Equity

Matthew Taylor: Hello, and welcome to Leading Improvement in Health and Care, the new podcast from the NHS Confederation, the Q community, and the Health Foundation.

Penny Pereira: In this series, we'll be speaking to the people leading the way when it comes to improving health and care in services and systems.

Matthew Taylor: We're going to be shining a spotlight on improvement done well, but we're also going to explore the challenges.

Penny Pereira: We'll be learning about the ways improvement can transform health and care and how to make change last. I'm Penny Pereira. I'm managing director of Pew at the Health Foundation.

Matthew Taylor: And I'm Matthew Taylor, chief executive of the NHS Confederation. And this podcast is part of a partnership between our organisations called Learning and Improving Across Systems.

Penny Pereira: We're working with health and care systems across the UK, boosting their ability to learn and improve collaboratively. We're doing that through a peer learning programme and insight and innovation projects, sharing what we're learning throughout. And we're also making this podcast spotlighting great examples of improvement in action.

Matthew Taylor: The last time we spoke, Penny, we were focusing on collaboration, tackling inequitable maternity outcomes faced by black mothers and their babies. It was a fantastic initiative we talked about, supporting maternity systems to offer safer and equitable care for all. This time, we're going to continue with that theme of equity.

Penny Pereira: And we're going to be thinking about that on a broader canvas, how to work on health inequalities. We've been speaking to two really fantastic leaders who've been at the forefront of efforts to improve population health in east London, placing equity front and centre of what they do.

Matthew Taylor: This feels really topical, doesn't it, on the back of the Lord Darzee review. His report highlighted something we know about all too well, which is the level of health inequalities, both in terms of outcomes, but in terms of healthy life expectancy.

So these issues, these issues of inequalities, really at the forefront of the conversation now about what we need to do to transform the health service.

Penny Pereira: Indeed. And there's an opportunity with the Darsey review and the ten-year plan to be thinking more holistically about these issues beyond the kind of delivery of NHS services. Because improvement approaches, they've got a lot to offer some of those big system challenges, like health inequalities, they're going to need action beyond the NHS.

And there are some differences in terms of the approaches that you use when you're doing change at that level.

Matthew Taylor: Penny, let's get into hearing about what's been happening on the ground.

Penny Pereira: So first up, we sent Gabriella Jones, the Confed's roving reporter, to speak to Dr Guddi Singh, a paediatric doctor in London and co-founder of the Wellbeing and Health Action Movement, known as WHAM. WHAM is a really powerful, interesting project bringing together child health professionals to fight poverty in clinical practice.

Guddi Singh: So, hi, my name is Guddi, and I'm a consultant paediatrician, but I'm also a health researcher and a broadcaster, and so I tend to tell all my patients that I'm also a jack of all trades.

Gabriela Jones: You spent a good few years working in community paediatrics in east London. Can you tell us a bit about that work and how it eventually led you to set up WHAM?

Guddi Singh: A few years ago, I was appointed to, I guess, what was quite an innovative post at the time, called the integrated child health quality improvement Post. And it was set up when the East London Foundation Trust actually took over children's community services in Newham. Gabriella, I don't know if you know Newham at all, but it's an incredibly diverse borough, right?

So, 102 languages are spoken in Newham by its residents, but it is the third most deprived borough in the whole of London. Sadly, it totally exemplifies this truism, which is that deprivation and diversity go hand in hand. Almost half, so that's 49 per cent, of Newham's children and young people live in poverty. And I was brought into this job to try and bring a focus to some of these issues. 

Let me just give you a bit of history. This community child health service had been underfunded for years and years and years; it was previously under a different management and the staff were totally overwhelmed and so I think, even despite all of East London Foundation Trust's valiant attempts to try and get the staff to be engaged into community and child health and also quality improvement, were really falling flat. And I realized that the culture historically had been very siloed.

And so even though we were meant to be working in these multidisciplinary teams, you had therapists working very separately and even then speech and language therapists working differently to physiotherapists and occupational therapists. Doctors tend to stick to themselves and the admin team being completely separate.

And so I just started building relationships and I started wondering actually if the two problems, deprivation and health inequalities in Newham and this idea of actually bringing joy into work might not be connected. So how are we going to bring together a multidisciplinary team who just don't have any interest in QI because it seems too technical. It feels a bit elite, especially for non-doctors in schedules that do not allow time for anything beyond their daily jobs. How are we going to get people to be interested in QI?

So I started these multidisciplinary teaching sessions and badged them ‘Making Things Better’. I mean, effectively, my strategy was never to mention QI. And instead to focus on things like, how do we find joy at work? And what is it that people most care about? And it turns out, ordinary clinicians really care about child poverty. And they really care about deprivation. They really care about the lives of their patients. 

Child poverty is obviously emotionally compelling, right? And for clinicians who see it day in, day out, communicating the case for change is really straightforward. Clinicians, of course, are human beings, and appealing to them as human beings who have like a sense of morality, actually, it was really, really motivating. And we started seeing that people were then willing to go that extra mile to do that other thing, that thing that was on top of their to-do list, because it mattered, because it mattered to them as a human.

And you know, this is basically what led to us developing a poverty screening questionnaire with the multidisciplinary team there. Along with a resource leaflet, and this is all co-produced, right? You know, through conversations with families in that community. And it began to be this coalescing point for the service, who started really thinking about health inequalities in a very tangible way.

So not, not in that way that we tend to do, which is to think about, oh, well, someone else will fix this, whether it's policymakers or the leaders of an institution. It was really ordinary clinicians taking, taking action themselves with their patients that they were going to see. They felt like they were able to make a difference and that on its own was its reward.

Remember, what I said was that most of these clinicians were not doctors, and therefore most of them had no previous experience of doing QI. And yet, by the end of this, they were employing techniques that would be totally at home within QI. 

I think this thing of like really getting to what people care about was what made this successful and clearly addressing health inequalities in that particular population was the biggest driving motivating factor that, you know, I could have found.

Gabriela Jones: So like QI by stealth.

Guddi Singh: Most of my career has been QI by stealth. So I've spent most of my career as a clinician basically not feeling at home in medicine at all. I've always felt like health is so much more than hospitals. And so the way I've gotten around it has been to use QI when it's helped me because obviously in some audiences for some people actually QI is something to be respected, it's something that we can invest in. It's how we change health services, right? So obviously that's a good thing. 

In other ways, I've had to, as you said, use QI by stealth because for some audiences QI is not the language that they speak and so often we're talking about the people who are not doctors, who are not managers. Why would QI matter to them when it's like painted to be this kind of special thing for special people? Changing healthcare systems is not going to be left up to those who are in power. None of us should leave that to happen because we have a health system that's really in a mess. 

I believe that health system change should come from the ground up. And I believe actually QI can be a tool to enable that. But I think it also depends on us, whoever it is that's trying to do the QI to actually figure out ways to reach audiences and to engage audiences in a way that will bring them along as opposed to alienate them. Changing health, but them, the clinicians, patients, being at the front and centre of that process.

Gabriela Jones: So can you tell us a bit more about, WHAM now? how that work has evolved?

Guddi Singh: WHAM is what I call a social incubator, and a digital platform, and it allows the peer to peer sharing of the knowledge, tools, and community to inform, empower, and unite clinicians who wish to address the social determinants of health and health inequality in their clinical practice. WHAM arose out of the fact that there was a massive gap between clinicians who had this desire to do something about their patients’ lives on the ground and what was being provided in conventional medical education and practice.

You know, I mentioned how I'd never felt at home in medicine, not least because of my own demographics as a small brown woman from a working class town in the northeast of England, but also because I started becoming very depressed when I realised that the medical profession did not care whether my patients had enough of the right kind of food to eat, what their house was like, whether they had enough money to pay their heating bills.

And over and over again I'd be told, that's someone else's job, sweetheart. And I just kept thinking, but whose? The reason that poverty matters to me is because it is the most important determinant of child health in the UK today. 

Poor children are up to three times more likely to be injured. They are twice as likely to die as rich ones. And poverty basically insinuates itself into every aspect of a child's life, whether it's developmental, educational, or long-term social outcomes. And it results in there being an increased likelihood of things like cardiovascular disease, diabetes and cancer later in life. 

It never seemed easy to bring in my interests in the social factors into my clinical practice. My colleagues made me feel like I was the problem for bringing it up and in the end I realised that either I was going to quit or I was going to change things from the inside out and that is what WHAM is about. So WHAM is the Wellbeing and Health Action Movement and it is an organisation that I founded myself with a group of other paediatric registrars, so trainees, who were also feeling similarly about the fact that they wanted to do more on things like the social determinants and health inequalities.

We actually formed in 2021 during the pandemic when health inequalities in a way became really like obvious to everybody. The COVID-19 pandemic revealed health inequalities to a very wide audience in a way that hadn't been revealed before. And we have somehow managed to create, with very little resource, this nationally connected digital resource, which people are Loving.

We basically provide on this website a lot of the papers that we've published where we've tried to use QI to tackle things like child poverty in the emergency department or in our clinics and we welcome people - it's an open source website, right? - we welcome people to take what we have and to go and adapt it. The one thing I know about QI and any health care improvement is that none of us really have the final word on it. 

What we also do is we try and shift the attention of health systems and health policy Towards that idea of like upstream, holistic healthcare. And we're doing it by trying to change cultures and capabilities. And ultimately the care that's delivered on the ground. And has led to us actually applying for funding from the Health Foundation and being successful to do more work and our latest project, Powering Up, is an example of that.

Gabriela Jones: Can you tell me a bit more about Powering Up?

Guddi Singh: Powering Up's ethos is that it is for young people by young people. So we have employed young people on this project from day one. It's a collaboration between WHAM and also a group called Canal Project, which is based in Birmingham. I've also brought on to this group, a fantastic digital and film company called One to One Development Trust, who really punch well above their weight, but are also small, have come together to create this thing called Powering Up.

Health inequalities are actually worst for young people in this country. So those who are aged between 15 to 25 face some of the steepest health inequalities, and they are also the group that is the most neglected when it comes to health system change. So Powering Up exists to try and remedy that. 

We wanted to basically test new approaches to health with young people from the most underrepresented and neglected communities and use creative ways to bring them on board. And so we actually tested in Birmingham and London. And the idea is to look at how arts and science methodologies could help us to bring about meaningful co production in health. 

So we used citizen science in Birmingham. We literally trained a whole bunch of young kids to become their own scientists in their own communities to find out what health problems were going on in Birmingham.

And that was fantastic because they reported that up to directors of public health, the CEO of Birmingham Children's Hospital, including clinicians and people from NHS England, and were able to reveal really interesting and profound things about what was going on in their community, stuff that would not have been found out otherwise.

Now, we just recently did the London arm of the pilot, which involves arts methodology. So using things like theatre, dance, music, poetry, to explore what health is like for young people in south London. And again, I cannot tell you, Gabriella, how incredible it was to see a group of young people who are transformed by the process of hanging out with clinicians for a week. And that alone, I think was transformative, right? For these young people to suddenly look at someone like me, and then be like, maybe I could be a doctor too. 

I have now seen, in this project, particularly the power of creative methods. So things like music, dance, and art to bring people who are otherwise unheard, unseen, and uninvolved to the frontlines of clinical medicine. And the messages are really powerful. This works and people want more of it. And also let me just reiterate something like at the beginning of the week, young people were really suspicious of doctors and did not think they would have anything to say to them. By the end of the week, they would not let go of us and wanted to have a rap battle with us.

So something happened in that week that would not have happened in like a normal clinic consultation or would not happen even with regular meetings with your GP. So like I said, we've got one music video, we've got two tracks, one track by the clinicians, one track by the young people, four little plays and 12 poems at the end of just one week.

Obviously, I'm not saying that the NHS needs to become like a talent contest or something. But I am saying that being creative about how you involve ordinary people into this process of reimagining health, I believe that everyone can be part of that process. And I believe that even in a short time, we have shown that with Powering Up.

Gabriela Jones: I'm just picturing like the clinicians and the young people having a dance off to one of the tracks. 

Guddi Singh: My challenge now is to figure out like how to keep this sustainable, because even if you have a great idea, what is not a given, sadly, in the healthcare landscape today, is that people will fund or resource things like, like we're doing. What we have done for far too long is closed off channels of communication, and what we should in fact be doing is building relationships and opening those communication channels.

Gabriela Jones: That's wonderful, Guddi. Thank you. I can't wait to hear the tracks. 

Zooming out a bit, what would you say you've learned about how improvement can support addressing health equity and then how this might lead us to think differently about what constitutes improvement and who gets involved? 

Guddi Singh: The way that we're trained, you know, whether you're a doctor or a nurse or a different kind of clinician, all of us come from quite a narrow kind of epistemology, by which I just mean a way of knowing. And so our world in terms of the way that we think our jobs need to be done is quite limited.

What QI does is that it offers us a whole other set of tools that are not ordinarily part of the clinician's toolkit. It's through doing things in QI where I've been able to be exposed to things like, how do you run a business? How do you think about things like flow? How do you think about efficiency and how do you start changing some of this stuff?

QI, in a way, makes that all available to you, and it also gives you tools to be able to measure what you're doing, figure out what your impact needs to be, and demonstrate all of this stuff. So, I found that QI was an incredibly useful Trojan horse for structuring the change that I wanted to see in the world.

It allowed me to basically serve it up to people who might otherwise be questioning what I was doing with my time, in a way that was more palatable. The numbers of times I've been told by my bosses that I should not be wasting time on families that are effectively only a problem, in quotes, because they are poor.

However, me doing a quality improvement project on how to improve flow through an A& E, which might happen to deal with deprivation was okay. QI is a big focus for health systems across the country. You know, in recent years, it has become a very important way that health systems measure their performance.

What I think QI can mean for clinicians of all stripes in the health system is opening up the idea that anyone can make change. If you look at the people who are leading the NHS today, it is still predominantly demographics that do not match the bulk of the workforce. Managing health services has been a bit elitist, tended to be older, richer, dare I say it, whiter, people who are more professionally trained within the health service.

But the people who have the best ideas are the ones who are on the ground facing problems day in day out and who have had to contend with these problems for the longest time, they feel it the most acutely, and because they think about it in their every waking minute, they probably have the best solutions.

And WHAM exists to be able to enable people who would not otherwise think of themselves as change makers. to step into that role, to step up and to become changemakers of the future. WHAM is a success because we have nurses involved, because we have speech and language therapists involved, occupational therapists involved. We have medical students involved. And again, people who come from backgrounds that are not even traditionally seen to be medical. 

Using QI when it is married with purpose, when it's married with what really matters to each of us as human beings, when it's married with morality, that's when QI is magical and powerful.

When you can start seeing ordinary people being able to have extraordinary effects on the world.

Gabriela Jones: Where do you think senior leaders should start looking if they're looking for the people who are already doing work like this to improve equity across systems? Where would they find them?

Guddi Singh: We're fighting centuries-old hierarchies and structures and systems here. So it actually requires not just health system leaders, but also medical education and health professional education, more broadly, the leaders of all of those institutions.

So universities, schools to instil in students as they are learning that you're going to look after patients. And yes, quality care is your priority. But part of producing quality care is understanding how you can help to change systems. 

If you change the focus of the leadership, which often means bringing more diverse people into leadership, and if you start having a focus on thinking about things from the ground up, as opposed to from the top down, that's where you're going to find the best ideas, the best talent.

You're looking for these marginal spaces, right? So you're looking for not the mainstream. You're looking for organisations like WHAM who bring people to them, or you're going to emergency departments; you're going to GP practices; you're going to clinics, where despite all of the difficulties that they may face in their local environment. So whether that's a complex population with complex needs, or whether it's to do with low, low resources, it's there that you're going to find ordinary people who are making the best of it and despite the limits of the limitations that they have in terms of resource constraints are coming up with incredible solutions to try and make sure that their patients’ lives are benefited.

Matthew Taylor: Well, I mean, what an inspirational interview there between Gabriela and Guddi. I mean, there's so much to take away from it. But I'm going to pick on two or three things, Penny, and ask you to kind of reflect on them. The first one is, is just the importance of relationships.

I mean, nothing could happen until the relationships got better between people. They started to talk to each other. in a different way. Is that something you recognise?

Penny: Indeed. And I think the relationships got better by design, by some deliberate leadership practices, by creating a different kind of environment. And that's where I think some of the methods of improvement combined with like really thoughtful, skilful approaches to collaboration can, can move us from talking about relationships as being important to actually starting to see a different kind of dynamic and action coming from that.

I think it was particularly striking how Guddi is enabling a kind of different range of people to come together in a different way that moves beyond some of the professional and other hierarchies that can limit our approach to deliver change in healthcare.

Matthew Taylor: And what did you think of this idea, QI by stealth, that in a sense you needed to kind of get people thinking and working in a particular way before you kind of reveal to them there was structure and process behind all this. I mean, you're a QI advocate. Do you worry about the idea that it has to be somehow kind of hidden away in order to get people involved?

Penny: I really recognise that I spent three happy years in Newham before I joined the health foundation and had a remit that was half about kind of big strategic developments and half about supporting quality improvement - together with some other things. 

I probably spent as much time using the principles of improvement in the other parts of my job, which reached a different kind of audience and enabled us to have a different sort of influence as I did when explicitly using and talking about QI.

So in some ways it can be a little bit depressing that these really powerful methods that are used very widely in other sectors do need to kind of come in by stealth into the health sector. And I think East London Foundation Trust is a really interesting example of what happens when you, you don't need to hide them in quite the same way that they become kind of legitimised by the organisation.

You don't start with the method. Start with the relationship, start with what you're trying to achieve. Keep some of those ideas and methods and principles in mind because that was what will help you start to actually reliably deliver results. And that's important to maintain the momentum and kind of start to show kind of progress and keep things going.

Matthew Taylor: And I think those themes, going to pick up on some of those in our second interview. I'm delighted to say we're a member of the board of NHS Confederation, but also many other things. So, so tell us who you spoke to.

Penny Pereira: I spoke to Marie Gabriel, chair of NHS North East London and chair of the NHS Race and Health Observatory.

You've been a source of wisdom about how to embed and lead improvement for, well, certainly as long as I've known you and much longer, I suspect. Perhaps you could just tell us a little bit about your journey with improvement and the different roles that you've held in the health sector.

Marie Gabriel: I suppose I've been doing improvement, particularly in terms of a population health, health inequalities aspect ever since I decided I wanted to be a bit of a change maker and radical, but formal improvement started when I was at East London Foundation Trust, I was chair there. And we were a good solid trust, but we wanted to be more than that.

What do we need to move from good to even past excellent, to inspiring and ever improving? And we wanted it to fit with the East London way of doing things, which is bottom up, real true co production with people who use our services and their families and carers, and something that really focused on who we were as a diverse, aspirant population, and one that is actually challenged as well in East London, so it would never be enough just to focus on improving healthcare services.

So it was key that it was in all parts, our council, governors, our board of directors, that our service users were equal part of that conversation as well.

And QI became an expectation as an enabler rather than something that you could or you couldn't do. 

As I've now moved into my role as the chair of two organisations, so one is NHS North East London, which is a system and trying to think about how do you apply quality improvement in the system, in a partnership between local authorities, a voluntary sector, the NHS and our residents. All of you use different terminology, and I'm also using it at the Race and Health Observatory. So we're working with IHI to develop an anti-racist model for quality improvement.

Penny Pereira: How would you describe a kind of anti-racist approach to improvement?

Marie Gabriel: What we're trying to do is support the NHS in delivering that. So we've got a focus on maternity. We know that black and Asian and minority ethnic women die up to four times. more in childbirth than white women. How would working different enable us to reduce that? 

And I suppose it's about a decolonisation approach to critically reflect on our history, our identity, hierarchies, and cultural nature as a Euro centric health service, and actually use that to understand inequities that such structures actually perpetuate. And then to try and find ways of working that counter engage systems of dominance and power, looking at lived experience and making that just as important as the established concepts of how we do things, which improvement is about is actually saying, what is the reality of this experience and how do we use that to improve services? 

Penny Pereira: Co-design, co-production, really core to improvement, as you say. How do you think that looks different when you're working with populations on issues like health and equity, rather than seeking to improve an individual service?

Marie Gabriel: we've just completed in north east London, what we called a big conversation where we wanted to understand and have conversations with our residents. And targeting conversations with those people that experience avoidable health inequalities to understand what they would define as success. What would be the key success measures in a system that is integrated to improve health and health outcomes. 

And so it's using that breadth to come up with, we've got five indicators of, or success measure areas, that our residents have said what's important to them. And now we're going back out to test the five areas and then to have a conversation about how do we keep this big, deep conversation going and actually residents, just the same way in which we have people who use services, become part of the delivery mechanism for improvement. So it's the same methodology. I just think it's the complexity and scale and trying to focus in on the areas that matter.

Penny Pereira: How do you kind of maintain, sustain a kind of attention and vision over that period and build, build belief when, when the benefits might take a while to come?

Marie Gabriel: It's quite interesting. So we actually started as an integrated care system with our first initial conversation to agree our ambition and to agree full flagship areas. And actually one of those really interestingly is employment, enabling our residents to get into employment. And actually when they are employed in health and care to show that is good work, enjoyable work. But the other three are health focused in a in a more direct way. So they're children, young people, mental health and long-term conditions of a focus on prevention. 

And there are mechanisms that you already have in place, such as a residence jury, because we recognise that not all our residents are citizens, not to forget that local government have an ongoing dialogue with their communities in a different way to health.

So it's actually about pulling all those conversations together. Really importantly, at a very senior level, we've got a chief officer for place and participation. So placed resident participation at the heart of our leadership team to ensure we have a really strong resident involvement, not only just in the planning and the ambition, but the delivery of what we're trying to do, and we've resourced as well, support for voluntary organisations across to have a voluntary sector collaborative in the same way in which you have acute collaboratives or mental health collaboratives for NHS organisations.

Penny Pereira: Great. I mean, you've talked about actually people having all sorts of different methods and that being part of what you need to navigate when working across the system. When do you keep the methods below the surface and when do you need to talk about it explicitly?

Marie Gabriel: It's quite interesting, actually, because quite early on in the East London Foundation Trust, as a board, we had a whole day training. Understanding as a board, the information that you get from QI. And actually QI does not need to be complicated. You don't need to understand all the technology. So I remember when I was chair, my council of governors did an improvement project.

So somebody else facilitating the discussion, we didn't have to understand all that methodology. One is not to talk about it being improvement at all. It's just about saying what matters to you and how do we make it better? And actually what's really important, I believe, is an equity between all those involved, whether you're, you know, you've come from social care, whether you're using services, whether you're a doctor, whether you're a nurse. Each of those individuals are just as important in providing not just a planning, but the delivery, the reflection, the understanding of the information you're giving on what the next stage should be.

Penny Pereira: In terms of bringing in equity as a domain of quality, what's kind of exciting you that you're seeing in the world of using improvement to address equity and health equity in particular? 

Marie Gabriel: There's two things for me. One is that you can apply improvement to anything. You know, you're trying to overcome structural racism and the impact it has on the delivery of care – improvement has a place. Using those tools to be able to focus down on what the challenge is, what matters to the communities and the people that you're working with.

And actually how you create that change together is absolutely important. Unless you start to tackle the wider determinants of health and the fact that there are differences between and within populations, and there are avoidable health inequalities. You're never going to completely improve health outcomes unless you start to think about how am I going to understand and ensure that my methodology seeks to tackle those as well.

Penny Pereira: I know the rest of the UK will be continuing to look to East London as you're on that journey. Where do you think you might be in five years’ time, particularly where that might lead us in terms of equity?

Marie Gabriel: So what I'm hoping in five years’ time is that we will have that common language and we'll have an understanding of improvement that each of our local places would have embedded an improvement approach with their residents and be working on initiatives and programmes, improvement informed or improvement, I suppose, framed.

I talked about our four flagship priorities. We are already using improvement networks within some of those to enable us to improve across multi business teams from different organisations and actually embedded into our collaboratives, be that an acute mental health or voluntary sector, because for me, Cure Quality Improvement is kind of like a movement, isn't it?

We are seeking better outcomes through a method that enables you to clearly say: “This is our ambition. This is how we're going to plan. This is how we're going to reflect and we're going to learn. And this is how we're going to continuously build on the improvements that we see.” 

And actually as an organisation, we're able to pull out the learning from that and drag it across the system. Because that scaling up bit is perhaps one of the most complicated bits I found. In elf, because it's that balance, isn't it? Between it's really working well here. What do we take from what's working really well in Redbridge and put it across to Tower Hamlets and enable them to redefine it, but still build on that learning.

So, really active learning from improvement that can help all the different parts of an integrated care system.

Matthew Taylor: Well, Penny, another fascinating interview, a couple of things I want to pick up on. The first is that this is improvement in pursuit of a really kind of ethical, powerful set of principles around equity. You know, it starts with a kind of hunger for change - and for justice, actually.

Penny Pereira: Sometimes some of those kind of profound issues facing society as well as facing our services can feel kind of out of reach. Either out of reach because of the scale of the change or maybe out of reach because of what we're allowed to work on. 

And I think there's something about how the work that Marie describes kind of opens up the possibility of actually taking practical action in relation to racism in relation to some of the injustice in the services around us.

And how you could imagine that that might just further overwhelm and add weight to people who are already incredibly stretched in healthcare, but I think from both of our interviews, I'm sensing that the opposite is true, that this is an opportunity to deeply connect with what people really care about and what's often brought them into public service.

I think that one of the themes again from both interviews is just how far improvement methods can be used everywhere, whether by stealth or explicitly, you can approach a particular agenda in a way that, as we've shown with some recent kind of health foundation analysis of the benefits of improvement.

You can approach improvement in relation to one particular area and have a whole set of side benefits in terms of staff engagement and morale in terms of kind of productivity, as well as some of the kind of explicit longer-term goals around increased equity or safety or whatever it is that you're working on.

I think there's something about the mode of working and improvement that is suited to the multiple goals that we need to meet together all at once when we're when we're leading healthcare.

Matthew Taylor: And finally, in terms of that interview, you know, Marie is such an amazing leader. And it's not surprising, I think, that in your interview, one of the issues that emerges is the role of leadership and of the board in, in driving change.

Penny Pereira: Indeed, and a form of leadership, which goes so far beyond that kind of tick box sponsorship or a distant relationship. 

One of the things we've noticed in terms of healthcare improvement over the years, and we haven't perhaps taken far enough, is that improvement has a bottom-up frontline grounded kind of ethos and focus. That doesn't mean that an awful lot of the work and activity that's needed to succeed actually happens kind of higher up within organisations and systems. And I think we need to rebalance some of our assumptions about. The level of active engagement that is needed at board level for this work to be a sustainable success.

Matthew Taylor: And when it comes to leadership, also, we have a change in the national context and it was good to see Darzi referring to some of the work of the Race and Health Observatory, for example. It did feel a little bit towards the end of the previous government that talking about health inequalities was not very fashionable, but we do have the great work around Core20PLUS5 that NHSE has been, has been taking forward, and I know that you're doing wider work at the Health Foundation around health and inequalities, Penny.

Penny Pereira: Yes. I mean, we've been diving here specifically into some of the issues around improvements role, but the Health Foundation more widely is doing a fantastic suite of work on understanding and addressing health and inequalities. So there's a whole range of data, research and programmes on our website, as you'd expect from the Health Foundation.

And if this is a topic you care about, please do check out our Health Equals campaign. That's helping raise awareness of what shapes health to influence policy and practice.

Matthew Taylor: Well, thanks so much for that interview, Penny. Uh, that's it, sadly, for this episode. 

In our next episode, we're looking at how improvement and collaboration approaches can boost system productivity. So a very different Focus do please tune in to our next episode.

Penny Pereira: Very different. But, as I think we've shown through our conversations in these podcasts, we will see connections between productivity agenda, which is sometimes held separately and the kind of equity quality improvement work that is generating such interest and energy in service. 

So that, that just leaves me to say, thank you so much to Dr Guddi Singh and Marie Gabriel. 

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