Improvement is more than an add on or ‘nice to have’

Matthew Taylor

Hello and welcome to a very special edition of Health on the Line. I'm Matthew Taylor chief executive of the NHS Confederation. And today I'm joined by Penny Pereira, who's director of the Q community of the Health Foundation, and a good friend of the Confed, Sam Allen, CEO of North East North Cumbria Integrated Care Board.

It's a special podcast because it comes a few days after the launch of our system improvement offer, an offer we're making jointly with the Q community and the Health Foundation. It's been something we've been building up to for some time. We're incredibly excited about it and this is an opportunity to talk to our collaborator Penny, but also to somebody who is widely seen as one of the kind of leading voices thinking about both improvement, but also what does improvement mean at a system level.

So let's get into the conversation. Can I just say first, welcome, Penny. Welcome, Sam. 

Penny. I'm going to start with you. Tell us a bit about the kind of history of this idea of improvement. Improvement with the capital ‘I’. 

I mean, all of us in all our work as leaders, we're always trying to do things better. Nobody deliberately tries to do things worse. So what does improve with a capital I mean and what’s its history in the NHS? 

Penny Pereira

Yeah, well, so improvement is a systematic method and set ideas that help people to achieve change in a way that gives the people who are closest to the issues that are affecting care, the kind of time, permission, skills to address those issues.

So it will help you think systematically about how you understand an issue properly, how you coastline a solution, how you then implement that iteratively. Often that's guided by kind of real time data. 

It’s a field that's been around across industries for a very long time. I guess I've been working at it personally for about 20 years.

And you know, the Health Foundation has been watching it for several decades. The history in the health service, again, has a long, proud history, but the national picture has been a little bit erratic. There's been a whole range of national organisations and initiatives. And then in, you know, steadily building experience and capability at a local level, a kind of maturing evidence base and recession structure.

The Q community that you mentioned that would be part of this partnership is an indication of the scale of capability in the work that's happening at the moment. So over 5,000 people now doing a whole wide range of work using these different improvement methods. And it's moved a long ways from being about small scale project improvement and individual clinical teams. So there's an awful lot now that's really relevant to the work of systems. 

Matthew Taylor

Thanks, Penny. Now, of course, one of the people who’s influenced us in the development this offer was Patricia Hewitt, because she talked in her Hewitt report about the idea of self-improving systems. And I guess in some ways that was an argument for a more dynamic model of change in the health service, one which saw change and improvement coming not just top-down, which has tended to be the way the NHS is organised itself, but also laterally, people learning from each other, challenging each other, learning from good practice, and also bottom-up by responding to public, patients, communities and staff.

Sam, people sometimes say or imply they're too busy for improvement. You know, we all know about the pressures on the health service, but I think - and I don't want to pre-empt you - you'd say that in a sense, improvement is the only thing that's going to get us out of this feeling that we often have day-to-day, that we're on a kind of endless hamster wheel.

Sam Allen

Yeah, absolutely, Matthew. I think that anybody who sees improvement as a nice-to-have or something that is soft and fluffy and the domain of the few and not the many is missing a massive opportunity. 

There's so much improvement happening every day. A lot we don't hear about, you know, in interactions between clinicians and patients and carers and residents. It's happening every single day. 

But the opportunity we've got is to learn from that, to spread that, to scale that. I don't know about you, but one of my biggest frustrations as a patient and as a resident as a citizen, is when you hear about something really good happening just down the road, but it's not the same experience you're having.

And so the way leaders can create cultures that enable people to not just improve, but also to share their learning, to take the time away, to think about how they bring that learning into their practice and how the many benefit and not just the few is, for me, an essential task of leadership. 

Matthew Taylor

And of course this is a view shared by NHS England, and Amanda Pritchard has often talked about her enthusiasm for improvement.

And of course we have the NHS Impact initiative from NHS England and I think, Sam, you've been involved in that. I guess the question for both of you is in a reflecting on NHS impact and the way improvement has been talked about in the health service, it's tended to be through an organisational lens rather than through a system lens.

So what do you think is different about improvement in a system context? Maybe I'll start with you, Penny.

Penny Pereira

When you're improving in any context, you're often needing to rely quite a lot on influence, so not always formal authority. But when you're trying to do that sort of work across organisational boundaries, that's particularly the case. So the additional complexity, the additional imperative to work with and through people increases with the number of different organisations that you're working with. 

There are different methods that you would bring into play. I think a lot of the iterative improvement, so understand and issue. try and test out some things quickly and then see how you can scale it; that applies at any level of the system. But when you're starting to think across large systems, you're going to want to be drawing on design methods that are suited to large systems and to ideas from social movement theory or from other methods that are coming from the improvement fields that are particularly relevant.

I think at system level, we need to be realising this is the kind of leading edge of what people are trying to do in terms of change. And so you need to be particularly open to innovating and learning as you go rather than expecting that there's going to be a kind of established evidence base.

To underpin the work that we're going to be doing together, we've been listening to system leaders, we've been looking at the evidence base, the people who are doing large scale change, and we've identified kind of 18 key considerations that are particularly distinctive when you're trying to do change across large systems. So we're really hoping that we'll have an opportunity to particularly work through those with people in this partnership.

Matthew Taylor

Give us a couple of examples, Penny.

Penny Pereira

So, for example, when it comes to thinking about creating an operating model to support improvement, there isn't really clear consensus about what's best at system level, the different responsibilities that there might be between different people in the system. When it comes to actually understanding the system, it can be quite hard to get kind of clear data that gives you a clear idea of an issue, not just from an organisational perspective, which is where a lot of our data is, but actually to help understand something across a system as a whole.

And for example, if you're trying to coordinate a large programme of care, you need to be doing things that are at the level of the overall redesign of your care pathway. So if that's the end of life care or diabetes care, and then you need to be combining that with the kind of iterative work to improve all of the services along the steps in that pathway.

And then you also need to be thinking about how you're pulling in particular innovations to underpin and support that work. So the actual process of change requires a higher level of coordination, many, many more people involved, and there's different methods that you can use to help people, help people implement change on that scale. 

Matthew Taylor

Well, there's a lot to chew on there, Sam. Let's start with the first point Penny made, which is in a sense, this question of what is the value-added proposition of the system leaders. I think that's one difference, which is that if you lead an organisation - I lead an organisation - of course, working out what you want to do and what's important is challenging, an important part of the strategy setting.

But the question of how do you add value as a leader in an organisation isn't as complex. Whereas when I look at systems, when they vary so much from yours, one of the largest, I think, right through to systems like Somerset, Gloucestershire, the systems are to have a different account of the value added that they're contributing. 

Sam Allen

Yeah, and I think each system needs to take a view on what's the right approach for them. Just on NHS Impact, I think it's a bold move from Amanda to absolutely get behind NHS Impact and I'm really pleased the opportunity to be on the National Improvement Board. And the principles of NHS Impact, you know, it's all about building improvement capability and capacity, embedding systems, developing cultures of improvement and building that shared vision and purpose are completely transferable to systems.

I think the added benefit of a system though, is we've got the real opportunity to work together and convene. And if you look at many of the wicked issues that the NHS is facing, for example, not all of the solutions are within the gift of the NHS to solve. And in fact many of them sit in communities, they sit with our partners and therefore the opportunities of systems to come together to think about how do we use our collective expertise, our assets and our resources to improve health and wellbeing for all. 

Most of people's health and wellbeing happens in their home and their neighbourhoods. It doesn't happen in emergency departments or hospitals. So if we think about an example we've looked at, for example, safe transfers of care, discharge from hospital; where we really need to start is avoiding admission. And so the opportunity to bring systems together through an improvement lens, to use the data that we've got, people's lived experience, that expertise in the system, we're far more likely to get solutions and make improvements to the real wicked issues that we're facing at a system level where quite often there is no textbook.

This is about relationships, it's about building trust, it's about looking at new ways of doing things and also testing things out. And sometimes that also means testing things that don't work and being able to do that within an environment where people feel able to take those risks. But equally where it is working, how do we scale that?

And then you mentioned our system, Matthew, and we like to call our system a ‘system of systems’. And again, one of the real privilege, when you look across the system is you see such examples of good practice. And one of the things we've done in our system is we've developed a learning and improvement community where we're convening people to be able to share practice, to do peer-to-peer learning.

But probably one of the things I'm most proud of is that we've placed the voice of the people in our communities in receipt of services. People’s lived experience is absolutely at the heart of this. 

Matthew Taylor

And Sam I think you're referring there to the to the BOOST programme. Is that right? Tell us more about Boost, because I think it's a fascinating example and particularly with the emphasis and I came and spoke at an event last year in your patch where Boost was starting to be developed.

There's an emphasis on partnership, there's emphasis on inclusion. The improvement is about everybody feeling that they've got a stake. 

Sam Allen

Well, Boost really came about because in our system of systems, all of our partners and members of the integrated care systems said: “You know what? We could probably be doing more to share our learning and learn from one another.”

And instead of a sort of a top down hierarchical approach, recognising, I think, the sort of the new power in system, which is the power of many, more distributed leadership, We set about creating a learning and improvement community. And actually I remember back in ’22, sitting outside the Confed conference in Liverpool, Matthew having a conversation with Helen Bevan about where do we start?

And we started looking at what people were doing around the world, so [Yon Copping], Sincinatti, and we said: “Actually we need to start by convening people.” So we brought people together. We had over 250 people in one room and what we did together was we said: “What are our improvement opportunities across our system?”, and working with that community we've built seven priorities for improvements and Boost - anybody can join this - www.boost.org.uk - come and join our learning and improvement community - is an online platform that aims to really bring people together. It's that opportunity for sharing innovation, sharing ideas, networking, supports the improvements. But we're also starting to use it to build improvement capability. 

And I was really pleased, Penny has been supporting us through the Health Foundation on this over the last year. We've also got an evaluation partner - quite fortunate - at Newcastle University, a lot of the academic research around learning systems has been developed there. So Toby Lowe has also been quite instrumental in helping us with this. 

But essentially it's about how do we create a movement for change, how do we bring people together to really work on our wicked issues?

And I think what we've really found through the power of communities of practice and collaboratives, actually, we are making some real inroads into some of our challenges. Discharge, for example. We've been able to make improvements on that over the last year and also reducing ambulance handover delays. But we didn't do that through the power of performance management.

We've done that by convening people, building trust, and we now have partners in our system going to visit other parts of the system, sharing practice, doing the peer-to-peer learning. So actually, Boost is really about a movement for improvement and change, Matthew. And it's completely aligned to all that NHS Impact is asking us to do. 

Penny Pereira

I wonder if I might come in there. It's such inspiring work you're doing in North East North Cumbria. Within Q we've been supporting people in all of the integrated care systems and indeed elsewhere in the UK with some of their infrastructure, some resources and tools that help people not start from scratch when they're thinking about building their improvement community. So, for example, Nottingham and Nottinghamshire ICS, we're supporting them with creating an across-system quality-improvement design collaborative.

So a similar idea and platform that allows people to be sharing all of the different work that they're doing around improvement. Supporting a number of systems; Surrey Heartlands, South West London, to develop their local improvement network. 

Not just because networks are an enjoyable, kind of a energising way to work, but because actually there's really good evidence that that's the way that you shift culture. That's a very effective way in a complex system to enable innovations to actually scale. 

Matthew Taylor

So I'd like to explore this question of the kind of underlying model of change a bit more. So what I bring to this, which I guess reflects my life of policy making and leadership, is a view that essentially all of us human beings, psychology tells us that we are driven really by three types of motivation.

1. We are driven by authority. You know, we do what we're told.
2. We are driven by belonging and values. So we're driven by a kind of sense of the kind of person we feel we should be given, the kind of tribes that we belong to. 
3. And then finally we’re driven just by some notion of what we want for ourselves. 

It doesn’t mean selfishness, but it's wanting to be the author of our own lives, wanting to fulfill our potential. 

Now, if those are the three drivers that we have, then one of the things you’d would want to do to achieve changes, you'd want all of those drivers to be pointing in the same direction so that when people come to work, what they're being told, what they feel is right and what's in their own interests, what makes their life good, would all line up.

And the reason I think that's important is because it speaks to a balanced model of change. I think when we've talked about improvement in the past, not just in the NHS or other places, we tend to think of it as a kind of top-down authority thing, something driven by a manager. And what excites me about Boost, but equally, take another example, the fantastic work that Anthony McIvor’s done in Mid Essex around stewardship.

So they've done work on reforming care pathways where they describe the clinicians and managers, the patient representatives, the third sector. They're all stewards committed to a process of change. So there's very strong emphasis on inclusion. 

So Sam that’s a part of this, isn't it, that the way in which we think about improvement has got to use the power of the collective, hasn't it?

Yeah. And I still have got the book, The Power of One, The Power of Many. So I think you're absolutely right, Matthew, people generally come to work and are doing their best to make a difference. You know, there's something that gets everybody out of bed every day to come in. There's that whole bit about self-actualisation as well.

So if you've got that sort of real growth mindset, we're all growing. It doesn't matter who you are, what position of authority you have or not. We're all growing. We're all learning every day. 

One of the things I've found so liberating actually through Boost - and you're right, you did come and talk at one of our events last year where we did convene people to share learning. They’re constantly reflecting, “What have we learned here? What are our priorities? What's our theory of change?” - was actually the real solidarity, the real sense of ‘We're in this together.’ And I think that one of the real opportunities we've got, is how do we convene and create spaces where we can build trust? But also we recognise difference. 

I think it’s one of the real benefits, but also one of the real challenges of working in systems, which is the difference; you know, people come at things from different perspectives, slightly different approaches. But one of the things I found even in a large system, is there's so much more that unites us than divides us. And if we can provide the spaces, the opportunities, the learning, the growth, and if we're sharing that with colleagues, then I think we've got that real opportunity to drive a sense of belonging.

And we have shamelessly stolen our mission here in the North East North Cumbria, which is to be the Best at Getting Better, which is that sort of ongoing striving for improvement. And we shamelessly stole that from Cincinnati Children's Hospital who gifted it to us, and they are participating in our events as well. 

So for me, we've got the opportunity through the network at the Confed to learn from the other 41 systems. But we also need to be looking beyond. We need to be looking globally at what other people are doing. So I do think providing a community - and Boost is a community, it's a membership, it's a group of people - we can create that sense of belonging and really enable people to use their passion and expertise, which everybody wants to make a difference. They all want to improve and make that difference to our residents, to our patients, the people living and working in our communities. 

Matthew Taylor

Penny, there's a lot there to take up. The first thing is Sam's point about learning from each other. I have to say that coming into the health service from the outside, one of the things that has surprised me is, is that there isn't as much systematic learning from each other as you might think.

You might think one of the great advantages of the health service is the scope that exists. And it's not a criticism of leaders; leaders are under immense pressure. These are challenging times for the health service. But how important, Penny, do you think it is for a kind of commitment to improvement that leaders give themselves the time to visit other systems, to understand in depth what other people are trying to do, what they've achieved, what they've learned?

Penny Pereira

I think it's critical. It's critical that leaders are doing that and they're kind of legitimising that process of learning, which I think culturally we feel a bit guilty about. And I think as the organisation and the sector becomes under increasing pressure, you do see people retrenching. You see that sense of belonging becoming more institutionally focused on people losing sight of a wider sense of belonging that spans the system and is focused on the community that is being served.

I think going out and visiting other places is a really important way in which that you can get a deep understanding of the totality of another system. I guess that can be difficult given the pressures that people are under. I guess part of our partnership will be to help people get a meaningful but really time-efficient insight into different systems, something that leaders can really absorb and take time and that can also be shared more widely to the people who are working within their system.

I guess I give a little bit of shout out – Sam, you're right, there's loads we can learn internationally, from Scandinavia, from the US and from elsewhere in the world. There's a lot that we can learn from elsewhere in the UK as well. So within Q we have for a long time been bringing together the national teams from the UK and Ireland and Q spans all of those territories, and we've been working with those people to really understand large scale change.

They're all on a journey to integration. They've had different forms of integration in other parts of the UK for a while and actually have a different sort of heritage around improvement and the practice of how people learn. 

In Wales, for example, a really quite sophisticated model for how they think about systematically learning at each stage of their improvement work.

And in Scotland they've really led the way in the idea of what's called quality management systems. So how you don't just have separate innovation and improvement processes or communities, but how can we actually shift the main work that we do as organisations to be aligned to reliably achieve performance and quality goals? And at the heart of that idea of a quality management system - as it's known - is a learning system.

So how do you really systematically baked in processes where you're understanding bright spots? You've got data and methods that help people learn and then go see what's working. 

And yeah, as Sam says, you equally have the culture and the space where you're learning from what's not happening. Because if we're not very good at learning from what is happening, we're pretty terrible when it comes to honestly and openly learning when things aren't going right.

Matthew Taylor

Yeah, and one of the interesting things about the Scottish model that Chris Ham talks about in the report that he's done for us on self-improving systems is that in Scotland it's really the leaders in the system who identify the areas that they want the improvement agency to focus on. So it's not defined in terms of, well, these are the things the centre says you've got to improve, but it's actually engaging leaders in a conversation about what they think most matters to them. And it seems to me that's a really interesting thing. 

I just want to go back to this point about the power of the collective, because one of the conversations I've heard a few times, Sam, as I've gone around the country is from and this has been kind of more leaders of trusts, but they've said, look, during covid, we worked in a way that had a strong emphasis on staff welfare. It was quite egalitarian, it was quite flexible because in a sense we were all driven by this emergency and what we had to do and people went the extra mile. Now we're back into a world that's slightly more normal in a sense, and we have to focus on issues like productivity and performance. But we can't go back to the ways in which we worked before covid, the kind of genie is out of the bottle: that emphasis on staff engagement, staff wellbeing. 

And so what I see and I guess this is part of Boost and other things, is a recognition by leaders that the definition of what we need to improve and have improvement has to genuinely be something which people feel that they have got a stake in. 

It can't simply be that the centre - whether it's the centre of a trust or of NHS England or a system - can say, well, this is what is important. We have to listen to what our colleagues, our staff are saying is important. 

Sam Allen

Absolutely. Matthew. I think that whilst anything can be set as a national requirement to do, improvement and what I would call sort of true improvement is a cultural change. It's a way of being, it's a way of acting. And actually it does need to be led at the local level.

Just going back to your point on competition versus sort of the collective and collaboration, one of the things I've really learned since moving into a system role has been I think the real power of the work that's undertaken in the LGA and a real peer review. And I've been really struck by the sort of solidarity and support amongst leaders of local authorities and always a willingness to help, support, wrap their arms around each other in terms of where they've got particular challenges and also successes.

It's not to say there aren’t still some of the challenges that I think we see in leadership behaviours at times of the NHS, but I think one of the downsides of the more competitive foundation trust regime - that that did serve as well in many respects, and I led a foundation trust and, and an organisation through covid as well - I'm always struck by the competition, the approaches, do people revel in people's failures? And actually the absence of more peer-to-peer learning. 

But I've seen a real shift in that over the last year. And I think part of that has been the leadership that Amanda's brought; the focus on NHS impact. But these types of cultures do take time to turn around, so we mustn't ever look up and wait for anybody nationally to say: “This is what you need to do.”

The opportunity we've got in systems is to lead this change, this cultural change, and provide spaces where we enable leaders to come together to have these conversations quite deeply and to tackle some of the more legacy behaviours of the past. 

So I do think the collective way of working - it can be really liberating and what I have found is that a lot of our colleagues working in clinical services are desperate for this. They have seen the opportunities around pathways, integration, they don't want to be limited by organisational boundaries. They want to be set free to do the best that they know for patients, and also as do our neighbourhoods and communities. So I think as leaders, we have to do better to create the environments to enable that to flourish. 

And I think if we don't, we will run the risk of kind of slipping back into our organisational silos, a real sort of performance management approach to how we do things. And, you know, that's just not going to deliver the change we need to happen. 

Matthew Taylor

I mean, I could talk to the two of you all day, but we're drawing to a close. And I want to ask you both one final question; the same question, and I'll start with you, Penny, which is: I sometimes feel the one bit of this conversation about improvement, that's still a bit underplayed, is that a third dimension of the kind of bottom-up drivers, the responsiveness to the public.

And sometimes that's just responding to the public's preferences as consumers. You know, there's nothing wrong with that. Nothing wrong with the idea that the public should have services delivered in ways which are convenient for them. 

But it's also more deeply about how we engage patients / public carers as partners. We've talked in the Confed that said in the contract that one of the things that really has to change in the health service is we need what we've defined as a new social contract with patients.

We've argued that we need to both offer patients more but also to expect more from them as partners in a system that empowers and engages them. 

So, Penny, two things; do you kind of share my view that we need to develop a bit more strongly in this account of improvement an understanding of the role of the public and patients?

And secondly, are there examples in your work that show the power that that can have? 

Penny Pereira

I mean, I would say that the concepts of co-production and co-design are absolutely inherent to improvement. Just as Sam says, the challenge with the world of improvement is that we see absolutely incredible work, but we don't yet see it scaled and mainstreamed. 

I think that in terms of particular examples, there are methods that are about actually embedding the concept of design with patients.

So an idea called experience based co-design, for example. So how do you work with people not just to map pathways and improve them in some technocratic way, but to really understand patient and population needs and then to think about the experience touch-points along that particular pathway and design around that. 

In terms of what we've been doing with Q, so when we set up here, we designed it with 230 people that included a number of patient leaders, community leaders who were involved in improvement.

We have people from voluntary and community sector and from kind of patient groups who are kind of equal members of the Q community and are developing their skills and bringing their particular perspective as part of integrated teams leading improvement work, and I think we're only going to see that grow. 

When we're talking about systems, it's really important that we are not just getting to the point of involving individual groups or patients who have a particular experience or need around care. We need to be looking at whole populations and increasingly we really need to be thinking about equity. Of all of the domains of quality that we tend to think about, equity is something that has only really got the attention that it deserves since covid. 

And we're now seeing an awful lot of attention on not just involving communities overall in terms of thinking about how we design care, but much more proactively and purposefully understanding the inequities that exist and thinking deeply about how you design services in order to address that and counter those inequities. 

Matthew Taylor

So Sam, I'm really interested in your perspective on this in that you know, very often what people say about the NHS is that the care they get finally when they get through the issues, the kind of access is great, but that the systems don't seem to be designed around people's lives and how people want to be treated. 

And putting it converse in the positive sense, when I have looked at good practice so often the North Star has been improving patient outcomes and experiences. But to do that, we've really got to think of patients as partners, don't we? 

Sam Allen

Yeah, we do. And I think the public have absolutely every right to be challenging. And, you know, again, my starting point, in my mind, what I always think about this as a patient myself; you want the best. 

You want to have a service that fits around your life. But equally as a leader in the service I'm aware of, you know, of the constraints in the service, you know, Matthew, and some of the frustrations, you know, it would be great, wouldn't it, to have multi-year settlements, to be able to plan for the long term and to be able to have, you know, the capital resources we needed to really, really get the benefits of, you know, digital.

But I was thinking the other day when I opened my NHS app up and I was thinking actually if I was a real partner and I absolutely agree with you, by the way, we should have a new social contract with the public on the NHS. You know, the NHS is owned by everyone and good health isn't the sole domain of the NHS. Actually it’s in us as individuals.

But you know, why is it in our NHS app. you know, we should be recording our own blood pressure. We could be doing so many more things and using different tools and innovations in different ways. And I don't think I've met a single person who doesn't want to be more in control of their own health and care, to be able to have access to resources or people in their communities and be connected to people in the communities who can help them?

And, you know, we've got some amazing providers; whether it's social prescribing or support for people to become more activated in their own health and care. And so often when we think about the NHS, we're thinking about hospitals and ambulances when actually the vast majority of this is in our communities. So we need a conversation with the public.

We need for people to recognise that this is a service in public ownership being funded by the taxpayer. And we need to demonstrate real accountability there. 

Just finally, you know, every year I get something through my letterbox which tells me how my council tax is being spent, and whether or not, you know, we've got a social care levy on there, we're putting more into policing.

Let's think about doing the same for health. If we look at the cost of drugs at the moment, I mean the cost of prescribing is going up exponentially. You know, this will not be unaffordable. Yet are we confident that everybody is aware of that and knows and understands the importance of reducing waste and getting efficiency? 

You know, this isn't for the NHS to solve. This is for the nation to solve, and we need to do that together. 

Matthew Taylor

Yes. And I think that one of the great opportunities of system and place working with our local government colleagues, is that local government has had even less money than the NHS has had and that has forced local government on the one hand to have some pretty difficult conversations with the public about what priorities they should focus on and also in some cases to say to the public, we simply can't provide these services unless we provide them with you, unless you help us to provide them. That's for example, often the case with libraries, which have moved into kind of community ownership and leadership in order to maintain the service.

And I think it's also true that local government has really had to kind of look at how it uses its diminishing budgets in the most effective way. And I've heard local government colleagues say that they find it surprising that the health service doesn't have a particularly clear account of the relationship between investment and outcomes, and also that we have an account of risk which is very much focused on kind of clinical risk rather than the risk, for example, of thousands of young people who aren't getting the mental health care that they need.

So I think working with local government gives us an opportunity to have a much more open conversation with the public about our priorities and about where risks lie. But maybe that's for another conversation. We're hoping in the new year to launch a new strand of podcasts focusing on improvement. But this has been a fantastic start to that conversation.

Thank you, Sam. Thank you, Penny. 

And if you'd like to learn more about Boost in North East North Cumbria, do as Sam suggested earlier, visit boost.org.uk. And for details on Confed, Health Foundation and Q Partnership and how to sign up for more information, visit our leadership and improvement pages at nhsconfed.org. You'll find lots of useful improvement materials and resources also at q.health.org.uk