Productivity

MATTHEW: Hello and welcome to Leading Improvement in Health and Care, brought to you by the NHS Confederation, the Q Community and the Health Foundation. 

PENNY: In this series we're talking to the people leading the way when it comes to improving health and care in services and systems. 

RUTH: Before this work began there were 803 people waiting for packages of care, now we have 270 people waiting and that large decrease is fabulous.

MATTHEW: We've been shining a spotlight on improvement done well. But you we've also been exploring the challenges. 

PETER: Things like risk of running out of oxygen over the weekend, having no critical care beds, record numbers of staff off, and recognising that actually the solutions to some of those things came from frontline staff who really knew their service and how to meet those challenges. 

PENNY: We're exploring the ways improvement can transform health and care and how to make change last. 

I'm Penny Pereira. I'm managing director of Q at the Health Foundation. 

MATTHEW: And I'm Matthew Taylor, CEO at the NHS Confederation. And this podcast is part of a joint programme between our organisations called Learning and Improving Across Systems. 

PENNY: Yeah, so we've been working for a while now with health and care systems across the UK, boosting their ability to learn and improve collaboratively. We're doing that through a peer learning programme and insight and innovation projects, sharing what we're learning throughout. And then there's this podcast spotlighting some great examples of improvement in action. 

MATTHEW: Now, Penny, this is the last episode of our series. But I'm delighted to say it's actually the last episode of our first series because plans are underway for a return in the not-too-distant future. Last month, we zoomed in on health equity in East London. But this time, we're looking at a different topic. We're looking at productivity, which is a word we hear a great deal, we often hear about it talked about as if it's kind of, it's a matter of life and death for health service. If we can't improve our productivity, we're in deep trouble. But sometimes when we talk about productivity, again, it gets removed from other things that we care about: looking after patients' safety, the broader shifts that we're trying to achieve in health. And I think you're going to hear today how people are working on productivity but it's not really productivity that drives. Productivity is a byproduct of a focus, nearly always actually, on improving care for patients. 

PENNY: Yeah, indeed. In our first episode in this series, we talked about reclaiming and reframing productivity. Productivity being a means to an end, sustainable, high-quality care, and the way in which improvement can help bring a kind of fresh perspective to productivity, which is really holistically and systemically understood as opposed to productivity becoming a kind of term that is often used to describe, in fact, driving individual products or targets harder. 

I'm really excited about this episode because it's a real opportunity to think about productivity from a system perspective, which I think is really neglected in the debate so far. 

MATTHEW: So tell us a bit more about what we're going to hear today, Penny. 

PENNY: Yeah, let's get into it. So this time we've brought on board a brand new roving reporter to the podcast, the Confed's deputy director of policy, Ilsa Bosch. She's spoken to two improvement leaders tackling productivity at a system scale in the Mid and South Essex ICS in England, and Northern Ireland's South Eastern Health and Social Care Trust. So first off, let's hear from Peter Scalding.

PETER: I'm Pete Scolding. I'm a doctor by background and I'm clinical director of stewardship for Mid and South Essex Integrated Care Board. 

ILSE: And just taking us back to the start of this work, what was the situation like in Mid and South Essex that inspired you to start?

So I suppose just to kind of set the scene a little bit, think it's due to came from three things principally. The first was our experience of Covid locally and reflections on what we saw during that. And same as everybody else during Covid, you know, we were trying to face challenges that we never thought we'd have to cope with. So, things like the risk of running out of oxygen over the weekend, having no critical care beds at a system level, record numbers of staff off sick or shielding.

And recognising that actually the solutions to some of those things, they didn't come from the likes of me at that time and I was working for NHS England during that period. They came from frontline staff who really knew their service, knew the resources that they had to work with and how to get the best out of them to meet those challenges. And so it was really recognising that power of frontline leadership and the best kind of instances of meeting those challenges.

It was frontline leadership that made the difference for us. So that was the first thing. Second thing was kind of a similar time and when health and care partnerships were kind of moving towards becoming integrated care systems and they were being born and it was our finance team, actually, who were looking again at service line budgeting and looking at that and thinking, you know, how could that help us to really deliver on what integrated care is supposed to be about? 

The idea of looking at the totality of resource for a particular kind of care area right the way across the system, ignoring the kind of organisational boundaries and the kind of kitchen table to kitchen table model of someone sat at their kitchen table, they have a stroke, go by ambulance, which comes from one pot of money, to the acute hospital and get some care there, another pot of money, to community hospital for rehab, another pot of money, and then back home again, back to their kitchen table for the recovery and post-care, another pot of money. They were looking at that and thinking, how can service line budgeting and that thinking of resources across a whole pathway of care, the whole of a care area, really help us to kind of understand resources work at that system level. 

And then the last thing that kind of helped bring all of that together was Eleanor Ostrom's work on stewardship, she won the Nobel Prize for it in 2009. And that's all about the tragedy of the commons scenario. And that's the situation where everybody is living around the common land, graze their sheep on it, grow their crops on it. And it kind of makes sense that they would need to cooperate, to collaborate with each other, to get the best out of that. And it doesn't really make sense if one family decides we're going to bring 50 extra sheep onto the commons tomorrow because we're going to get, we'll get the upside, all the wool and more meat and more milk and what have you.

And everybody is going to share a little bit of the downside. So we're going to end up winning out of that. As if everybody thinks like that then clearly Britain brings 50 extra sheep on tomorrow, that common resource is going to get eaten up and depleted really, really quickly and everybody kind of loses. And the two kind of traditional solutions to that, one is you split it up, put fences up between all the different sections and subsections, put someone in charge of each of those sections and say, look, you look after that little bit and we'll see how we go. And the other solution is you have a really strong central authority, your watchdog, who sets and then polices the rules of how it's used, how everybody behaves. And clearly we've kind of got versions of both of those things in the NHS and have done for the last 40 years. And, you know, there's pros and cons to doing that.

What kind of happens is you lose any of that sense of the commons and being able to move resources flexibly around a system, it’s really difficult to do that even if you know that a particular bit of resource might be much better being in one place than the other. Really hard to do that. And that's where Ellen Ostrom's third way comes in. And she won a Nobel Prize for her work looking at real-world examples of where the things like common resources like fisheries or farmland or forests, the people who use that result, who really knew it and depended on it, they would come together, agree a set of rules about how they would use it and it would work. They would act as stewards, get the best out of it and still have a sustainable common resource. So it was trying to take that, apply it to our NHS context with our thinking about frontline leadership, understanding resource at system level. And that was kind of the backdrop. That's the basis of where our version of stewardship came from. 

ILSE: Wow. That was a really, really helpful segue into how you adapted and what you mean by stewardship. I think it's really clear from what you describe and how you kind of use the model that you need buy in from the whole group or the whole flock to be able to do this kind of thing. Can you talk a little bit about how you've got engagement from this approach from the beginning? 

PETER: Yeah, absolutely. So, you know, it's lovely on a piece of paper, you know, or inside some of our heads, you know, really good idea. But yeah, it's not going to work if nobody kind of gets it or buys it. So where we started three years ago was a couple of calls in dark February evenings, two different groups initially. And we brought together around ten people in two different care areas. I think it was cancer and it was frailty, ageing well. 

And, you know, gave them the story about the sheep and the tragedy of the commons and just said, look, what do you make of that? Is that going to work in cancer in frailty? And the strong answer we got was, yes, it made sense. They recognised the NHS health and care system that they exist in, in that scenario, and it connected and sparked something. And we built from there. I think the other point I'd make, just in terms of thinking about buy-in, was we're quite conscious in the way that we tried to put those groups together and have done that over the three years in that no more than ten people and those ten people have got to be a mix of your frontline staff, so clinical and managerial specialties from across our organisations and a mix of professions. 

So in clinical terms, it does include allied healthcare professionals, pharmacists, psychologists, nurses, doctors, and then also the range of managerial specialties that mix in there. So, we did really consciously curate that kind of people from right the way across that pathway of care with a flat hierarchy. So they brought with them what they knew about the care area, about pathway. 

ILSE: Really interesting. And from what you describe, these are all people who are in and off the system. They've got day jobs. They're delivering at the same time. What kind of support did you put in place of people who wanted to be these stewards to encourage them to get involved and enable them to do it professionally? 

PETER: So a few things. We have a kind of ‘crawl, walk, run’ framework. And the first phase, the crawl phase is like a six-month program, the training and development. And that's focused on those teams, ten people. And we provide a programme of leadership and team development. That's one half of the stuff that they'll do. And the other half is the stewardship and the value bit. And they have a day or two per month over those six months to form as teams to start to get to grips with their system. 

Because obviously, they look a little bit different for each of those groups in terms of how their world, their system works. So that's the first bit of support they get. Then as they go through the walk and then the running phases, there's a few things. So a little bit of backfill time. So a session a week if you're a clinical staff member, because that's probably one of the big challenges is being able to carve out time to actually put towards some of this work. So a little bit of backfill support. 

And then we now have a stewardship programme team, just a small programme team who can help guide and support them a little bit as they go through that walk phase, as they get to know their system and how it works. And then once they develop their confidence, they know their system in terms of their population, their resource set, service activity, outcomes, and so on, then they start to become effective and start to influence how things work. 

ILSE: Really struck by the analogy where the model came from and also this kind of underlying principle of integration, really obviously how you use resources, as you described, it's really easy to carve out that field into separate pens, isn't it? So how you use resources and who controls them is understandably contentious. So really just to know how this approach helped in terms of aligning people to use those resources differently. 

PETER: Yeah, absolutely. And there's probably four ways. So first one I would say is probably pathway improvement. You know, like using QI to improve a particular pathway of care or service. Bringing in new models of care, so whether that's from something nationally, whether it's another system has developed something that we really like and want to trial here, whether it's occasionally something we've developed locally. Third thing would be kind of actual system improvement, system change. 

So, is there something fundamentally they want to change about how their particular care area works. And the last one would be value improvement and particular activities looking at what value does our current set of resources actually provide and can we improve that by shifting where some of that sits. So in terms of pathway improvement, I’ll point towards a piece of work that our cancer students did and their problem that they started with was with our skin cancer pathway. 

And we had really high numbers, 1,200 people waiting more than 62 days between referral and treatment, one of the worst in the country in those terms. And what they worked on and brought in was a national recommended model of zero-day patient tracker list. And what that means is bringing the clinical team and the managerial, the operational team together in an MDT model and all the culture and relationship work that comes with that and to get that to work, to look together at individual patient journeys, work out where the bottlenecks, the blocks were, and then work together to straighten those out and sort them. And they stuck at that over 18 months and brought that down tenfold from 1,200 to 100. 

In terms of new models of care and leading on bringing those in, a point towards our musculoskeletal stewards and something they did just a couple of months ago and that was based on some work that they'd done in Sussex recently, a really good model of care. And their problem was really high community physio waiting lists in one part of the system. And so they adapted this model of care called a community assessment day and brought together in one place, Basildon Sporting Village, on one day, 14 different providers. 

So some from NHS background, community physio team, weight management services, smoking cessation, talking therapies from a mental health perspective, local authority services, so housing and employment advisers, and third sector providers. So we had Active Essex, who get the lottery funding, versus Arthritis National Charity and hyperlocal groups, so the local tai chi and gardening groups, for example. Invited 100 people who came along on the day and they had the chance to have that personalised conversation and then go and see whoever they needed to see on the day. And as a result of that, 55 per cent got what they needed on the day, didn't have to go anywhere else and were discharged with patient-initiated follow up. And for those who couldn't make it, their waiting time was reduced by three and a half weeks, just by that one day of work. 

I think in terms of the system improvement, trying to change something that doesn't really work. So our frailty stewards really early on, really clearly identified that actually understanding and identification and use of frailty data was really pretty limited across the system. So they did a couple of things. They first off started a training and education programme and brought 300 people over a year or so through that training programme from primary care, community care, acute care, social care, open to everyone who might be involved in looking after people with frailty. That was the first part. 

And the second part was they developed an assessment tool, FREDA tool, frailty, end of life and dementia assessment tool, and the piece of software, the care coordination system, so that firstly, people with frailty would be identified and properly assessed. And secondly, that information would be available to anybody involved in their care, wherever they're coming from, whatever organisation. since the start of bringing in that assessment tool, there's now 15,000 more people with a diagnosis of frailty than there were when they started. A real impact in terms of understanding and looking after people with frailty. 

And then the value improvement work. The example I give there is our stroke stewardship group who ran a STAR process, a socio-technical allocation of resources that was developed by Health Foundation and London School of Economics. And that was all about picking one pathway of care, so acute stroke, top ten interventions across that pathway, and then looking at what resource do we put in to those ten interventions, and what's the population health benefit, the population qualities, quality-adjusted life years that we get at the system level from those. 

And then you have a discussion bringing together, I think we had about 30, 40 people in the room, including staff, people who'd had a stroke and people who cared for those who'd had a stroke, brought them together to have a discussion about what that looked like and what opportunities there were to improve the use of resource to deliver more value. And that was about two years ago. And from that, the message that came out was actually too much of our resource locally is going into acute care and we need to put more into, shift that into the community setting. And we're now seeing the fruits of that, working through the business case process and the consultation and so on to actually enact that. 

So, you know, it's a slow burn, but it's had real impact as a piece of work. 

MATTHEW: I love that interview. But, you know, I didn't take much convincing, Penny. I'm an enormous fan of the stewardship programme in Mid and South Essex. It is fantastic. But what particularly jumped out to you? 

PENNY: Well, I just loved the way you take some inspiring fresh perspectives, this idea of the commons, of the stewardship, those things really speak to the values of the NHS and the public sector. So a way in which we can engage people in a different way in discussions around productivity, which can often become quite reductive, negative and narrow in their conversation. So I love that angle on it, but then the really systematic attention to get from some great ideas and inspiration to change in practice. I liked the attention to creating the conditions for more ambitious change by doing work at a slower pace to start with, so crawling and walking that then enables us to run. 

I also thought what was really fascinating about the examples was that it spoke really clearly to a framework for thinking about transformation across systems that we've developed as part of our partnership. So, we've talked about the need to get better at connecting changes to overall care models, that was the example of the community appointment days, connecting that to pathway and process improvement, and then to innovation. So the FREDA data tool was an example of digital or technological innovation that actually connected in and served a wider system purpose. Finally, I think it's so important to be thinking about productivity from a system perspective rather than what we're doing at the moment, which is sub-optimising individual organisations or departments. So I mean, that's what struck me. You're very close to this work. What inspired you about it? 

MATTHEW: Well, a lot of what you said, Penny, but I guess the first bit is I love the process and I love the egalitarian nature of the process that in these stewardship teams, consultants, nurses, patient representatives, people from outside the health service working in a completely egalitarian way, everyone's voice is valued. I think that's so important. I've done quite a lot of work on process and inclusive, well-structured process like that really makes a big difference. Secondly, I think we'll hear this a bit where we hear from Ruth Gray in Northern Ireland in a moment, they do take the time to build the foundations for improvement and particularly to build the understanding and commitment from staff. 

Then the corollary actually of that kind of egalitarian process, that commitment to engagement is leadership support. The commitment to this programme has been consistent and that's impressive. And then I think the third thing that really struck me was that they weren't ashamed to learn from other people. They didn't have to invent it all themselves. They heard about the community days in Sussex. They heard about things that you'd done and they thought, ‘okay, that sounds great. Now, how do we repurpose that?’ And, you know, I do often think, that the innovation cycle that we see in NHS England on a bad day, it's not always like this, don't get me wrong, but on a bad day, which is, you know, find something that's happening, over-define it in a way, then tell everyone to kind of copy it as if it's an absolute blueprint. That has failed so often, really, but this approach, learning from each other, learning from peers, and saying, ‘okay, we can own this and we can make it ours. So we'll take what they've done in Sussex and we'll make it the Mid and South Essex version of that’, and I think that form of learning, not lifting and shifting, but understanding what's at the heart of something and then repurposing it, that is so much more effective as a means of innovation than the kind of lift and shift, particularly when we're talking about complex things like pathways, places, and systems. 

So, Mid and South Essex, I'm an enormous fan. Penny, you want to add to what I said? 

PENNY: I do. I guess I wanted to reflect on what you describe around that process of scaling innovation, there's such strong evidence now, and yet we don't follow that evidence when it comes to the approach to often thinking about innovation in the NHS. One of the things I love about this podcast series is that we're not just talking about and reflecting on this, through our partnerships and the networks we're creating, and hopefully Q is also playing a role, we are helping to create an infrastructure that enables that different sort of peer collaboration and learning. It feels appropriate at this point in our series to be connecting back to previous episodes. Do you remember when we were at ConfedExpo, we talked about actually, what would it take for ICSs to realise the potential to be a structure at a system geography that enables the more effective scaling of innovation. We talked about how it might need quite a different way of thinking about the bureaucracy and the infrastructure of an ICS. And perhaps some of this points to some fresh ideas, thinking about stewardship, commons, as a different way of thinking about what it takes to be an institution. 

MATTHEW: Which really, I think, takes us nicely on to our second interview, because what we're going to hear there is a particular methodology, ecomapping, think it's called, isn't it, Penny? And that was really the basis for this. So Ilse also sat down with Ruth Gray, who's Assistant Director of Quality Improvement Innovation at the Southeastern Health and Social Care Trust in Northern Ireland. This is another fascinating example. 

RUTH: Hi, my name is Ruth Gray, and I currently work as the Assistant Director for Quality Improvement and Innovation in South Eastern Trust. My background is that I'm a dentist and public health consultant and have worked in the area of health care and prison for 20 years. 

ILSE: Really like to start kind of at the beginning. What was the situation that really made you pay attention to domiciliary care and really kind of triggered the work that you guys are doing? 

RUTH: So within South Eastern Trust, we have a quality strategy, quality for all. And it's got that real ambition about how we're going to embed a quality management system within the trust. And so that was launched in 2021. So domiciliary care was seen as an area with just demand outstripping the resource we had and projecting forward into the future knowing that demand was going to increase. And we felt that this was an area that we should really start to drill down, understand, apply some collective resource around and see what difference we can make. 

ILSE: And can you tell us a little bit more about what you did? 

RUTH: So I think with any complex system it's really important to pause. In health and social care, we very quickly respond and react. That's part of, I think, our psyche. But when we're dealing with complexity, it's really important to understand the system. And so we wanted to apply some systems thinking to not just the domiciliary care pathway that was being provided, but understanding the different interfaces across our area that we provide health and social care for.

And we got a designer in, a system designer to come and collaborate with us, Tom Inns. And together, we applied a new way of thinking, which was called ecosystem mapping. What we wanted to do was really to understand the interdependencies and the complexity and to see where there are challenges, but also opportunities. And so patient ecosystem mapping is a really collaborative way to start to visualise that complex system and do that from the perspective of patient journeys. And so we got together a collaboration of people from across different services who were involved in planning and assessing domiciliary care, providing domiciliary care, scheduling it, but also the contract side, the independent sector providers. And then from there, Tom and I held a series of workshops that created the ecosystem map together. So we had over 90 stakeholders, patients, carers, service users, lots and lots of community and voluntary organisations, the independent sector who are providing domiciliary care, our councils, our planners, and together, each bit that is discussed then gets added to the map and the map gets built and built and built until we have this visual representation of the whole system. 

And that really creates an opportunity for very different thinking because we're no longer just seeing our piece within the pathway but we're starting to understand it as a whole and that gives you a different scope to then design differently. Tom describes it as a London Underground map and it's a really good description because you can very quickly follow one person's journey from A to Z, but then you can see how many other detours there could be or different pathways within it.

And I think a visualisation is something that is so important if you're going to then get different viewpoints around an improvement problem. 

ILSE: And one of the other aspects that I found really interesting reading the overview was involvement of carers and patients. Can you talk a little bit about how important it was to involve them in all the different parts of the process? 

RUTH: Absolutely, it's fundamental. There's a saying that people who are closest to the problem will be closest to the solution and the experience and the expectations and the ideas of carers and service users is fundamental to any change. They were involved within the mapping. Many people joined and had conversations, but we also had sessions separately with the patient client council because we thought it was really important to give the carers and service users a space as well. We then brought it back to the carers and service users to ask them was this a representation that they could identify with. And so many, many people are involved through partnerships and our service users and carers are integral to those different workstreams that are now live within the trust. 

ILSE: Could you give me an example of one of those? 

RUTH: So when we were conducting the ecosystem map, there was already some fantastic work going on in parallel around digitalising the scheduling and planning of dom care provision, that's called Careline Live. And so that was going on and that was really quite radical innovation in our sector at that time and it's been championed across the region now. So that was going on to enable the staff who were providing the dom care to be able, instead of having schedules posted out and telephone calls and someone's not available and then they're driving halfway around the country, to really start to be able to map and bring efficiencies into the system around their care and their provision. 

So that was going on and then alongside that, was another big, big piece of that work was really looking at our structure and how we provided domiciliary care and modernising it for the future and understanding that a lot of this work was driven by our pressures in our acute settings and trying to increase flow as people are needing to leave hospital with some sort of package of care, support domiciliary care. And so what we wanted to do was try and increase the flow, not lose the quality of care, but enable people instead of staying in hospital waiting for their package of care, to be able to go home and be provided with care. So people come out of hospital, they can be assessed in their home or as they leave hospital and the domiciliary care package then package is wrapped around them in the most suitable need that they have for a period of six weeks. But then it is reassessed. 

And for many people, it's really fortunate at that point that their care is no longer needed or the package can be diminished. And for others, they're going to need long-term care. And then they go on to a different pathway. But by restructuring and reallocating our teams and thinking differently around how we were providing that care, there's been really large gains around increasing our capacity and enabling people. I hope one of the aims is to give agency back to people that when they leave hospital, when they are recovering, that they can feel that confidence that they're able to then not rely on the package of care if that is appropriate and they can live well beyond that.

ILSE: Wow, so it sounds like it had really strong impacts around how you use your resources to best effect and on outcomes, which is definitely the kind of holy grail. Have you measured any of that resource use or how it's better used versus if you hadn't made any interventions? 

RUTH: Yeah, so the Careline Live has released 900 hours back into the system for domiciliary care. And that's an incredible gain because we need in health and social care, we're not going to get big new pots of money coming in and we need to use our services in the most efficient way. But remembering the six domains of quality, that efficiency and timeliness are only two of those domains. We always need to keep our care safe and patient-centred and equitable as well. We have released hours and that enables our efficiencies within our service. One of those measures is about how many people are sitting on our unmet needs. So those who are waiting for packages. So before this work began in October 22, there were 803 people waiting for packages of care. And then come jump forward to March 24, now we had 270 people waiting. So there was quite a large decrease. And that large decrease is fabulous, because that means that 600 people are either not waiting in community or waiting in hospital beds for care. But it's also about that quality of care, making sure that people are getting their care in a timely way and in the right place. And so the results have been incredible. 

MATTHEW: Fascinating stuff there from Ilse and obviously particularly from Ruth. Pick out some of the highlights for you, Penny. 

PENNY: Well, it just reminds me of how important it is to make complex systems visible to themselves and how that work of developing a ecosystem map in itself creates a platform for engagement and change. The way that we need to bring together all sorts of different data, that actually the hard data that we have is often an institutional basis. So there's going to be gaps when we're thinking about that at system level, which makes it all the more important that we're tapping into different people's perspectives to make sense of this. I remember when I first started doing improvement, I was mostly doing work to map a process in an individual clinical setting. Now we're thinking about improvement on a much bigger canvas and that makes that diagnosis understanding of what you're dealing with more complex, but actually all the more important.

I thought what was really fascinating was that they were then able to identify a really simple holistic measure of impact that would guide that work on an ongoing basis. So the idea of hours back to the system to care, given the complexity of the system, being able to hone in and identify something that's going to guide you feels really, really important. And I just loved the idea that you do IT innovation in a way that's embedded and guided by a system view, so a kind of change program built around IT to generate results for the system as a whole. My favourite quote was probably being creative and collaborative in the face of complexity. What struck you? 

MATTHEW: I liked many of the things that you've described but I thought, you know, in a way, just what a great example, because in some senses, it feels a bit counterintuitive. I'm sure if you talk to politicians and you talk to improvement in the NHS and innovation and technology, they don't want to talk about robotic surgery and, you know, elective hubs and new things. Don't get me wrong, these are really important things. But they probably wouldn't say, well, domiciliary care and also similarly, counterintuitively, I think if you were thinking, well, is there a space where you could actually do things more efficiently you could actually save money. I think again, people will not do auxiliary care because it's just so unbelievably overstretched. You're just in crisis management. But here, those two kind of instincts are defied, aren't they? In the sense that you're seeing improvement in a really very kind of human face-to-face care process at the heart of this. But also, although I don't think they really set out to tackle the productivity challenge particularly, they set out to improve the way that care worked, they did find significantly better ways of using their resources. So, starting with that sense of let's really understand the system, let's understand why we're providing care the way we're providing it, and how could we provide it potentially differently. They do actually genuinely surface the possibility of being more efficient as well as being more effective. 

Well, thank you to our roving reporter, Ilsa Bosch, for those wonderful interviews. That's all we've got time for on this episode and indeed this series. But I'm going to tell you again, it's not going to be the last series, I promise.

PENNY: I wouldn't let it. It's been too much fun, hey? Before you head off, please do make sure you subscribe wherever you get your podcasts. And if you liked what you heard this week, go ahead and share this episode or get in touch with us to let us know your thoughts. You can find us on X @NHSConfed, @theQcommunity and @Healthfdn. And if you'd like more information about our learning and improving across systems partnership, please email improvement@nhsconfed.org

You can also find transcripts and our show notes on our website. You'll find the link in the bottom of the podcast description. 

MATTHEW: And to wrap things off, haven't we been talking a lot about the importance of teamwork? So it's about time we gave a shout out to the team behind the scenes who put this podcast together over the last few months. We owe another huge thanks to all the guests who have been kind enough to share their stories and their time with us.

As we plan our next series, we would of course love your feedback, ideas for future episodes, tell us about the improvement you're undertaking so that we can visit you, talk about it and tell the world about it. And thanks so much for listening. See you all soon.