How the NHS can better engage with citizens and communities

Matthew Taylor

Hello and welcome to Health On The Line. We're starting this year with a look ahead to the future and an important debate on how to meet the needs of future generations. It's really easy, isn't it, to be consumed by immediate challenges and pressures. But the job of leaders, of you health leaders, I guess of all leaders, is to align those urgent tasks that we have to undertake with a vision, a longer-term vision.

The debate on the health service of the future, what people can and should expect of it in years to come, is one that needs to involve everyone, people in the health service, public, stakeholders. But to get this right, to engage meaningfully, we're going to have to develop the relationship between the health sector, citizens, and communities. I've written and spoken in the past about the need for a newer, more ambitious national social contract with the public; a way of resetting the relationship between the public and our health, between the centre and the NHS, between all organisations involved in health and care. 

And a lot of this is about how we can work together to meet the needs of future generations. Well, that argument seems to have resonated with many, and then included the head of national voices, Jacob Lant, who in response to a blog I wrote about this idea of new social contract wrote an excellent piece on how to create an active relationship between the NHS and patients. One in which, to use his words: ‘the NHS continually engages with communities to identify what is getting right, asking people for their suggestions for improvement and then working with them to implement these together’. If you haven't read Jacob's blog, then do spare two minutes to have a look. You'll find the link in our show notes. 

But these issues are a question of how we meet the needs of future generations, how we engage people. Our interest in that was why we invited Jacob to lead a conversation about this at our recent integrated care system ICS Network Conference last year. 

And that discussion is the focus for today's episode of Health On The Line. Alongside Jacob, who as I've said, is chief executive of National Voices, the leading coalition of health and social care charities in England. We're glad to hear four perspectives on changing the relationship between citizens and communities and the health service. 

You'll also get the take of these thinkers and speakers on whether and how progress is being made and what integrated care systems can do now to better engage with and prepare for the challenge meeting the needs of future generations. So I invite you to settle back into the conversation and if you're so minded to share your views in the comments or on socials using the hashtag #healthontheline

Jacob Lant

I've got a great panel with me to engage in this conversation today. So we've got Oliver Coppard, who's the mayor of South Yorkshire. We've got Haris Sultan who's a young NED for West Yorkshire ICB. Leonora Volpe, who's from South East London ICB. And Marcia McAdam, who's a peer consultant, but also works as vice-chair for the Mental Health Network for NHS Confed. We're going to go from opening remarks from each of the speakers, and then we'll just open up into a conversation about this topic of the changing relationship between the NHS and communities. 

Just to set the scene a little bit, I think it's fair to say that we all know that all the kind of the quantitative and qualitative data out there says that communities and people are not getting the experience they want from the NHS at the moment, all of the indicators are going in the wrong direction. At the same time we know the workforce and services and health and social care are working harder than ever. We see that in the productivity stats. We see that on the faces of our colleagues every single day about how hard people are working. 

So you've got these two dual problems that we're working harder than ever and yet people are less satisfied with what we're delivering. And it can get a bit tense. It can get a bit frustrating for people. And that's not the right place to be in. We should be aiming for a more constructive conversation between services and people. This is a team sport, we're all in it together to try and make sure that the health service is as good as it can be. 

So we're going to pick up a few themes of that kind of challenge and how the relationship is changing. And to start is off with some opening remarks I'm going to go to Oliver first. So Oliver over to you. 

Oliver Coppard

Thank you very much and thank you for the introduction. I don't think I've ever been described as a wonderful finale before so I was grateful for that. So I'm the mayor of South Yorkshire and for those of you that don't know South Yorkshire, South Yorkshire is Barnsley, Rotherham, Doncaster and the core city of Sheffield, 1.4 million people. I have been mayor for 18 months and I am the only metro mayor in the country to have also become the chair of the integrated care partnership.

The reason I took on that challenge was because when I got elected, I said very clearly in my manifesto, in my campaign, and then when I was elected, that I wanted to turn around the fortunes of South Yorkshire. And I particularly said that I wanted to make South Yorkshire the healthiest region in the country. Now, often when I speak to audiences and I make that claim, the people in the audience won't necessarily know how big or bold an ambition that is. I feel like in this room, you will absolutely know how big an ambition that is for us.

I am absolutely clear in my own mind though, that I'm unlikely to achieve that myself. That is an ambition for the long term, it has to be. It has to be a 20, 25 year vision about how we turn that tanker around. And I'm absolutely fine with that. That is absolutely okay.

But we have to turn that tanker around, because the health inequalities in South Yorkshire are stark. We are a post-industrial community. We are a community with all too many health challenges. The healthy life expectancy gap from richest to poorest is 20 years. The life expectancy gap from richest to poorest is eight years. And that's simply not OK. One of the things that I think I have been most surprised by getting into this world is how normalised we've made those statistics.

We normalise the fact that somebody who grows up in a poor part of Doncaster is likely to get too sick to work in the mid-50s versus somebody in a rich part of Sheffield who's likely to be able to work right through to their 70s. It's not OK, and yet somehow we've made it OK. And so I'm determined to turn that around. But I can only do that through working with colleagues in the ICP, ICB, ICS, etc.

I can only do that through those levers in the first instance. But what I think is interesting about that is that arguably now, because of my role as a directly elected politician taking charge as chair of the ICP, we are arguably the most connected democratically, health system in the country. And I think it's a really interesting dynamic that we're creating in South Yorkshire. Because what that allows me to do then, is join up services and systems and approaches right across the whole of the region. 

We've quite clearly made a specific set of objectives in our strategic approach around health inequalities. That was driven, I hope, largely by the work that we've been doing at the MCA. We've brought in people to help us, on our what we call our health equity advisory panel. Sadly, it's therefore HEAP. That was an unfortunate acronym that we didn't think of first. But the HEAP is a really important piece of work which is looking at health inequalities more broadly in the social determinants of health and that will report back to me as mayor but also as chair of the ICP and then allow me to take a broader view of how we engage with our communities to change the systems as they impact on those communities. 

Jacob Lant

Thank you very much. You seem very eager to take on a lot. That's a good start. Haris, would you like to give us some opening remarks from West Yorkshire? 

Haris Sultan

Hello. We've got a lot of Yorkshire representation on this panel. As it should be.

I am on the next director for citizens and future generations on West Yorkshire integrated care board. Which means I was told when I applied for the job, Haris you can do whatever the hell you want and that was my favourite job remit I've ever got. So that has involved looking at future generations, looking at climate change, looking at future workforce, looking at prevention. All things that as a, well, 19 year old at the time when I applied for this non-exec role.

I was like, the NHS isn't really focusing on this. And to me, I started off, I was a sixth form student, and I was looking at the NHS, I was like, I want to get involved in mental health, because my sister went through some stuff with mental health, and I was like, I want to help her and see how I can help it from the other side. So I got involved like that, and the more I saw, the more I was like, I really wish I had a magic wand to change, and this opportunity came up to sit on West Yorkshire Integrated Care Board. And...

…I still don't know, somehow I got it. So my favourite thing is visiting people because I'm a really strong believer that...

…I can't do my job without talking to people. And the example that I use about involving communities all the time is I was talking to a chief nurse a few months ago and there was this lovely new hospital built and down the road is one of the most deprived areas in the region. And they went down and it's about 400 metres away from the main entrance, this new centre. And they're like, what do you think of this new hospital? And everyone's like, oh, yeah, it's great. Look, it's like a massive sky scraper, like, oh, do you want to work there? And the residents of that area said, no, you don't want people like us working in this hospital.

And to me, as someone that knows people in that community, I was like, why? Because they're like, oh, you want fancy people from this area and this area who have all these degrees, you don't want someone like me. So when I go to work, and I only work three days a month, so it's not that much, but I was in a session earlier and young people were talking about climate anxiety. And...

…that's one thing for young people, but does the NHS really focus on climate change? I'd say not really. We do the odd bit, but not as much as we can. And the reason I get up and do my job is, a) I want when I have kids in a while and when hopefully I have grandkids, that I can bring them into world where I'm sure they'll have healthy healthcare and I'll be really happy to bring them up. 

Jacob Lant

Thank you, Haris. I know you said it's a personal commitment that's kind of led you in a personal interest that led you into doing this, but thank you, because not enough opportunities are given for young people to get involved, I think, in some of the kind of more complex government-type conversations, and what you bring is really important. 

I'm going to move on to Marsha now, who's also someone who comes from the peer experience we were talking beforehand, whatever kind of label you give it, but Marsha comes with a lot of personal kind of experience and passion. So Marsha, do you want to give us your opening remarks?

Marcia McAdam

So, I feel like I’m Cinderella, because there's quite a lot that gets me here. I access social care, domiciliary care, because I've got both physical and mental health needs. Everything that I do is voluntary, but...

I literally do feel like I'm Cinderella. I say that my carers sprinkle magic dust on me and then I can do, I can use my brain like this. I was involved in GM devolution, Patient Leading the Way, with someone called Warren Hepalette. I was co-chair with him on a Greater Manchester Personality Disorder Strategy in 2018. And then from there, I've gone on to lead some work nationally around borderline personality disorder and stigma. I have used my voice since 2013. Originally it was quite tokenistic. Up until the last two or three years it still was, but now it's really good in that. The way that things are changing and there's different levels of co-production and co-delivery in that.

It's not easy for you to do, I've got to admit that. Because what is co-production? Whatever you do, if you like start something and then bring someone in a few weeks afterwards, it'd be like, that wasn't co-produced, everything like that. So you really are damned if you do and damned if you don't. I was lucky enough a few years ago to shadow Andy Burnham. I have been on the Mental Health Network board as a service user rep for one or two years and I've become vice chair at the beginning of last September and I get to do some amazing things. I get to go on road trips with Victoria to different services and have such an amazing time. I'm 48, it's only in the last four or five years that I have purpose and I'm actually proud of myself. Those statistics that you were mentioning, I am those statistics. I am that person. So I think…

…it takes a lot to sort of, you know, I am living this type of thing. But I do have purpose. Like I say, there's different levels of co-production in that. Sometimes at the exec level, you will want to do co-production and you'll be like, right, let's do this. But it gets lost in the middle. And then sort of service users may get paid £12.50 per hour and stuff like that.

Whereas a clinician or that's on however much and then you know so there needs to be a bit of parity and payment in that. I applied for a Churchill Fellowship and I was successful. I've just got back from Australia. I'm going to America in May. I am living my life like I never ever thought possible.

But as I tell my story in that, it's about early intervention and prevention. Imagine if I got that therapy that saved me from myself in my early 20s or my 30s. It would have meant that I wouldn't have these long term. I cost the government on benefits and care.

But imagine if instead of taking the overdoses all the time and the harm that was done, and eventually I was put in an induced coma because I developed pneumonia and almost died. And it was only then that I got that therapy in 2010. So remember I said I'm proud of myself and I finally have purpose? Imagine if I had that support years and years ago. Imagine how different my life trajectory would have been.

We need to be able to sit round tables and hear some of these things and that you may have to think slightly differently about how you work or that. But remember, you are giving the person some purpose. Sean Duggan is a mentor to me and everything like that. I have some really amazing things - I've gone to the Mental Health Network Christmas dinner next week and then I'm going to the Anna Freud Christmas lunch. I never ever had anything like that and now I finally do. And it's because people like you, Chloe, you believe in me and stuff like that and I think that is what you could bring going forward. 

Jacob Lant

Marsha, thank you so much for sharing. I'll take that. The conversation about shifting power, but actually how when we do that it can give people purpose and it can actually be something quite magical. I talked at the beginning about this being a team sport that's precisely the point I'm trying to get at. To close our opening remarks, I'm going to go to Leonora. 

Leonora Volpe

Thanks. So my name is Leah. I come from Southeast London Integrated Care System and I lead Southeast London's anchors programme, bringing together anchor institutions to make more meaningful use of their resources and their power to make a difference for communities.

But the way that we do that is by starting with building community power. And my programme that I work on was spun out of the South London Listens programme, which is a mental health partnership between three mental health trusts across south east and south west London, two integrated care systems and 12 councils across South London. And in partnership with Citizens UK, we've taken a community organising approach to preventing a mental health crisis.

And that was born out of the pandemic as a response to the widening inequalities that we saw in COVID-19. And it started with listening. So in community organising, you start by bringing people together, but then you listen and you listen because you want to act, not just for the sake of listening in and of itself. And from that listening to 6,000 people in 2020, four priorities were generated and developed and agreed between communities and institutional leaders in parity with one another.

And those priorities were focused around preventing mental ill health and moving investment upstream, out of services and into the communities, in recognition of the significance of community power, agency and connection as a driver of good mental health. And one of the priorities in the programme was working wages, so looking at how poverty can impact on mental health, and how good, meaningful work and a living wage can reduce the impact of inequality on people's health. And from that, the Anchor System Programme was created and commissioned by South East London ICS, and that's the programme that I lead. Taking a similar model, so working with community organisations to listen, come together, and then co-design solutions to the pressures on people's health and wellbeing.

And so over this past summer, we listened to 4,000 people again across south London. And it was communities that defined the question that they wanted to ask of themselves to feed back to us as system leaders on what they wanted us to do about the pressures on their health and wellbeing. 

And that in itself, I think shifted the balance of power from not what we wanted to know from communities so that we could then think about what we were then prepared to do as a result of those insights that we had generated that we could then publish in a report on our website and tick an engagement box and say we've listened, but rather that communities came to us and said we want you to work with us on the things that we think are affecting our health and wellbeing. And those things were work, wages and cost of living, so low pay and poverty is pervasive across south east London communities. 

Social isolation, mental health, waiting times and access and housing. Taking the example of housing, we had a debate about that because as an ICS, what role do we really have to play in tackling the housing crisis? And if you're in London, you'll know that rents have gone up by over 20 per cent since the pandemic, homelessness has soared. So this is a real health crisis in our communities. But we in the NHS at first sat back and said, well, that's not for us to deal with.

And we can't step on the toes of our local authority leaders because actually it's for them to solve. And communities said to us, well, housing is the health issue for us. And so as the health body is with the system conveners in south east London that have the power to bring people together and talk about housing, we need you to act.

And so the way that we worked with communities was we developed a series of pledges. And then at a community assembly two weeks ago in south east London, we then had our system leaders, so our chair and chief executive of the ICB, as well as the chief execs of the mental health trusts in south east London, got up on stage at a community hosted event and made those pledges to act on the drivers of health inequalities in South East London. Alongside that, we've got the anchor alliance, which is a network of 12 anchor institutions in south east London. So all five trusts, six councils and two universities coming together, really for the first time in our system, to talk about what influence we have on local health and wellbeing through our economic drivers and our assets. 

But not thinking about these things just as money and buildings and products that you buy or sell as a group of institutions, but actually how they're the sort of currency that we have to make a real difference upstream of the four walls of the hospital.

So I've got, I suppose, just three sort of final reflections to sum up in terms of how we as ICSs have an opportunity to move the needle on some of these really ingrained generational challenges that people are experiencing. I think redefining that relationship with communities and being willing to really shift power. And when I say shifting power, it's not just giving away our power, but recognising that communities have power and they've got ideas and they've got strengths.

That this isn't just about us going out and working with communities, but actually recognising ourselves as lucky enough that communities want to work with us to make things better. Because we don't have all the answers, and communities don't have all the answers either, but they have a lot of ideas, and so being willing to kind of work in partnership with them shifts the conversation in ways that has allowed us in south east London to make some progress. 

Secondly, I think being creative about our role as ICSs and trying to break down those silos. So not taking housing as an issue that people tell us is affecting their health and saying, sorry, there's nothing we can do about that. But using our convening power as a system to think creatively about what we might be able to do, both as healthcare providers but also as system leaders, to create more dialogue between us and local government, creating more equal partnerships with communities in the voluntary sector and thinking about what we can do with the data and the evidence that we already have.

And then finally, looking beyond the four walls of the hospitals. The work that we do on the anchors programme and on South London Listens is concerned with the building blocks of health, not with health services. It's an anti-poverty programme, it's an anti-discrimination programme. It asks us to think and contend with the disadvantage created by discrimination and inequality and really tackle that head on and have the courage to address it and acknowledge it.

And that necessitates a cultural shift and a willingness to invest and get out of our comfort zone and work in slightly different ways. It's been quite transformational for us, but it's a huge, huge work in progress. Some of the challenges around hierarchies of evidence, short-term funding cycles, challenges around workforce pressures and operational pressures distracting us all the time. We always have to remind ourselves to bring our focus back to communities. And we do that by making sure that our engagement with them is kind of consistent rather than a one-off. 

And then finally, I suppose, just to quote an ethos of Citizens UK, the community organising charity that we work with, they say that they organise because if you're not at the table, you're probably on the menu. So we have committed to making sure that communities are at the table and very much not on the menu. 

Jacob Lant

Thank you very much.

The first question I want to pick up on, as you mentioned, Leonora, in those words, that engaging with communities can feel quite transformational for services and the people in charge. And certainly, I know I've experienced that in positions of power. You feel like it is a much more transformational experience. But from the community perspective, actually, how do we know that it's feeling transformational for them? How do we know we're getting it right and it's making a meaningful difference? And I might start with Leonora and then go to the rest of the panel. So how do you know you're doing it well from the community perspective? 

Leonora Volpe

So in our programmes, we turn regularly to the pledges that we've made and the commitments that we've made. And we work with communities to kind of co-design how we deliver on those pledges. And then we have a habit of evaluation. So at the end of every event and every meeting, we check in with communities and they check in with us on how well things are working, what the impact of any given initiative has been.

One of the projects that came from South London Listens was an idea from a community leader in the initial listening campaign of creating Be Well hubs. And a Be Well hub is a community organisation, whether it be a school or a mosque, or a voluntary sector organisation, and they receive training funded by the NHS South London Listens organisations to provide community mental health support to each other. And so tackling stigma, reducing isolation and addressing the causes of mental ill health within communities. We've had an evaluation done and it has shown a kind of impact in terms of the level of connection that people feel with each other and the impact of the institutions that they engage with on their mental health. I think knowing whether something is working or not requires you to go in with an open mind that the idea that you might have come up with as a system as a result of the data that you've looked at might not be the right one.

But I think if you've worked with communities to create and deliver the ideas and the solutions, then you have a kind of fighting chance that it might be the thing that makes a difference. 

Jacob Lant

I think that's a really useful idea, that idea that kind of, I've got to change my question I'm asking, and also the continual nature of it. Haris, you want to come in? 

Haris Sultan

So in West Yorkshire, we have some formal governance bits. So we've got West Yorkshire Voice, which I'm one of the supporting non-execs for that. That's the way as an integrated care board, they hold us to account to make sure we do. We also have our West Yorkshire Youth Collective, which is a group of young people from across West Yorkshire who come together and be like, hey, you're not doing right for young people. I'm a strong believer that these are really formal groups and they're not for everyone. And there's, in thinking outside the box, and I think a way we can check is if the communities have the ideas, the ideas are probably bound to work.

So, for example, for young people, there's a young person in Bradford who set up a barber shop where young people can come and talk about their mental health on the chair. For young people as well, school nurses, I know they've been really cut back, but they're in schools with young people. And that's one way we can shift that relationship from, so in the hospital and in GP practice, more into the community. 

For more middle-aged people, so to say, we can have... [Who's he talking about? LAUGHTER]… older young people. [LAUGHTER] For those of you who haven't read the Director of Public Health Report for your area, I really commend you to do so because I read ours for Kirklees and they had great ideas of someone said all they want to do is go into their local community centre, which has since closed, and talk to someone. And in that community centre there was a nurse, there was a mental health support there. And it was the way of putting it in the community. 

Also, there was another place, I think it was a supermarket, who nominated one person to be their health and wellbeing champion. And that was a way of connecting the NHS into the work sector and for older people. Age UK runs something where young people can go along and talk to old people. 

And I was speaking to a paramedic a few days ago. And they're like, this week they've seen the same person five times and they didn't actually need to be seen by a paramedic. It was just because they were lonely and needed someone to talk to. And things like Age UK's, I think it's called, Befriending Scheme, is a way for young people to go into them. It helps the young people and it also helps the older people to actually talk to someone and shifts that dialogue from really in the hospital to more in the community. 

Jacob Llant

So a vote therefore...You know it's successful if you're doing things that are not on your turf. It's on the person you're trying to work with's turf.

Marsha, I'm going to come to you next and then Oliver. I'd like to know how particularly, how you know it's working in Sheffield given that you know you're a democratically accountable as well. So Marsha, do you have a view on how it feels from your perspective? 

Marsha McAdam

So it was someone from the Crisis team that encouraged me to use my voice. She saw a twinkle in my eye and encouraged me and I always say to people if you know someone that is like a service user, encourage them to use their voice.

Shadow. Get them to shadow you or that. Do things slightly differently because you'll get just as much as they will at shadowing. You'll find out things that you never would have picked up in a meeting or in a document or that. Recently the Mental Health Network launched A Mentally Healthier Nation report and I was one of the speakers and there was two young people there.

And Victor Adebowale, who was chairing the session, he was like, you are the voices of the future. You know, let us know what, you know. So then at the end, after they'd presented one of, it was a chief exec in the audience, went, you just need to go and you just need to use placards and that to use your voice. And the young guy, Michael, went.

But we're already doing that on digitally wise, but you're not there, you're not there. So straight afterwards, I went up to Sean Duggan.

And Victor and I went, we've got an NHS Confed, Confed Expo, we've got a Mental Health Network conference, we've got an ICS conference, why can't we have a children and young people's conference and actually let the young people from the organisations lead on it and you come and you hear it firsthand. I know it's going to be slightly, but we could do that through the children and young people's mental health coalition, your organisation and that.

We could actually really do something slightly differently but we need to win the lottery first. 

Jacob Lant

Okay so well it's a good point about resourcing to fund this stuff, this stuff doesn't, engagement doesn't come for free. 

Marsha McAdam

And that's what leaders don't realise they want it to happen, but they don't realise that, there's no budgets for it at all. 

Jacob Lant

Okay, that's a perfect segue onto a leader here who might have some budgets at all. 

Oliver Coppard

Absolutely. Look, the all too simplistic answer for somebody like me is that it's called an election, at which point I will have a verdict delivered to me. But I don't think we should lose sight of that because like I said in my opening remarks, South Yorkshire I think now has an element of democratic control directly over the direction of health services that maybe is unique to South Yorkshire, so I think that is an interesting dynamic 

But I want to go back to something Leah said because actually taking that community organising approach and you almost apologised on the housing issue for the ICS getting involved in housing. And actually I would, good, I'm glad you shake your head because good, because I think that's absolutely right because housing absolutely is a health issue. And I guess the real answer to the question is, you know, it's working when you're in a place where the energy is. 

So I'm, my background is campaigning and to a certain extent, community organising. So the ideas of Sol Olinsky and Jane McAlevey and people like that. And they would say to you, go where the energy is. It's a kind of quite simple organising rule. If you go where the energy is, that's how you know you're going to a place where you can not just access that power but multiply that power. 

And I think the important things that you were saying there, equally Haris, were leading to the conclusion that I think is also a community organising principle, which is energy is not finite, right? Power is not finite.

And actually, through taking that community organising approach, going where the energy is, and applying your own organisational resources to it, focusing in on it, and then allowing a community to come together around the things they want to talk about, you multiply that power in a way that otherwise you just don't have the opportunity to do. And that's how you know you're succeeding, because you have the opportunity to multiply that power.

I think that's what we see in the best examples of community organising and different approaches to politics and political engagement. 

Jacob Lant

It's a really interesting flip because obviously from a community engagement side, I often say well go try the path of least resistance on an issue to try and engage in the system. So where do they want our help in designing things? But it's a really like where is the... 

Oliver Coppard

I would say maybe we do things slightly differently in South Yorkshire. I'd like to think I try and do things differently as the mayor of South Yorkshire. I want to go into the angry room.

I want to go to the place where people are most frustrated, most angry, most concerned, because that's the place where the energy is going to take you forward in a way that maybe you might not expect, maybe you might not be able to control, but actually is most likely to lead to the outcomes that people in your community want to see. 

And that is scary for a politician, it's scary for any leader, but I think actually putting yourself in that space is the way in which you actually engage with and listen to and learn from your community. 

Jacob Lant

Strong vote for some bravery there in the conversations we're willing to have. So just go to the audience, see if we've got questions from the audience for our panel. Hand up right down the front here. Thanks.

Audience question

One of the things that NHS leaders are sometimes concerned about when they're getting different people involved, especially politicians, so looking at you Oliver, is that they're going to make their life difficult and kind of stop them doing what they want to do. But of course that's the whole point, you might stop them doing something stupid. So I wonder whether you've got any examples across you of stupid things you've stopped NHS organisations doing?

Jacob Lant

Great question, not at all loaded. Haris, you bravely put your hand up there. So, do you want to come in? 

Haris Sultan

So, this takes me back to about five years ago. I was 16 years old and Leeds Community Healthcare Trust was creating a mental health unit for West Yorkshire. And they were going to call it the Mental Health Unit for West Yorkshire, which I thought was really boring for a name. So, they actually involved young people and people with lived experience. And they named it Red Kite View. The next stage of this was designing the building.

Instead of just building a concrete block in the old-style mental health hospital, they involved young people in every step. I helped select the decor, I helped select the type of beds and the furniture. And the final step, which for me was the full cycle of co-production for every interview panel for someone band five and above, a young person sat on that panel. And the most important role in my books that a young person sat on was the receptionist, because that is the first person you see when you're going into this place.

And a young person sat on every panel, and it's getting that full cycle of co-production. I think that's something the NHS sometimes thinks, oh, we've got a load of data, we need to ask someone, let's just ask them straight away. It's involving them throughout that process, because sitting on a board now and being on the other side of it, one thing I always make sure is whatever thing we ask, we always tell them the outcome. 

Jacob Lant

Thank you, Haris. Oliver and then I'll come to Marsha. 

Oliver Coppard

Okay, I've got colleagues from South Yorkshire in the room, so I kind of feel like there are no stupid things that have ever come out of South Yorkshire's NHS, whatsoever. No, genuinely, I've been doing this role 18 months. There's nothing specifically that I would point to that we sort of stopped that otherwise might have happened. I'm really grateful actually for the way in which colleagues from the NHS are engaging with me, both as mayor and chair of the ICP. 

It's scary for politicians to engage with the full complexity of our communities and the full messiness of our communities, even in a place like South Yorkshire, 1.4 million people, relatively homogenous, but at the same time full of complexity, diversity, and to a certain extent the messiness that we see is where the energy comes from. But for a politician that can often be scary and I think that brings me back to the point that you were making about bravery. Now bravery can be stupidity if you're not careful and you simply run at those problems with no sort of plan or opportunity to try and bring order to that chaos, but if you can engage with the community in the full diversity of their richness and you can absolutely come at that with some authenticity and integrity and openness to being wrong, It gives you the opportunity to move forward with your community rather than doing things to your community. 

I don't say that because I think that's easy but I do think that is the right way forward and I think we have to engage with that idea if we're going to do things in a different way. 

Jacob Lant

Thank you and Marsha I think you're going to end up with the last word here on this so if you want to maybe reflect on that complexity point but also, if you've ever stopped the NHS making a maybe let's say a boring decision rather than a stupid decision? 

Marsha McAdam

Just before I became vice chair, I said to the board, I want us to use the opportunity to look at what co-production can be and what patient leaders, patient directors, everything, peer support workers, whatever it is, because it depends where you are, what you're called and that, what that could properly look like, and getting people like myself with reasonable adjustments, that are able to contribute and that, are on benefits and that. Imagine if we got a proper infrastructure in place for someone that has mental ill-health and who's been in the benefits for many, many years like I have, but you support them with that scaffolding for about a year and they still get the benefits in that, but they start integrating so there'll be that security because it's a whole different avenue with what the government are trying to do at the minute about getting everyone to say I'm just really straight away I think oh my god if I get pushed back to work in that it's then going to set me way back I would love us to do it but we need to do it responsibly and do no harm. 

Jacob Lant

Thank you Marcia a brilliant point to end on actually reducing some of the burdens to engagement that you know how we support and put that infrastructure, that scaffolding, I think is the word that you used in place. 

Thank you to our panel for engaging so well in this conversation. So I'm just trying to sum up very quickly, but I think definitely I've heard about engaging the complexity, go where the angry people are. That's where some of the energy is and where the issues, the burning issues we need to engage with. Make sure that engagement is continuous. Don't stop, it's not a one and done thing. Engage on their turf and be prepared to be surprised by the questions and the topics that people want to talk about, and go where they want to go.