, I guess if I was to speak to almost any health leader, they would say, well, there are things that we do to try to engage the community - public services of all kinds talk about this. But often it's a bit half hearted. It's not thought through. People end up, the people being consulted and engaged end up more disillusioned than if you hadn't even spoken to them in the first place. So what's different from your perspective about South London listens? 

Norman Lamb

Yeah, it often feels like it's a bit of a tick box exercise. You know, we've consulted with the public, so we carry on with what we plan to do anyway. This approach is very different. I mean, it is very much co-production, to use the jargon phrase. 

But it's important to say how this started, Matthew. At the height of covid, when we were in the middle of lockdown and it was clear to me and others that there was going to be a psychological fallout from this pandemic. No one at that stage was really talking about it, but we decided to convene a summit. We did it jointly with our local authorities. It was all virtual. Over a thousand people signed up to participate in this summit. And actually Lade Smith, one of our consultants who's now president of the Royal College of Psychiatrists, who spoke at that summit, said something I think is really important. 

She said, we've got to change from being an ivory tower to a community asset. We've got to work with other people. And so from that summit, we set up a working group, but I talked to our very imaginative and creative director of comms, a guy called Ranji Kale, who had very good relationships with Citizens UK. And that was the sort of start of a collaboration with them. 

And we knew that they could reach parts that we can't reach, that they have a level of trust through their member organisations within communities, which we don't frankly have. It's a disturbing aspect of mental health, particularly in inner cities, but the levels of trust, particularly within black communities, where there is clear disproportionate impact of detention under the Mental Health Act, use of coercion and so forth, levels of trust are very low. 

So we've got to find new ways of engaging with people and building trust. And you can't in the very short term point to an X hundred reduction in the number of people requiring secondary mental health care as an outcome. You have to have faith in this as a different way of behaving and it will take time to be effective. But I am absolutely clear that we will not achieve better health and wellbeing in our communities unless we engage much more closely with them and build that trust. 

And I think our collaboration with Citizens UK, which, and this whole project, I think has been pretty unique, but I think it's been very powerful in building relationships which weren't there in the past, which enable people to start to see that we're not something to be frightened about, that we can work with them.

And that we can reach out to them to use our skills because we have an extraordinary connection of very capable people within our organisation. We can use our skills to help support communities to be more resilient. And that's surely better than meeting people after they've fallen into crisis. 

Matthew Bolton

I mean, Matthew, just to come in on that, because you started this session with the does the NHS have a listening problem? I mean, I think to make sure that we see this as a ‘takes two to tango’, communities sometimes have a coordination and coherence problem, I'll come on to that. But I think you can characterise, there's sometimes a tick box exercise, but also some of the kind of patient and public engagement networks that we've seen can end up with individuals coming with a particular concern or a bad experience or just, you know, just one thing that they particularly care about. And while that can have some value in some forms of engagement, the established network of communities represented through South London citizens, schools and colleges and churches and communities, engaging with them, they have a broader interest. 

There are people in those organisations that have got positive and less positive experience of the health system, but they're also just being a community. 

Norman Lamb

I totally agree, Matthew. And incidentally, we've held a series of events which have been organised by community groups, which we've attended. And without singing, without dancing, without music, I mean, I've never witnessed anything quite like it. Certainly not in the NHS. And this is completely different. But people expressing joy, happiness, enthusiasm, excitement. And I think some NHS leaders who've appeared on the stages of these events have been completely gobsmacked by what they've witnessed. 

But it's brilliant. And it's engagement in a totally different way than I've ever experienced in the past.

Matthew Bolton

Yeah, and that kind of communities have a coordination problem. You know, we see it as our role to help bring communities together to do the listening, to do the prioritisation. So that rather than coming to the NHS with a long shopping list of things we think need to be different or complaints about the way things are, you know, we try and work together on a manageable number of constructive things that we could do together. And that's the role of the community organisation. And so it could be a bit of an easier partner, I think, for the NHS.

Matthew Taylor

So Matthew, let's delve into this a bit more because I'm really keen that people listening to this conversation are listening to it in a very practical way. And I'm imagining somebody listening to it who is attracted to the idea of doing more community engagement in the kind of way you talk about it, but they're nervous. And so I want to kind of explore some of the things that they might be nervous about. 

And one of them is the kind of unpredictability and messiness of this. You know, the health service is an organisation that spends an enormous amount of time trying to control things, control risks, do things in uniform way. This incredibly hierarchical and regulated organisation. When you and I first spoke, Matthew, it's kind of a revelation to me because I'll be honest with you, I had a kind of perception of a Citizens UK that your model was really to go around and find something that people were pissed off about and then kind of give them banners to wave. 

And this was, you know, this was what community organising was. Now I have to obviously apologise for such a kind of crude view, but sometimes that is, I have heard people describe community organising in that largely kind of a kind of slightly oppositional, agitprop kind of way. Now you've described it in very different terms, but it is important, isn't it Matthew, for people to understand that if they are going to engage, it is going to have elements of unpredictability and messiness. 

And one of those is you do have to start from what communities say matter rather than necessarily what you think matters. Is that right? 

Matthew Bolton

That's right. And the listening campaign is a really fundamental part of the method and the practice. And I would say yes to the messiness and unpredictability and creativity. But also yes, to quite carefully choreographed processes that have got a method that underpins them, working through trusted community leaders. So this is not a kind of free for all open exercise, but it is an exercise of creativity and it does start with listening. 

One important difference to kind of see there is it's called South London Listens, but really it's sort of south London partnership, south London relationship. The listening is there to bring out the concerns and the hopes and the issues that people are facing. But when we do the listening campaign and South London Listens was listening to 6,000 people, face-to-face conversations, walks in the park, getting out into the community. But what we're also looking for is leaders and we're looking for energy. 

And so the listening campaign is both about surfacing those concerns that people have, the CAMHS waiting list and a worry about young people's mental health, but also surfacing those people who want to make a change, who are prepared to come and stick to it, work pragmatically and be part of the solution. 

Norman Lamb

And I would say, incidentally, that it's the very opposite of people waving banners. I mean, people simply do not expect the NHS to behave like this, but, you know, we've got to show a bit of humility. We've got to be willing to join in as equal partners with community organisations. We've got to be prepared to just listen, not worry about the sort of discomfort of it and the unpredictability. Just go into it, just have the conversation. And in that way you build trust and people actually don't want to wave banners at you. They find they can talk to you about the problems they face. 

And then if you actually start to say, yeah, well, we could do that, we could support you on that, they start to see that the answer is not always no. And I think if you don't engage in all of this deep engagement, deep conversation, you're more likely to end up with people waving banners outside your front gates because you'll be seen as an organisation that doesn't listen to people. 

I would like to see this approach across the whole of the country. I think every community sort of has a right to have an open conversation with their health organisations in their locality and should not be excluded. And it is very different to the sort of patient and public involvement that we've traditionally done, which as Matthew Bolton says, too often the same people repeating the same issues because they've experienced a particularly traumatic event at the NHS. This is totally different to that. 

Matthew Bolton

To recognise Norman, you and Ranji and Andrew Bland, David, some of the characters there who have approached this in that kind of open and courageous way, just recently through some of the sort of second round of listing that we've done, it was just so clear that questions of overcrowded housing, damp and mould, unresponsive kind of repairs was putting pressure on people's health. 

We asked what's putting pressure on life, what's causing health concerns around here, and whether it's the stress or the physical health, housing was so important. And from when we first began that conversation with SLAM and the south London health system, there was a nervousness. What could we do about housing? It's such a big and difficult issue. 

Well, actually, there are some things that we could do. There are some small steps, pragmatic steps. How can we embed housing experts into some of the health systems so we can make small adjustments? How can health leaders add their voice to a broad section of the community saying housing is a priority and we need to have more affordable housing, we need to have better repairs and that housing is a health issue. 

There have been a few steps along this journey where Norman and others have really said, actually, we can do this and we can be courageous and work in his way. 

Matthew Taylor

So Norman, I think one of the things that holds people back at the moment, quite apart from the kind of sense of a lack of kind of head space, is a fear that because the health service is so far away from being able to give the public what the public wants and what the public deserves, that this conversation with the public will start in such a position of deficit that leaders might say, well, if I speak to the public, the first thing they might say is, well, you know, we don't want to have to wait.

We don't want to be in a system where people are sent out of area in mental health. We don't want to have to wait, like, you know, a close friend of mine did 13 hours in A&E department. So to do this when your starting point is that you can't give the public what you think the public needs and deserves, that I think, may be part of what holds people back. 

Norman Lamb

Yeah, but the last thing you should do in that situation is to retreat and to sort of go into a bunker, because then the public just sees you as the problem. If you're open, if you show humility, if you just enter a conversation, if you're honest about the challenges that we face, the lack of resource and so forth. People aren't stupid; they will understand the challenges that we face. They might actually have some ideas about how we could use our resource more effectively. We don't have a monopoly on good ideas. And actually we sort of know that the NHS doesn't optimally use its resources. 

So actually having an open conversation with the people you're serving might just result some interesting opportunities to use money more effectively and to intervene earlier to stop people falling into ill health in the first place. 

Matthew Bolton

And just the point about listening. So with the CAMHS virtual waiting room project, you know, we didn't stop with: you're on a CAMHS's waiting list, that must be difficult - what is it that's frustrating and difficult about being on the waiting list? And what we started to hear from that was, one of the parts is not knowing kind of where you are on the list, not knowing when you might get to see someone. 

Norman Lamb

No one's communicating with you, left in the dark, which is what happens. 

Matthew Bolton

Exactly, a pragmatic, creative and possible idea, which was to say, actually, let's communicate better. Let's try and help people understand where they are in the list. Let's provide them with some resources about wellbeing, about support that you can get. And yeah, again, there was a, you know, let's call it risk averse, but actually there's something that we can do if we work together. 

Matthew Taylor

One of the kind of false dichotomies I think we often get in these kinds of debates is that people who want to talk about public engagement and consultation and listening I don't know, asset-based community, but all these kinds of ideas, it all sounds a bit soft and squidgy. And then there are the people who say, no, we're going to focus on data, the one best way of doing things. 

But actually, I think it's a false dichotomy. I actually think that good data can really be something which fires up these conversations. So talk to me both, and I'll start with you, Norman, talk to me about the importance of good-quality data in framing and shaping the kind of conversations you have with the public.

Norman Lamb

Yeah, I agree with you. It's a false dichotomy. We can behave differently, in a more humane way, in a way that offers a bit more humility. But also at the same time, be absolutely rigorous about our use of data and our understanding that we gain from that data. No contradiction at all there. 

And in the work we're doing on developing a much more community-based model of care, which will necessarily involve very close collaboration with community organisations. And incidentally, it will completely dovetail with South London Listens. It's all part of the same mindset that we intervene earlier, we collaborate with other people who might have much more influence within the community and who might be able to influence some of those social determinants of health that we know cause problems in the first place. 

But as we develop our approach, it's critical that we evaluate it properly, that we gather data so that we understand the impact that we're having, that we can then compare and contrast. And I think the exciting thing is the combination of science, of data understanding, of the use of technology and potentially AI, but with a more humane approach. The two are not mutually exclusive and can work together to create a much more sustainable health system, I think, for the future.

Matthew Taylor

So Matthew, I'm interested in your view on this. I was talking to someone very senior in the NHS just the other day, and she was saying, the public keeps saying that they can't see a GP, but you know, with the 1.4 million contacts of primary care. And I hear this a lot, this kind of, why can't the bloody public look, read the data? Why can't they understand what's really going on? I'm really interested in how you engage the public in a conversation which brings together both their personal experience and perception with the data.

Matthew Bolton

So what I think we need to do is start where people are at. And that means starting where they live and where they gather in the communities, in the community organisations that they're in and out of every day, rather than expecting people to kind of come to the one-off consultation exercises that we might run in the building that we choose. So there’s starting where people are at. 

Then there's really starting with where they're at in terms of the listening, you know, what's putting pressure on you and your family? What would you want to change in this community? But with that eye towards what would you want to change, not just what can we provide differently to you. And let's try and have that partnership to work together and make things happen. 

And within that listening exercise, there's definitely a room for, well, this is what the data shows about population health in this area. And this is what the data shows about what services are and aren’t providing. 

But the crucial bit that needs to be built is the trust. And we've been through several rounds over several years of that public relationship and making a difference on practical things that people have expressed as priorities. 

I think people are much more ready to hear sometimes quite difficult or unexpected messages about what the data shows or indeed what the health system can and can't provide and what restructures and reorientations of health services might be needed. And, but that, you know, those kinds of conversations I think can happen once that trust and partnership has been built. 

But just the other thing about data, one thing that the data shows is that health inequalities and health problems are driven by social determinants of health. And if that's a really serious message that we need to take, then how can we empower communities and how can we empower health leaders to work together on those social determinants of health? 

And this is about the democratic engagement and it's about the role of health organisations working together with other community organisations to say, yes, maybe it's difficult, but if housing or if low-paid and insecure work is part of what the data tells us is driving ill health around here, what can we do about that in a way that's safe, reasonable, effective? And in the case of South London Listen, that's ended up with all of the health trusts across south London and soon to be London becoming living wage employers.

Matthew Taylor

I could talk to both of you all day, but I've got one last question for both of you, but feel free either of you to come in on this. I'll start with you, Matthew. I think one of the things I think is important to emphasise here is that community engagement is sometimes seen as a means to an end. And we've talked a bit about, you know, outcomes and evaluation, but it is a good in itself. 

And we're doing work with the local trusts, our work around integrated neighbourhood teams and how they can feel like they are community-based organisations rather than just kind of multidisciplinary teams. 

I've got a lot of evidence which shows that health outcomes are very different in areas of similar levels of deprivation depending upon the degree of connectedness in those communities. 

If there is more social capital, it makes a really big difference. There used to be a statistic that was thrown around a lot that social isolation was worse than smoking for your health. I wonder how deeply based the evidence is on that, but nevertheless, social connectedness is an important part of health promotion, isn't it? In itself. 

Matthew Bolton

South London Listens is an investment and a partnership that builds relationships within communities and between communities. And that tackles the social isolation. It builds the sense of relationship and connectedness. It also builds a sense of agency and addresses the kind of powerlessness and a powerlessness and mistrust.

Norman Lamb

And all of these things incidentally are crucial to your mental wellbeing. 

Matthew Bolton

So it might be about the Be Well hubs or the community embedded workers or the CAMHS virtual waiting or the, you know, of course there are the initiatives and we've talked a bit about them, but absolutely the process is a good in itself. 

And as Norman said it's one that we'd really be keen to share. And if there are listeners are keen to find out more, we'd be delighted as SLAM and Citizens UK to have a conversation about the lessons learned and how we could spread this model elsewhere and connect into local context.

Matthew Taylor

That, Matthew, is a perfect kind of prompt for my final question to Norman, which is we absolutely want to do that. And we do more and more work around improvement, working with our members, and I'm very keen that we develop - as well as the work we want to do on creating neighbourhood teams - that we do develop some work around improvement in terms of community engagement with our system, place, trust, partners. 

So final question for you, Norman, which is when we think about how it is we can encourage and support other leaders to do what you have done in south London, how do you think we should go about that? What are the critical capabilities, techniques, assets we need to try to give to leaders if they're to follow in your footsteps? 

Norman Lamb

First of all, we're very happy to share - as Matthew says - any of the learning that we've gained from this joint working over the last two or three years. And we're enthusiastic about the opportunity to spread it across the country. And it's brilliant that the NHS Confed is up for playing a role in spreading the learning of this type of approach. 

I think also, Matthew mentioned it earlier, the ICS has played a really constructive role. They have helped to fund this whole enterprise. It can't just be done entirely on thin air. We've committed resource to this and the ICS has committed resource to it, but it's a key point because south east London is a very stressed health system and yet they've been willing to invest in this collaboration and I pay tribute to them for doing that. 

And so across the country, we have to convince ICSs of the case for investing in this sort of new way of engaging with our communities. And I think also I should just say that we should recognise that what we're doing is work in progress. We haven't got the perfect method of doing this yet. We're still learning as we go along. 

I want to see a much closer collaboration with local authorities as well. I've chaired the Health Devolution Commission along with Andy Burnham over the last three or so years. And we believe very strongly in the need for a much closer collaboration between NHS and local government. It started with the ICSs, but it's not gone nearly far enough. 

But they have a role in so many of the social determinants of health that to leave them outside the discussion would be a massive mistake. And we've involved local authorities in this work in south London, but I think we could deepen that involvement much further. And I think that's a necessary component of making this really effective.

Matthew Taylor

Yeah, I completely agree, Norman, and we have very strong links with local government colleagues and local government association, ADASS, directors of public health. We see partnership with local government as absolutely critical to the future of health. 

Well, Matthew, Norman, it's been fantastic. And for those of you listening, do watch out because it's only a matter of time before we invite you to spend more time with Matthew and Norman and learn more about how is we can apply the principles, but it work in progress. The successes, the failures, the risks, the things that go right, the burning. 

And by the way, as I'm sure Matthew and Norman would say, nobody would want to copy exactly what's happened in south London The whole point is different places need different kinds of approaches. But Norman and Matthew, thanks so much for your time.