Redesigning complex pathways: improving frailty care

Penny Pereira 

Hello and welcome to Leading Improvement in Health and Care.

Matthew Taylor

In this episode we're looking at frailty and how improvement approaches can help redesign services for older people, people who have care needs that are complex, demand a whole system approach.

Penny Pereira

We’re going to get a national perspective with Tom Downs who's a consultant geriatrician at Sheffield Teaching Hospitals and also national clinical director for older people. 

We're going to start this time with a local example. I had the pleasure of interviewing Simon Harlan who's a GP and Peter Chessam, associate director of nursing, who are both at Walsall Healthcare NHS Trust. 

We'll hear from Peter first who starts by explaining how the impressive transformation work that they've led came into being.

Peter Chessum

We started focusing on how can we support the ED by safely shifting risk out of the ED and into other areas where expertise lies. So that was increasing the throughput of a medical SDEC, increasing the throughput of SACU and also the frailty unit so that the patients get to the right hands first time. 

And then as a result of that, their care is much more expedited. And of course, some patients will need to be admitted from these areas. But ultimately, we want to get to a position where we're assured that any patient with frailty has seen the right people first because we know the risks are much greater to them should they be admitted into the base wards of the hospital.

Simon Harlin 

Much that was taken by the quote from Mark Britnell about hospitals needing a route out. So we were working in a system that was delivering the wrong results for our older population. So it was a problem with design. 

So very early on it was a consideration in how do we redesign our services, how do we redesign our pathways of care and because of it being an integrated organisation, developing a whole pathway of care. And then also as we were able to develop place partnerships, doing that in partnership with the whole system.

Penny Pereira

So what improvement skills did you use as you were looking to redesign the approach to frailty in the organisation?

Simon Harlin

Well, the trust again, very early on, took a focus on trying to ensure that as many of its staff and its workforce have the capabilities to be able to do improvement. The trust established a quality improvement department and it offered training for its staff using quality improvement methodologies and the significant proportions of our staff that have undertaken that training. 

So we've been given the skills to improve and we've been given the support to improve and it's been inbuilt into what we do and how we're measured and monitored on the impacts of what we're changing. 

So, Ned Hobbs, our recent COO that has left was, and he, pretty much every meeting we had was an SPC chart of improvement or challenge when there is an improvement and an encouragement to go off and make changes to see if it improves and recovers. 

So, it's been measurement. You can't change what you can't measure, ultimately can you? So it's been a focus on, let's try and measure what matters for people, which can often be particularly difficult for older people, can't it? 

But certainly measuring what matters and then changing what we see from the data that we've been presented. And do that with confidence.

Peter Chessum

So I think that's been really key, certainly on the journey I've had here in the last three years was you were given the job to do and then you were sort of empowered to do it. So, it'd be quite broad from the board, you know, we want to achieve X percentage of the increase in activity in a certain area. This is the finances that we're going to give to help support it. Can you work out a plan to try and drive that forward? 

I think that that works really well. And I think certainly that relationship between clinicians and operations teams at Walsall has been really powerful and it's been quite dynamic because it is quite a small trust, so it can be quite reactive. 

And a lot of faith was put in the clinicians that were working in the areas. I think the same is true in terms of, you if we look at the frailty improvement that has occurred, it was really about empowering the people that work in the unit already, asking about where the system holdups were, asking about how we could maybe streamline some of the processes through FS-DEC and then increase the activity through the area. And then just by giving the staff in that area are voicing a bit of support, the solutions to the problem start to occur.

Simon Harlin

0500 Some of the other things as well that's been important in the design principles is that I think we've been able to try and have a focus on what do we think ‘good’ looks like. So at the very beginning of establishing front door for frailty, again this was many years before there was any national direction to do it, and it was as simple as it's 22 patients a day and 75 per cent of them are going home on the same day.

And as I've said earlier, often we find ourselves ahead of the guidance and we're able to innovate, not because of guidance, but despite it. So the only thing that really exists in front door frailty requirements at the moment is that you've got to have a front door for frailty service established and you've got to deliver 70 hours a week. 

So I think that ability and that's it, full stop, which is, establish it and do it, but it doesn't sort of give any sense of what does good look like, what are the good outcomes that we need to be aiming for. 

So we've been able to define what good looks like. We've been able to set our standards against it and measure our service against it. And that sort of ties into that. If you can't measure it, you can't improve.

But also what we've been able to do is bring that into peer review and peer challenge. We've got a frailty clinical network that exists within the ICB that we go off and talk to ourselves about what we're doing, learning from each other, challenging ourselves to improve, learning from what is good elsewhere and trying to adopt it, and in fact even looking and welcoming external support. 

So having people like Tom Downs come and have a look and give us a view and give us some insights is always extraordinarily useful and then taking the feedback that we receive from that, both the good and the bad, to improve is something that we welcome.

Peter Chessum

I think there's a bit as well in what's made a big difference in change here is that the gap between the board and the clinicians is so tight. 

So, how, you know, there's this thing in resilience engineering about work as imagined and work as done. We keep that really narrow in Walsall, and our chief operating officers and our directors of operations, they're visiting us almost daily, historically, to find out what's working, what's not working. How do we narrow the gap? How do we make the improvements? And I think the translation of strategy is delivered by the people that are working on the shop floor. So again, I think that's something that Walsall has a great strength with.

Penny Pereira 

And could you say a little bit more about any of the principles or methods that have helped you alongside the data, like really properly understand the flows and redesign care in the way you're describing?

Simon Harlin

Well, it's been about making sure that the staff have got the skills to be able to deliver impactful change and to run with it and to embed it. And I talked earlier, didn't I, about the organisation investing in projects that would enable staff to have those skills. So, that's been critical to some extent, or to a large extent, as well to making sure that we've got impactful change. 

But I think it's been, again, it comes back to the culture and the leadership. The culture and the leadership has been to support this, because of that opportunity that has been invested in the organisation because of transforming community services, but also that burning platform as it were of, our performance is needing to improve, and our improvement can only exist and only happen if we look outside the walls of the hospital and we think about working in teams.

Peter Chessum

Yeah, you're absolutely right. Walsall loves its data. And I also think that actually one of the things I love about Walsall and love about our operational team was that you would be challenged. So you would be challenged by operational directors, and they would present data and then we would question it. So again, if you look at our Summit 75 data, there's a lot of positivity in there, but there is also evidence that a higher number than average of patients who are over 75 years old coming in and then die in hospital within 48-hour timeframe. 

So when I looked at that data, the next thing I did is got in contact with the clinical nurse specialists in palliative care, spoke to the in-hospital palliative care lead and said, what do we need to do about this? Because is this about, we're not identifying well in the emergency department? 

I think there's something about that. What about identifying in the community? What are we doing about that? And I think also, I'll give you a clinical example, I said this to Simon yesterday, if we're writing respect forms for patients whilst they're in hospital and they're alluding to us that they don't want to come back to hospital, they want to be cared for at home, we have to have the services that are able to deliver that care, otherwise they do end up back in an ambulance and they do end up back in hospital. 

So again, we tend to use data as a way to sort of understand our system, understand our opportunities and then empower those people with the best experience to make the change.

Penny Pereira

You've talked about the willingness of the organisation to invest in the areas that are seen as going to be likely to make the biggest difference based on the data. Sometimes the financial context, the way in which financial incentives work can make that a little bit difficult. 

So I'm kind of curious about how you had the kind of conversations about where to put investment that may be thinking differently about costs and benefits from typically how that plays out.

Simon Harlin

It has been extraordinarily challenging. So we've got good services, as we all know, that are block contracted in the main. So here's your amount of money and then just go off and deliver. But it's been hard to try and deliver more in that financial envelope. 

And it's also been difficult in the environment of cost improvement plans that organisations are needing to deliver on and whether or not that is proportionally given across a whole organisation such as ours, which has got acute and community services within it.

So, do we have an opportunity perhaps to think about a disproportionate application of CIP, which is some of the things that we've tried to establish over many years. But it's that bravery and the boldness to actually be able to say that our data demonstrates that we do this with what we're doing in community services, for example, which is we're keeping this many people out of hospital, we're delivering this experience and these outcomes for our population too. 

And if it were to be scaled back and not are not expanded, then this is the likely impact at the hospital. So we've been able to turn it into a language that actually does resonate with hospitals quite deeply, which is about your UEC performance, your RTT and your length of stay. 

And that's the stuff that keeps chief execs and COOs and everybody up at night, isn't it? And if you can turn it into their language, from where I'm sitting in community services to say, this is what we can do and do more of, then it actually allows those to continue to be big and bold and brave and ambitious.

Peter Chessum

We talked earlier, Simon, about we have had significant amount of change at board level recently, but historically what always resonates to me was that the COO would come and say, where's my pound best spent? And certainly when we invested in medical SDEC, you know, that was a £1.2 million investment. 

And that came out of money that was directed towards the emergency department itself. But it was sort of acknowledged that you can make your ED as big as you like, but it's not going to necessarily solve the problems that you seek to achieve. 

And if you look at the way Walsall did set up that model,, as an example, it is responsible for a lot of the four hour EAS performance. I think also within frailty now, with an acute background for 20 years, I would be saying we need to spend money in the community now because by the time the patients reach hospital, it gets a lot more difficult to then get them home again, versus if we can actually provide them care where we're not going to make them more delirious by bringing them into hospital. We're not going to make them as uncomfortable. If you're going to talk about doing AHP assessments, it's much better to do that assessment in the home rather than it is in a frailty unit because it's not realistic. You can't see their home. 

But I also understand how difficult it must be to deliver those services in the community and I'm not delivering it. I just can understand by how complex it is, how difficult it is to get the right people in the right place at the right time.

Penny Pereira

You said at the start, Simon, that there were the community-based service interventions and then the things that were introducing in terms of the frailty unit at the front door. Could you describe the nature of the community service model that you've introduced?

Simon Harlin

Well, it was just essentially doing what we were doing in hospital, but into our population before they got there. So trying to identify people that had needs that we could fulfil in community services equally as good, if not better - in fact, some of the data suggests that we give better outcomes to our population who are frail outside of hospitals. 

And then what we look at is things like readmission rates into hospital, deterioration, whether or not they need access into intermediate care services and if you keep people out of hospital, then all of those things that are indicative of what's actually going on in the hospital are much, much better.

So it was about trying to case find. It was about trying to shift it as much into we will react and we will coordinate care from outside of the hospital rather than within it. 

So having and building, well, I called it the four C's, that capability, capacity, culture and offer of continuity of care that's just so important for outcomes of our population and making sure that we're right sizing it in the right place which is into community services.

So, the front door of the hospital is essentially the back door of ED and our community and patients homes extend into that space and we see that sort of real true whole pathway of care that is seamless and doesn't tend to get confused by organisational silos or walls that exist between care and care provision.

Matthew Taylor

So Penny, that was really interesting. Let's kind of pick out some bits of that. I was interested that the concept of design was one of the kind of key ones at the beginning of the interview, the process of redesigning a pathway.

Penny Pereira

Yes, the idea that we should be thinking about actually the system generating the results that we get through a service, as opposed to focusing our effort on pushing that process to work harder. 

And starting to think not just about the guidance that exists in terms of what a different system could look like, but going much further and really using local data and improvement methods to iterate and improve that design of the system until you're really getting the quality and performance outcomes that you want.

Matthew Taylor

And it reminds me a bit of the joke: the world is divided up into two kinds of people, the kinds of people who create false dichotomies and the kind of people who don't. 

Because this is a world of false dichotomies. And there were two that I thought, which came to mind in terms of Simon and Peter overcoming them. 

So one is the false dichotomy between national guidance and bottom-up local ownership. Because it's clear, isn't it, that in this area of frailty where there is a national programme, we're going to hear more about that later on from Tom Downes, there is a national programme, there is national guidance, there are national expectations, particularly around kind of frailty pathway at the kind of front door of the hospital. But also it's really important that you achieve local ownership and the other solution that is suited to the particular challenges of your local place or system.

Penny Pereira

Indeed, as soon as you start to actually get close to the detail of the work that's needed to turn national guidance and good practice into something that's going to work locally, I think it becomes very evident very quickly that the number of changes you need to make, the extent to which those are locally specific, and involve like far too many people to do anything other than build ownership, build skills, and then once you have that foundation, move to designing and developing the service. 

Unfortunately, you really can't go straight from national guideline to change in practice. You have to really go via a very sometimes long, sometimes involved route of building local ownership, building a local understanding of what's specifically needed in your particular context.

Matthew Taylor

Yeah, and then a second false dichotomy is that it's dichotomy between kind of technique and culture that some people say, it's all about getting the kind of very specific bits of this right, the improvement technique. And others will say, well, no, actually, it's really about hearts and minds. And again, Simon and Peter clear it's both.

Penny Pereira

Yes, I've often challenged the saying that's been around an improvement for a long time. In fact, I think Tom refers to it later, that improvement is 20 per cent technical and 80 per cent human. To my mind, it is all a mix of technical and human. The methods just really don't fly or don't actually have any impact unless they are done with attention to the culture and to the relational aspects of making change happen. 

But equally, if we don't have the kind of power of proper analysis and measurement, we can spend a lot of time speaking to each other, getting on very well. We're not really pushing services and knowing the best way to actually get the kind of different outcomes that patients need.

Matthew Taylor

And data is a big part of this, which takes me to the third kind of false dichotomy, which is between change within organisations and change between organisations, place or system level.

The other day I was reflecting  that the kind of failure journey from an elderly frail person coping at home to that person being stuck in hospital. 

You know, there are up to maybe even more than 11 links in the chain which you need to get right to minimize that failure journey. And it starts with a kind of population health management. So you know who's frail in the community, a proactive model of primary care, an offer at neighbourhood that goes beyond the health service into things like housing and social isolation, the offer of the voluntary sector. Step up provision as an alternative, care coordination if someone does reach a point of crisis, triage at the front door of ED, triage within ED, pathway management within the hospital, access to things like same day emergency care, discharge procedures, step down provision in the community and access to social care. 

There's so many things that you could get right or you could get wrong. And some of these are within the organisation and require organisational grip and some of them are between organisations. 

And it's interesting how Simon and Peter had to kind of make the case in both domains. So, to make the case for integration across the pathway, but they also had to make the case to individual institutions, particularly the hospital, that it was in their interests to work in different ways.

Penny Pereira

And don't they make the case brilliantly? I just wish we could kind of capture the way in which they just had naturally come to the conclusion that you have to take a whole pathway view. 

We should just have that playing on repeat in most boardrooms to keep them remembering that the problems, even if their problem is articulated and understood as emergency care performance in ED, actually the solutions to that are much, much wider. 

Thinking about some of the improvement methods that help you get there, and some of the attention to relationships and collaboration, as you say, there are a number of different steps that need addressing if you're going to get your kind of ideal service performance. And that's going to take some time to achieve. So, actually using improvement methods like driver diagrams, like a clear theory of change, getting everybody together, being clear about actually there are these say 11 areas that need attention, and we're all clear the work that is going into those different things.

So that you're approaching change in a way that is both connected but does allow progress to be taken on individual components at a time so that you can start to see progress and it doesn't become kind of overwhelming in its breadth and complexity which is I fear where a lot of systems get stuck. 

I wonder if I could add another false dichotomy. I don't know if that was the complete the end of your list?

Matthew Taylor

That's my three, Penny, so add a fourth.

Penny Pereira

So the fourth one I would add is the false dichotomy between frontline bottom-up change and change that is kind of led and supported from the top of organisations and the top of the system. 

The thing that I loved from what was being described in Walsall is that idea of closing the gap between decision-making at senior level and the kind of data and understanding that sits at frontline level. 

And then also that there was a huge energy and sense of agency to do what could be done at a local level and at a pathway level, but that ultimately there was also a recognition that actually your financial incentives will become a limiting factor on what can ultimately be achieved and the speed at which it can be achieved. 

So, for any kind of change in healthcare of this kind of complexity, actually it's also going to need attention and action at a national level. 

I sometimes think if the national level of the system or the regional level of the system could just put all of their effort on doing those things and perhaps not meddling or getting too involved in some of the things that they might do much closer to the front line of change, actually we might see progress accelerate faster.

Matthew Taylor

I would say there's another false dichotomy between the kind of science of improvement and the messy world of politics because I actually think that, you know, at the moment, for example, the small political point I'd make is that the centre of the government/NHSC/the department invests so much more energy in improving performance within organisations than it does on thinking about how to support change between organisations and they rely there on mechanisms like contracts, financial incentives, et cetera. But you've got to invest in people and you've got to invest in relationships and building trust if this stuff's going to work. 

Anyway, let's move on now to get a national perspective. We're going to hear from Tom Downes, who's national clinical director for older people.

Penny Pereira

And Tom knows what the team in Walsall would describe as the work as done as well as the work as imagined. He knows that from his time improving older people's care in Sheffield, which has been really impressive over many years, much of that the Health Foundation was happy to support. He's talking here in his national role as a clinical director. He started by providing the context for why focus on frailty is so critical.

Tom Downes

On the most superficial level it's a good news story. We're living longer as a population, the wonders of modern science and public health. But of course with that comes a challenge to both the health and social care system. 

Over the next ten to 20 years we're going to age as a society. The proportion of people who are not only old but old and living with frailty is going to increase. And let's pick out the word ‘frail’ there for a moment because I think it's really important to understand the difference between being old and being an older person living with frailty. 

If we look at Office of National Statistics data, an 80-year-old woman in England today has ten years left to live on average. However, if we look at that with a frailty lens and the frailty way we measure it most commonly across the NHS is using the Rockwood Clinical Frailty Scale, a scale from one to nine, one being a very fit and well independent person, nine being somebody who's in the final end of life stages. 

On average, ten years for that eighty-year old woman. However, if we apply the frailty scale, things change dramatically. If that eighty-year-old woman’s clinical frailty scale is seven or more, that is commonly somebody going into a nursing home, that ten years now becomes barely one year of life. And the usage of the health and social care resources is dramatic. 

However, if we're down at the other end of the scale, one or two on the clinical frailty scale, somebody who is, well, independent, exercising, then that ten years actually stretches now to 12 or even 15 years of life left on average. But not only that, an 80-year-old woman really resonates for me because that's my mum. 

My mum uses the NHS app. If she had any hospital appointments, she'd drive herself there, but she doesn't have any at the moment. And so her usage of the health and social care system is very similar to mine as a 55-year-old man. 

So this lens of frailty is fundamentally important to understanding the demand that we're going to be seeing on our health and social care services. Combine that with Chris Witty's report and the challenge of the increase in demand going up year on year for the next couple of decades. 

That's why we need to care frailty tuned both across the healthcare system and social care.

Penny Pereira

Tell me a bit more about some of the examples of work that's underway nationally and locally to improve care for older people and how does that connect to the vision for neighbourhood health?

Tom Downes

I'm lucky being national clinical director for older people at this time because we've got Chris Whitty's report and then we've had a new government who brought in new policy. And the policy of neighbourhood health and the three shifts is completely aligned to where we need to be going with older people and older people with frailties care. 

We're seeing improvement work going on in the frailty space in organisations, places, systems and regions now up to national level. We've recently launched a national frailty improvement collaborative to work to understand how to effectively implement the evidence base for frailty-tuned care. 

The demographics make this a real priority and the three shifts, especially the one from hospital to community, fits with the direction of travel. 

If we look back over last 40 years, we've seen the closure of long-stay beds in acute hospital sites. We've seen development of community services. We've seen development of intermediate care. And in the last decade, we've seen a real focus on home first. 

This is really encouraging. And now we have an evidence base for what frailty-tuned care should be for the planning, the proactive care, the urgent response and what we can do effectively in hospitals. 

Now we need to consistently apply that evidence base. That's what we're going to be learning to do in the seven collaborative sites.

Penny Pereira

Can you tell me a little bit more about some of the methods, some of the ideas that will allow us to achieve the kind of vision that you're talking about for improved care?

Tom Downes

I think there's going to be four key elements to the success of implementing frailty tuned care. I'm going to start with leadership and where sites are starting to really break away with achieving effective frailty care, we're seeing leadership move from organisational-level thinking to actually place and system. 

Because for frailty-tuned care, it's a pathway that starts in people's homes in their neighbourhoods when necessary go through hospitals, back through rehabilitation services, back into their own homes in their own neighbourhoods. And that system thinking is necessary to get the improvement to become effective. 

The leadership needs to be both managerial and clinical, moving from organisational thinking to system thinking. This seems to be a key factor for successful improvement.

 I'm going to move on to the improvement science aspect. 

Successful improvement in healthcare is 20 per cent technical. It's really important that improvement science. We're not tying the improvement collaborative to a certain methodology. All improvement methods have the same foundations. It's about iterative design to maximize value to the customer. 

And we're working to activate the resources of improvement capability in the seven sites across the collaborative to engage their frontline staff to create the conditions for that is iterative testing and design. 

The third factor is culture and behaviours. So successful change in healthcare is 80 per cent human. We're going to be teaching storytelling. We're going to be focusing on actually the change from hospitals community sounds so simple and yet actually, that's people's jobs. Good people going to work with good intentions who are going to need to be part of the change. 

So, great data combined with storytelling is going to be a focus for the behaviour and culture change that we believe will be necessary. 

The fourth factor is financial alignment. The ten-year plan talks about financial flow prototyping. The hope is that we'll be able to create the conditions for one or more of the seven sites to be involved in actually having the opportunity to prototype different financial flows to align with, to match with, the change to frailty tune care hospital to community shift.

Matthew Taylor

So Penny, I feel like there's almost not that much we need to discuss at this stage because there are so many parallels between what Tom said and what we heard from Simon and from Peter. If only always there was that level of kind of convergence between the perspective from the top and the perspective from out in the field.

Penny Periera

Indeed, I think it is really needed and also challenging to bridge the world of frontline organisations and the national world of policymaking, the expectations of the public and politicians as they're experienced at the centre. 

But I think the example of the work that's just being started with the Frailty Collaborative does show a kind of different way of thinking about how you can support change. So, yes, making sure that there is guidance that that's accompanied by change packages with some kind of credible understanding and theory about the appropriate improvement methods that will make sure that that guidance is supported and implemented properly. 

I think the centre giving some clarity of encouragement and direction in that way and then actually investing in opportunities for people to learn from each other and kind of go on this journey of inevitably complex local change together.

I think that's a good way of thinking about the role of the centre. If I could give a quick plug, I know that the national team have been benefiting from a piece of research that has just been put out by the Health Foundation on the effective design of large-scale national programmes. 

That research was helping to learn from all of the long history of very large, complex national change programmes and trying to distil what is it that's likely to manage the complexities of doing that nationally and actually design and implement those programmes in a way that's likely to be really supportive and effective at a local level.

Matthew Taylor

Yes and Tom provides a kind holistic picture, doesn't he? As you say, he talks about these four things, about leadership, about improvement science, about culture, about financial alignment. And I guess the theme of the programme today has been false dichotomies. 

So let's maybe end with another one, which is, should we think about change in that kind of holistic way which says you shouldn't embark upon change unless you've got all the ingredients there. That it's like cooking a meal, don't start out until you've made sure that you've got everything that you need sitting there, you know on your kitchen tops, ready to be used. You're not going to find halfway through the meal finding that you're missing an ingredient. 

But then there's another way of thinking about it which is, you know I've got to cook something in an hour what have I got in the fridge. I've got to make the best of what I've got. Again, I think we have to work with both those mindsets. We have to be agile. We have to grasp opportunities that occur for change. We have to respond, of course, a lot in the health service to pressing needs, to crises of one kind or another. 

But the fact that we have to do that doesn't mean that we should abandon the fact that in the end, change that is big and change that lasts is going to have this kind of holistic, full organisation full system perspective to it. 

But we can't wait for everything to be perfect, but we shouldn't only be reactive. We have to do both.

Penny Pereira

This is something I feel so passionate about and it is a complexity within the field of improvement because our learning, our research over many years is showing us again and again and again that unless the ‘context readiness’, to use the jargon is in place, you are going to be limited in the scale of change that you can achieve. 

Sometimes I think we have interpreted that in a way that almost becomes a sort of prescription for paralysis really.  You just get stuck or you become too precious that unless you've done all of this enabling work, you're not going to kind of get in there because, actually your prospects of success at the scale you're hoping for are limited. 

I can really understand how that has become a particularly kind of fraught debate at the moment because there's such massive ambitions for change nationally and sometimes that can feel disconnected from the time and the resources that are allowed. 

So I think that there is a really strong logic for making sure that we are investing and thinking holistically about everything that needs to come together to achieve successful change. 

And at the same time, one of the things that I love about the improvement community is that it's a really pragmatic discipline. It's a group of people who have developed a set of skills where they are frankly used to operating without much formal authority, without much kind of space within organisations to get things done.

And actually if we can't get on and let people start making change, actually you then, you learn and you start to show what's possible and you start to create the tension in the system, which means that some of those other contextual factors, the financial flows, the leadership environment, the long-term culture, you create some tension which will shift those factors over time.

Matthew Taylor

Well, that's all we have time for in this episode. Thanks again to our guests, Tom Downes, Simon Harlin and Peter Chessum. If you liked what you heard, please share it with others or get in touch with us and let us know what you think. 

Maybe you've got some great examples of improvement that you'd like us to talk about on the show. 

But until we meet again, take care and enjoy the festive season.