Prof Aruna Garcea: Navigating the future of primary care in England

Matthew Taylor 

Hello and welcome to Health on the Line. Today we'll be tackling the topic of primary care and exploring what lies ahead for the sector and for the wider system in England, a system that depends so much on primary care. And so I'm delighted to be joined by Professor Aruna Garcia. 

Aruna chairs the NHS Confederation’s Primary Care Network and is a practising GP. She is the medical advisor for networks and partnerships at a GP federation known as Leicester, Leicestershire City and Rutland Patient Care Locally. In addition to her role there, she is women's health champion at Leicester, Leicestershire and Rutland Integrated Care Board, visiting professor at Lincoln University School of Pharmacy, and associate non-executive director at University Hospitals of Leicester NHS Trust. Aruna, welcome to Health on the Line. 

Aruna Garcia

Thank you, Matthew. Thanks for the chat today.

Matthew Taylor

How are things at the moment? We know how busy life is in primary care. We've seen a 20 to 40 per cent increase in demand for primary care contacts alone. So how does it feel as we start to emerge from winter on the front line right now? 

Aruna Garcia

I wonder whether we're feeling that we're emerging from winter yet, Matthew. So I definitely think that general practice has a sense of uncertainty, actually, and dissonance. We've been feeling it for a while now, and probably more acutely with the recent contract negotiations and uncertainty of what's in store for the next financial year. 

I think that just reflecting a little bit on where we're at, the cost of living, inflation, compounded by the issues around recruitment and retention of GPs has just felt probably in general practice that it's impacted more than most, particularly against that increase in demand for appointments.

As you've said, despite recruiting 30,000 extra additional roles in primary care networks and delivering more than 40 per cent more appointments than pre-covid, we're still not meeting the need or feeling like we meet the need for our communities. And I think the impact on practices with a thousand less practices because they haven't been able to make the bottom line has been a concern for some of our ICB partners in terms of the sustainability and viability of some practices in that area. So, on one hand, fantastic achievement in terms of the number of consultations, but on the other, there's something about the fact that we are definitely feeling the pinch. 

Having said that, I don't think we're on our own, Matthew. I think it's talking to our national leaders, particularly in our network family at the NHS Confed. And then more recently with my role as a NED, Associate NED in the University Hospitals of Leicester, I think we're actually feeling this across system partners, but probably just feeling a little bit more isolated than our ICS partners because of the fact that we have a distributed membership in general practice and probably a lack of voice in the ICS. 

Matthew Taylor

Lots of issues to get into there, but I guess we should start with one that is kind of looming, which is that the government's offer of 1.9 per cent funding increase in the context of the kind of updated contract. It looks from the surface of it that that is not going to be acceptable to most GPs and could find ourselves in a situation of conflict. So I feel a sense of trepidation. I want us to talk and we will talk in this conversation about the future of primary care and our vision for primary care, but the clouds are gathering in the sky suggest that we might be talking more about conflict this year. 

Aruna Garcia

It's hard isn't it and it's paradoxical in integrated care systems where partnerships and integrated working women to be core and statutory. 

I think that that sense of isolation and the sense of increasing struggle with meeting needs with that smaller purse has been a burden on general practices. And therefore I think the BMA with its members have passed on concerns about the 1.9 per cent offer that's increased and it's certainly not at parity with the rest of the system. It's certainly something that won't meet the workforce requirements in terms of their increase in pay and certainly also won't allow the ARRS roles to be equitable either.

So I think they are taking a stance in terms of where they're at, in terms of that position of 1.9 per cent because of the worry about sustainability of primary care. And I think most of our members, being frontline clinicians within practices, will understand and support that because without general practice, we can't have primary care at scale. Without general practice, we can't have ARRS roles delivering an extra onion ring of services to support, create resilience and innovate on top of what is being delivered and protects general practice really. 

Do I think there's conflict? I think there's probably space for a rational conversation and probably a sense of recognition and value of primary care, which includes pharmacy, optoms and dentists as well as general practice.

And therefore, recognising and enabling the potential of primary care at scale and facilitating that support that exists with practice-based care. Because the conversations are very similar. It sits all around the delivery of care for patients and what we feel we need to deliver that care, which is always going to be workforce, as I described.

It's going to be about leadership and it's going to be about contractual enablement and funding so that we can deliver more for our patients, not more for less that we're getting at the moment. It's probably what we're feeling at the moment. Do I think that there's conflict? Like I said, conflict occurs when there's a sense of differing perspectives and maybe there's something about mutual understanding of what we're trying to get to.

Maybe there's something about understanding the role of PCNs and primary care at scale to support general practice in this conversation so that it's not just all on general practice alone. And then I think there's something about, we understand that there's financial pressures, but maybe there's something about redistribution that's equitable and that demonstrates parity and value of primary care, including general practice.

Matthew Taylor

Yes, obviously we in the conflict will be doing everything we can to try to be a voice calling for understanding, for discussion, for trying to find a way forward and avoid conflict. 

Now, it's been a really busy time, it's always a very busy time in primary care. You and I are speaking on the day the government has made a major announcement about putting extra money into dentistry to try to address or to at least begin to address the kind of national dentistry crisis that we've got.

A few weeks ago we had the launch of Pharmacy First, pharmacists being able to prescribe drugs for a limited but important range of conditions. We've seen over the last year the focus on access, the access recovery plan. So there are positive and important things going on. 

Let's start with that access issue. What's your kind of perspective? Because access has become the number one issue from the perspective of politicians and to a certain extent, I think from NHS England as well. 

So firstly, do you think we're going to make some progress on that, the kind of legendary eight o 'clock scramble? And do you think it's right to put so much emphasis on access?

Aruna Garcia

If we go back to the fuller stop take and Claire very clearly described in her access strategy that by generating solutions to access, we will create the space for proactive care and will create the space for continuity and personalised care with an ARRS team. 

So in principle, I agree that primary care at scale, whether that be PCNs and whether that be federations working within a neighbourhood level with 30 to 50,000 or at place level with their local authorities and community partners, I think we can really start to think differently about access. And I think that's where the primary care access plan was right. 

The idea of creating a single point of contact for our patients so they felt that their problems were addressed when they needed it was right. And a digital telephone system, a lot of practices actually adopted out of their own pockets through covid as we try to respond to the needs of our patients. And I think the plan was about levelling up the rest of general practice. 

We can't forget that it was a really big transformation for primary care and the patients to go from their routine way of contacting the surgery to a different way of contacting the surgery and receiving different people. 

So I think we just need to make sure that we allow that time and development and adjustment that's required across the partners. 

I think the way that we deliver care now has changed in primary care because we're not just working in silo as general practice. We actually, like you said, we have Pharmacy First now. We have in some places, federations or PCNs at scale, at place, developed red eye services with their local optometrists. We have community diagnostics, for example.

So therefore there is a plethora of services that we can have access to that we needed to modernise our first point of contact to navigate to and navigate our patients to. But the critical bit was always to take our patients with us on that journey. 

I think the last bit I would say would be the bit about we need to respect continuity of care. So where general practice and the front desk receptionist was the first point of contact, there was a relationship that was created over time with that patient. With that shortage of GPs that we have now, there's something about the fact that we need to think about that being a gold standard of care. And maybe with the resources that we have in the way that we're working, we direct our patients that need it the most to general practice, to continuity of care or team-based care. 

And that involves risk stratification. So a lot of our members, like Foundry, for example, have taken care navigation to the next level by risk stratifying their patient contacts and ensuring that those that need personalised care do get it. And those that just need simple, just standard contact, and that’s70 per cent of contacts usually can find access maybe at scale or digitally, or it could be personalised. 

I think the final point that I wanted to make was in some situations, general practice at scale have not just worked at PCN level, but they've worked at place level with their urgent care partners. So that includes community, that includes social care, for example, in frailty hubs, that includes their visiting service, for example, and 111. So they pull in the urgent care contacts of the day to deliver system solutions with a single point of contact, reducing problems with demand failure and fragmentation of care. 

And in some situations, some PCNs have gone on even further to deliver front door of A&E and have seen real impact on conveyance rates into A&E because general practice’s appetite and ability to manage risk and understanding of their communities and services is so powerful.

Matthew Taylor

There is a slight tendency, I think, in the health service that we, partly because it's so politicised, that we run after one particular priority. And certainly, throughout last year, it was access, access, access. was all the focus was on how hard it was to get through to your GP, how long people had to wait to see a GP. And we've taken action in the area. But I was interested in talking to Claire Fuller the other day, of course, who’s primary care lead now for NHS England that she was recognising the link between patient satisfaction and continuity of care. So actually, the kind of big public issue has been access, but when you ask patients what most matters to them about their experience, then continuity comes high. And sometimes there's almost a tension, isn't there, between access, which is, you want to see anybody and continuity, which is, no, you want to see somebody who knows you. 

Aruna Garcia

Yeah, I completely agree.

I think we're in a space of transition at the moment. And as I described, continuity is a gold standard for general practice. It is the bedrock on which we deliver our care. We've always talked about cradle to grave, generalism, being able to reassure patients quicker, manage risk better because we know their background, and also tackle some of those wider determinants of health because we know patients in their context.

With the pressures of a reducing general practice workforce and with a wider multidisciplinary team to start to tackle those wider determinants of health. I think there is a lever on general practice to think about continuity, still respecting it, but to enable continuity as a team of teams. And I think there is a big OD operational development piece that we need to probably think about within integrated neighbourhood teams within our vertical and horizontally integrated partnerships because it's absolutely critical to ensure that we don't just have continuity of care but we have continuity of pathway and continuity of data to support that patient. 

I think the experience of the patient is that the continuity only exists when they can find one person in the system at the moment because of the fragmentation and handup problems with handoffs. So I wonder whether the problem isn't just about enabling and supporting that transformation to continuity of a team of teams. And that's where research and innovation needs to come in, because the majority of research that's been done has been done on having a named general practitioner.

I wonder what would happen when you have a named clinician or a named lead within an integrated neighbourhood team managing your continuity. So it's just thinking a little bit differently, but respecting continuity. 

And again, we need to take our patients with us. This is huge transformation of care for something that patients take for granted. And we need to make sure we're respecting that at each and every step. And therefore there's a lot of reassurance and conversation and relationship building that needs to happen within a practice to support that primary care of scale conversation. 

Matthew Taylor

Yes, and I remember someone saying that when we talk about continuity of care, we need to distinguish between continuity of data, which is the most basic. see somebody, you want them to know what conversations you've been having with other health professionals, what conversations you had the last time you visited the GP surgery. 

Then there's continuity in terms of your care that there's a sense that the pathway that you're on is one in which it's kind of joined up, your care is joined up. 

And then there's continuity of person, which is actually wanting to see specifically the same person again. 

And we need to come along and package that because people care about different things. For some people, it is vitally important to see the same person because of the relationship you've built up with them. For other people, it isn't that so much. It's just not wanting to have to start all over again with the information and with the account. Really interesting. 

Now, again, every answer you give me prompts about ten different questions. So I'm going to discipline myself. 

Let's talk a bit about primary leadership, because as I go around the country, talking to system leaders, talking to trust leaders, particularly, for example, talking about kind of coordination around winter, single point of access, all of that. 

One of the really big variables is about the level of primary engagement. in some places, the places where things tend to be going best, primary is well organised, it's got a good voice, it's really involved in the conversation. In the places which are much less hopeful, primary isn't really engaged. 

It's often that the leaders I speak to say, don't really know who to talk to in primary. I even remember speaking to one place leader who said, well, the GPs in my patch are split down the middle. So if I talk to one group of GPs, I annoy the rest. And if I talk to the other, you know, vice versa. 

So first of all, do you recognise this point that it's hugely variable to place to place and it's a critical success factor in terms of integration? But secondly, what do we need to do to support greater primary leadership in the future? 

Aruna Garcia

So if I can unpick the first part, we've just got to be a little bit careful when we talk about primary care leadership because we have general practice leadership, was where PCNs were sort of developed and primary care, which involves our dentists, optoms and pharmacists, which is probably we're on the era of primary care collaborations at the moment and leadership. 

I think that when PCNs were developed, they were developed to create a space for integrated neighbourhood working to tackle local community care, develop some resilience with general practice, tackle health inequalities, and to deliver better outcomes for patients by moving care out of hospital. 

When covid happened, which is literally within a year of PCNs being born, we ended up with PCNs’ clinical directors being catapulted into a space of being leaders within their area, managing their services in an existential crisis, I think. 

So therefore, that lived-leadership development of clinical directors was huge and wasn't invested in. But we developed it nevertheless. And in some areas, there were pockets where the right conditions existed with their integrated systems. And they would have been embryonic in those days. With the right conditions, they were invited to have a voice at place and at system and as local PCN alliances. So they were invited to speak and think about strategy and create a space for thinking about agency of primary care. 

That was not consistent around the country. So we had a catalyst in some areas, or we didn't have in the others. 

PCNs have really only working within their contract, the direct and health service contract for the last couple of years. And within that, they've really started to work in their community, integrated neighbourhood teams, with working with community assets. And really those pockets of innovation are small. And I would say to you, actually they have demonstrated leadership with those local relationships and local communities born out of covid, because some of the work they're doing in health and equality, some of their work that they're doing in prevention, for example, with communities that need greater care, homeless, for example, BAME, et cetera. So we end up finding that we can recognize really good collaborative and integrated leadership already.

The issue comes because the systems change slightly and the system is now requiring more of primary care to have a voice at sort of place and system level, which PCNs were never quite designed to do, which is what you've described, Matthew. However, general practice through covid has started forming collaboratives at scale at place and system called provider collaboratives. And we're seeing the emergence of those in the last year or so, I'd say.

And this is where general practice is forming into a single voice in most places. And also then, they are also collaborating to become primary care provider collaboratives to deliver services at scale, to deliver efficiencies at scale, to think about integrated care pathways at scale. So you're creating that infrastructure and leadership management infrastructure and capability to be able to interact with the system at place and system. 

And I think finally, there is an aspiration for some to develop into, for example, trust-like models and have strategic ambitions. Now, I would say to you that that is the potential of primary care and collaborative to primary care. And where it's been achieved, there's usually been investment into leadership capability and leadership development within primary care from the ICB and of course investment into those structures that will deliver primary care collaboration at scale. 

I think the second thing is there's a culture issue that happens sometimes in ICBs that we need to think about creating the right conditions of culture so that we are thinking about ensuring that primary care clinicians or general practice leaders and others in terms of primary care leaders will end up feeling that they have the right to have a parity position within system and place because that doesn't always exist. And this is why it's really important, I think, for primary care leadership to have a system of development supported by ICBs, to have the ability to have a peer network. 

So a lot of our members actually really hailed the Confed's Primary Care Network as a space for the right conversations, for peer support, for inspiration, and most importantly, influence, because they're struggling to actually convey that voice and struggling to convey their ambitions to be a primary care partner at ICS. 

And I think finally, just need to remember that leadership in primary care needs to be invested in because clinical directors are really important to keep those communities going and keep the innovation up and making sure that we're working with the frontline and our patients. And therefore, creating that space, as I've seen in our leadership programme in the NHS Confed, it's not just been about leadership development, but it's been about creating a sense of value through peers to keep yourself in the space to develop integrated care pathways and care with your system partners. 

Matthew Taylor

Thanks, Aruna. And it's great to hear those comments about our primary care network, but also our leadership development offer that we're providing in a number of systems. I want to finish our conversation in a few minutes by asking you about the importance of that kind positive vision for primary care, one that we worked on with you and with that network. 

But I just want to, there's a couple of other areas I just want to delve into and they're also areas the Confed's working in.

So I've travelled around the country and seen some really good examples of primary innovation. And often that's been about primary providers, PCNs, FEDs, starting to take on aspects of community services and even in some cases, acute services. 

But I've also heard sometimes that when primary care starts to grow its offer like that, there's often can be a bit of pushback from other parts of the system about primary's ambition there. 

Now that kind of takes me to this question of the kind of primary secondary interface, which is something that is a bit of a hot topic. We're doing some work on that ourselves in the conflict, because of course we represent acute leaders, other trust leaders, as well as the primary sector. 

What's your insight, Aruna, on that primary secondary interface, and what do we need to work on so that it works more effectively?

And actually what we need, because what we need I think is more primary and acute and more acute in primary. We need collisions to find it easier to work across that divide. 

Aruna Garcia

Yeah, I think that it's about taking, we'll go back to taking people with us in terms of primary secondary care interface. We've lived in a very traditional estate ringfenced model of care, haven't we, so far in the NHS with hospitals delivering secondary care, general practice delivering their services within their practice and community of course working to reach those patients that can't come to either of those places. 

I think the primary secondary care interface is essentially those hot spots for where we need to look at connectivity and that story of continuity of care pathway that we've described. It really boils down to a shared language and communication.

So you often find a breakdown in communication, don't you? That sort of breakdown in handoffs when referrals, for example, are a problem. When we have incomplete discharges, for example, where patients don't know what they're doing or they've not had the letter for their appointment in secondary care. So things that you would normally expect somebody to be doing within their services may not be done, or you think somebody else is going to do it. And when people are busy we don't always have time to pay attention to that, I think. So I don't think it's anybody's fault. I just think it's people trying to do the best for the patients and the care and the work that they have in front of them at the time.

And we know also that there is a 30 per cent burden of demand that is related to demand failure. So this is related to the lack of continuity in care pathways that we've just described.

So that piece of work that we're going to be doing in terms of the primary secondary care interface is really important to highlight these issues and to start to co-create solutions together.

The second thing I'd say is that creating a sense of shared purpose and collaboration and starting to look at where there's been failures or where we've not done what we should have done with our patients together and basically placing the patient at the centre of our thinking will start to support that collective vision across the primary secondary community care interface. 

And it's the key part of where you have mutual accountability for outcome. And I'm not sure we have that yet. And there's a key part of developing, I talk about this a lot, a shared language across primary and secondary care, not just from clinician to clinician but also from primary care to trusts, for example, and to community trusts, so that we are all understanding what is important to us and that we're all focusing on the same priorities or trying to focus on priorities that we feel are important in our organisations. So I think this is a critical aspect of integration, which is the primary secondary care interface, and it should then shine through and should pull through that integrated leadership and systems working for our leaders across the system. 

Matthew Taylor

Yeah, thanks, Aruna. So we look forward to working with you on that issue. 

But another area that I'm really excited about us working with you on is around integrated neighbourhood teams. So this is an interview with you. It's an opportunity for me to get on my soapbox. one thing that I'm kind of slightly obsessed by at the moment is that we have two very different paradigms for thinking about the health service. There's what I'd call the industrial paradigm and that's kind of Department of Health, NHS England, regions, trusts, I guess, kind of primary care networks focused on national targets. And then we've got what I call the social system and that is thinking about public health more widely at a national level, it’s integrated care system, particularly integrated care partnerships, it’s place bodies, and it’s integrated neighbourhood teams. 

And these two paradigms are quite different in the way they kind of view the world in all sorts of different ways. The industrial paradigm tends to focus on organisations, the social paradigm tends to focus on places, for example. The industrial paradigm tends to focus on short -term targets. The social paradigm tends to focus on kind of longer-term shifts in investment and more in kind of prevention. 

But there's another divide, which is that in the industrial paradigm, we tend to see the problem as demand. And in a sense, the problem is the public. The public want more from us than we can give them. And that's why we have issues of access and long waiting lists. But in the social paradigm, the issue with the public is not how do we kind of fend off their demand, but it's the reverse. How do we engage them? Because actually, whether it's something prosaic like getting vaccinated or getting screened or more deeply, how you get individuals and communities to feel a sense of confidence and empowerment around their health, then actually we need to reach out into those communities. 

I think that dichotomy goes to the heart of how we think about integrated neighbourhood teams because sometimes when we talk about them, it feels like they're kind of multidisciplinary teams of the health service that might have a bit of a community representation on it. But there's a different model that says no integrated neighbourhood teams really need to feel like they're community organisations, that they are owned by the community, but that they have primary and community care at their heart. 

Now, I think that's very much our vision. We're really excited to do work in some of the most deprived areas about how to make sure integrated neighbourhood teams really do feel that they are of the community. But that's also going to be a challenge to colleagues in primary care because the skills that are involved in engaging communities can sometimes be quite a kind of messy business. You know, that's a new set of skills, but I think vital if integrated neighbourhood teams are going to work. 

What's your view of that? 

Aruna Garcia

I agree, actually, and I think our members agree. Our PCN network members are frontline clinicians or frontline managers working in the heart of their communities. And they worked with their PCNs to start working in their communities to deliver the needs of the community beyond general practice. And I think that's all about integrated neighbourhood working. 

I think we've evolved actually from the idea of an integrated neighbourhood team because it almost implies a singular entity that operates at 30 to 50,000, that's slightly beyond the PCN. And I think that's slightly restrictive in terms of its aspirations. I think this is about integrated neighbourhood working. 

I absolutely agree with you that some of that working is with different partnerships at different levels to ensure that we are working in collaboration with other care partners in the system, as well as communities, as well as patients to deliver the right care for patients. 

I go back to your point, not just deliver the right care for patients, but if you turn that and pivot it, it's meeting the needs of that patient in the community. So rather than thinking from a top down, it's a bottom up approach from the patient. What do I need? Where do I go? And it's our job to make sure we facilitate the partnerships or the team around it. 

Now, I agree with you that double paradigm that exists about demand versus essentially personalised care and prevention and population health, which we know are the tenants of a sustainable NHS and probably the tenants of a sustainable general practice in light of the demographic and complex care pressures that we've got coming our way. 

And we have seen with PCN some great strides within their communities to start to develop community assemblies, for example, to start to work with their communities and voluntary care sector organisations to create provider collaboratives even that can start to work at place. 

What we haven't seen is...I do agree with you that that involves a different skill set and I think we've sort of stumbled and started with clinical directors to deliver that. But maybe a leadership ask is to be able to facilitate that more proactively so we can get the best out of it. 

The bit that I always find surprising is where pockets of care have been delivered and it's innovative because it's based on population health or inequality data. For example, frailty,

for example, enhanced health in care homes, we have visibly seen an impact in conveyance rates to accidents and emergency between 10 and even 60 per cent in some situations, a better quality of life for those residents and better health. So we know that delivering care in the community actually will reap more rewards and dividends, but that's logic seems to fail when we try to redistribute funding to those pathways. So I think there's a funding issue that we need to think about with integrated neighbourhood teams. 

The second bit of course is that space and allowing the integrated neighbourhood teams to experiment and learn on what they can do and deliver. So, in some areas, they've actually gone on, like I said, to deliver urgent care solutions, to deliver care for our children but we know we're facing significant mental health weights, for example, with autism and ADHD, and even postnatal care. We're on menopause care, for example, in hubs. We need to go further and faster in integrated neighbourhood teams because that's where the magic that can happen will really start to catalyse sustainability in the NHS. 

So I feel like we're distracted a little bit with the demand solution because investment in this area, which we know from our work in the Confed, will deliver more per pound invested compared to secondary care. £14 economically versus £8 in secondary care. We know that this is the place we should be looking at. But national policy hasn't done that. And we were really disheartened when we lost the focus on integrated, or felt like we lost the focus on, integrated neighbourhood teams and meeting health inequalities with the primary care access plan last year? 

Matthew Taylor

We've nearly run out of time, so I'm going to ask you one last question, but I think really important what you say there and we in the Confed with an election looming are focusing a lot of our energies on being able to demonstrate to an incoming government that we do have leaders who are willing to make difficult choices, willing to think about reallocating resources, willing to think about how we move resources upstream, but we need a government that supports us in doing that work. 

It's not that we are hopeless and helpless and need a new government to save us. It's that we need a government that trusts us and supports us in doing the things that we need to do.

Which takes me to my final question, Aruna, and you could speak about this for a long time, I know, but we kind of made a strategic decision at the Confed around 18 months ago, which is although we want to recruit as many PCNs as possible to, and feds to our Primary Care Network - and I hope people have enjoyed this conversation will check out the Confed website and think about joining us - but actually what mattered as much as getting more PCNs and feds in membership was that they were PCNs and Feds who shared our view that we have to have a positive vision of primary care which whilst recognising all the challenges some of which you and I have spoken about, Aruna, over the last 40 minutes, we do have to have a positive vision and a positive vision that we can take to a new government and get behind. 

Just tell me, Aruna, because you work with us on that, just pick out a couple of the key features of that positive vision for primary care. 

Aruna Garcia

Absolutely. I think that where there's adversity, there's opportunity. And particularly as general practitioners, we want to do right by our patients and as primary care leaders we want to provide solutions, particularly in our network. 

I think we have a group, a membership of innovators, early adopters and late adopters who are looking for a different conversation and solutions to the problem. 

We have produced a vision for primary care that we believe will facilitate a sustainable primary care going forward that we published in empowered, connected and respected.

And to pull out a few key points, I think the main thing is about creating space for primary care leadership, for ensuring that we are respected within integrated care systems so that we have parity, that we are respected for being able to deliver services at scale, at place and at neighbourhood, as well as practice and observing subsidiarity, to respect integrated neighbourhood teams and ensure that we invest in them or integrated neighbourhood working, we’ve just described, and to respect our patient partners. 

Most importantly, there's a patient at the heart of this and empowering patients and self -management and holding them as partners as we move forward is key. 

Matthew Taylor

Aruna, that's a fantastic point to end and I think that question of how we think about our relationship with patients, how we empower patients is absolutely essential to the debate about the future of the health service. 

Aruna, it's been fantastic talking to you. 

Aruna Garcia

Thank you so much for joining us on Health on the Line. Thank you, Matthew. Thanks for having me.