Lifting the lid on neighbourhood-level improvement

Penny Pereira

Hello and welcome to Leading Improvement in Healthcare.

Matthew Taylor

Yeah, and since we recorded the last episode, we've announced the really exciting news that Q, you and the team, Penny have a new home with us at Confed. It's going to bring lots of opportunities to go further in the work we've been doing together. It kind of feels like the kind of culmination of these conversations we've been having on this podcast.

Penny Pereira

Yes, indeed we announced that we'll be joining Confed and I guess you've also then announced that you'll be leaving but we won't take it personally. Yes, we're really thrilled to be joining Confed as it builds on the work that we've been doing together over recent years including, of course, this podcast.

Matthew Taylor

Yes, and I'm not going for a while, Penny. And even when I do, I'll be looking to keep my hand in health. Maybe you can invite me back on a future edition of this podcast, who knows? Anyway, this podcast has looked at what it means in practice to lead change across boundaries. 

And in this episode, we're looking at the one issue that I'm most interested in, and that's neighbourhoods. Neighbourhood health is a part of the ten-year plan.

And so what we're exploring today, Penny, is how improvement approaches can help us with that shift from acute care, hospital care into care in community, working with primary and other partners.

Penny Pereira

Indeed, of all of the pillars in the ten-year health plan. This seems to be the one that's got some real vision behind it, more personalised, more sustainable care for all, something where there's perhaps competing different ideas, some challenges about getting the work off the ground, but so much exciting stuff to be getting into.

Matthew Taylor

And holding the virtual mic for this episode is Q's system-wide change lead, Jen Morgan.

Jen has been speaking to Heather White, practice manager and lead manager for South Hambledon on and Rydale LPCN, and Catherine Heffernan, director of health improvement in South West London.

So first up, Heather White on how the neighbourhood health model is building on existing good practice.

Heather White

Our patient population is older than the national average. We have over 30 per cent being greater than 65 years of age. And with this older age profile comes the diseases, prevalence that's associated with age. So cancer, cardiovascular disease, dementia, heart failure, and just generally greater levels of frailty. 

To compound that, we have a lower number of care homes resorting in ageing and frail people living really in rural isolation with poor or no public transport to get them to hospital appointments. So that makes it particularly pertinent, I think, for our particular patient population. 

So I suppose the next question, why is it important to me? Undoubtedly, our population is suffering from a health inequality because of this, and their health outcomes can be negatively affected. So, any service that we can bring closer to home is of benefit for our population.

Now we appreciate that's not going to be practised in all areas or all disciplines, but where it is feasible for a PCN or for a group of neighbouring PCNs to deliver a service within its neighbourhood, then the aim will be that instead of moving between primary care and secondary care and back again, which patients quite often experiencing, we'll be able to provide less fragmented, hopefully more personalised and local care and therefore help sort of ease some of those health inequalities.

The element to the ten-year plan is that whilst bringing the services out of hospital and close to the patient is not a new idea, I think this time the plan seems to have some teeth to it with enabling groups to break down some of the identified barriers to providing care closer to people's homes. And that could be such limitations as estates, the need for digital solutions, and also having an available skilled workforce to be able to deliver those services.

Jen Morgan

So maybe diving down the next level, I’m really curious to hear more about your views on what you see are the foundations and the core components of the future neighbourhood health service. And I guess the future, but also what are kind of the seeds of what's happening now, what's already happening that we can build upon.

Heather White

There are number of key components and some of this is building on what we're already doing. So, for example, using population health management to target preventative interventions. There's a lot of good work already happening across the country. This is something that we've been building on for years now. 

This can involve already our health checks for our most vulnerable patient groups, vaccination programmes, CBD prevention, stop smoking campaigns, and now we see a lot of noise around the weight loss industry. So that's already things that are happening at the moment and all we're doing is building on those good practices that are already happening. 

The modern general practice that is ensuring access to primary care via easy phone access and online queries and consultations. And then with regard to the neighbourhood health as well, another key component with regard to building on what we're already doing is a lot of practices are already running practice-based MDTs. 

The multidisciplinary team (MDT) meetings are quite often held on a regular basis within the practices and the exciting next step on from that is the neighbourhood multidisciplinary teams or the integrated neighbourhood teams,  as we used to call them the INTs, and that's to provide focused coordinated support for people facing more complex health issues that quite often have a socio-economic impact.

I must admit it took me a while to get my head around what an INT was and how it differed from an MDT. But within SHaR PCN, we firstly established an INT for our frail patients who needed enhanced support. It was quite a small next step for us because it was really our next step from the frailty MDTs that we've been running and it's very much being led by the PCN. 

And then I think another key component is around the secondary care contribution into neighbourhoods and that's to ensure that specialist service are effectively integrated within whatever local care model it is that you develop. This is happening already with CDC so we can see that the pattern is already set. 

However, like many areas, our patients fall quite a distance from our local CDCs. So, within SHaR we're establishing our own PCN-wide breathlessness service and we're doing that in association with our local hospital trust.

They're bringing out an echo clinic, one starts this month in one of our PCN hubs. What they're doing is they look at our admissions data, they look at how many patients are coming from our area and they're then putting on an echo cardiogram clinic within one of our local hubs, just calling the patients off the waiting list they've got who reside in our area. 

Looking at our admissions data, we had an ambition to develop a breathlessness service to provide not only sort of gold standard respiratory care, but we had to incorporate heart failure within that. So, the reason this came about is we approached the trust to discuss the possibility of incorporating an echo clinic into our breathlessness service. 

In discussions, it came to light that they have the staff and they have the ability to move a clinic out of the hospital, but they didn't have the equipment. We have the estates, and we have the ability to acquire an echo probe and so in partnership, our patients now on their waiting list will be seen within their neighbourhood and the knock-on consequence is that we've put in an extra day's capacity into the system, which means the waiting list of patients being seen back in the hospital will also be reduced. So, it's almost that win-win situation.

Jen Morgan

What do you think it will take to actually bridge from where you're at now, where you need to get to and specifically what do you see as the role of improvement in all of that?

Heather White

Okay, so I think there definitely needs to be a shift in mindset away from siloed working, be that the primary-secondary care interface, community teams versus GP teams, local authority boundaries, and even across healthcare and education. For example, as I've already articulated, what could be seen to build an INT for families that needs to involve schools, it needs to involve social care, it needs to involve GP practices, and it needs to involve our local authorities as well.

And what is needed is really to have the ability to sort of almost rise up and look down and see the bigger picture. Hand in hand with that comes a how can we do this attitude? So, look at where you can start from. The temptation very much is to look at how difficult this is going to be, how it's not been managed before, and then get stuck in a bit of a rut. 

Other practical enablers needed will be estates and how we can think creatively about the public estates we do have. Our developing children's centre has come about because there was an empty Sure Start building next to one of our local primary schools. The school could see the potential of using this building to provide a hub for parents with young children. So, they nagged the local authority both directly and through their local counsellor until it was granted to them to use. 

They started running parent and toddler groups from it and now it's grown to have the health visiting service doing routine baby and toddler checks, having a library, a walking group, and shortly it will be a base for health and wellbeing coaches, social describing link workers, and a care coordinator who's interested in pre/post diagnosis for neurodiversity. 

So, the role of improvement really is about learning as you go. We've consulted with our whole PCN when we've embarked on a new service. We've planned out how we think things will work theoretically. We've piloted it quite often and learned from the piloting, and then we've rolled it out across a wider footprint, sort of incorporating the learning at each stage. 

But it's a case of starting out. I think you start out and you adjust as you go along. Otherwise, you could become held back by just the fact that you're trying to make everything perfect. As I say, perfection can quite often be the enemy of actually just getting going.

Jen Morgan

So, we can move on to the barriers. If you want to share a little bit more about this vision and where you want to go, what could get in the way of implementation and integration? Some of those barriers, I guess one you just spoke about. Any elephants in the room that really need to be challenged or assumptions that need to be challenged as well. Now is the chance to get them out there.

Heather White

If I'm thinking about it, I can probably break it down into three main areas. You've got your systemic and structural barriers. You've got your implementation barriers. You've got your barriers rated to community engagement. So, if I think of each of one of those in turn, your sort of systemic and structural barriers, you've got really around the socioeconomic inequalities. 

You've got some really deeply entrenched and notoriously difficult to address factors like poverty, discrimination, and disadvantage. and they form the fundamental building blocks of ill health and these must be recognised and addressed to achieve that good neighbourhood health and that is not an easy arena to be working in. 

Transformation complexity is another barrier, shifting from hospital-centric care to community-based neighbourhood teams is a complex large-scale change. You know, this could involve contractual changes. When it comes to developing new services and recruiting and retaining staff, it's have we got the right skills in the right areas to be able to deliver those services? Particularly in more rural areas where the population is less dense, it's more challenging to recruit. 

When it comes to implementation barriers, you have resistance to change from various stakeholders within the healthcare system. These are new models of care, new integrations of services. Resistance could be down to a lack of understanding, what does that look like? What does it look like in reality? There's leadership and management issues. So again, this needs a different approach to leadership.

A lack of management understanding could hold you back. Poor involvement from top and middle managers can hinder success in implementation. And then you've got the resource constraints as well. That's around potentially a significant risk around the necessary financial resources. They're still going to be scarce. There's never going to be an NHS where the money is not going to be stretched. 

And then laterally, you've got the barriers related to community engagement. So, the temptation is to develop a one size fits all. And that's not the approach that's needed because whatever you put in place needs to be congruent with the diverse community needs. 

It's a bit too crude to just deliver the one size fits all and that then involves obviously your communication gaps around what the population actually needs. So, you know, are we engaging the population in what's needed? They helping to co-design and construct the particular service that's needed?

Jen Morgan

So the flip side of that would be speaking about your views on what do you think might accelerate implementation, support implementation, and support that integration that you speak of. If you could almost wave a magic wand, what would you love to see to support that implementation process?

Heather White

I've probably got two, one of which is possibly an achievement. This is just if somehow you can wave the magic wand and have everybody able to work collaboratively without the barriers, would be absolutely fantastic. But that is something that is going to take a lot of doing. 

So I think if it was one thing that was actually really quite achievable, it would be if we could have the governance of new technologies, keeping pace with development. There are so many products out there that will be transformative, but the governance structures seems to be playing catch up all the time. 

So, I'm not aware that there's a robust nationwide review of the new technologies for signing off and placing products onto the approved list, for example. When I'm talking about AI and automation and robotics and that sort of thing, at the moment it's being done at a local level and that's inefficient and it's just adding delay into the system due to resource pressures. 

I suppose if I could wave a realistic magic wand, it will be about trying to make the implementation of all this new technology that would make us move from analogue to digital a much smoother process. That would really help speed things along.

Matthew Taylor

So I found that a fascinating conversation. Clearly, neighbourhood working is not coming from nowhere. There has been a long history of attempts to work more effectively together, particularly around the needs of patients with longer-term conditions, patients who are in one way or another disadvantaged or living in disadvantaged communities. 

So, this neighbourhood work, it builds on and needs to learn from that. One of the things that goes wrong in policy is that politicians have a new idea and we forget the fact that lots of the elements of that idea are already out there and we should build on them rather than sweeping them apart and starting all over again.

Penny Pereira

Exactly. There's so much exciting talk for policy makers about transformation and revolution in healthcare. And sometimes that's absolutely the right energy that we need behind these changes. But when you're actually trying to make something work and be understandable, kind of practically for the people working in healthcare, actually making the connection and building what's already happening is much more likely to help people see it as achievable, something that they could start and get going on this week, next week, not something that's on the kind of medium to long-term horizons. 

So I really liked the examples that Heather gave, for example, how the kind of frailty MDTs were then the building blocks for integrated neighbourhood teams or how you could start with access to certain forms of data and then build up from that a more sophisticated approach to population health management.

I guess that's the way in which we can often usefully think about improvement is that you will combine some kind of bottom-up work building on what already exists combined with perhaps a new angle on it, a new top-down vision that might give it some additional emphasis, some additional enablers in order to allow us to go further.

Matthew Taylor

Yeah, and the other thing that I felt about the conversation with Heather and Catherine's as we’ll hear, they're very aware of the need to try to think across the different kind of boundaries, not just within the NHS, but with our partners. 

So, you need to have an imagination that says, how might all this work together differently to the benefit of patients? But then what you need is a very different mindset, which is a very entrepreneurial mindset, because actually the opportunities to take that vision forward and not predictable. 

And there's really interesting examples of these interviews of challenges coming up, opportunities emerging, and Heather and Catherine grasping those opportunities to move forward. It's kind of interesting, I find, these two different ways of thinking, one, the very broad systemic and the other, they're kind of entrepreneurial, agile and adaptive.

Penny Pereira

Yes, and I think people are doing that at different levels within a local system. So I guess through the partnership that we've had together, we've been helping people who are leaders across a whole place or system to do that acting like a system for everything that is going on and the big picture developments around the recommendations in the ten-year plan. And then being entrepreneurial at the level of the overarching enablers for an area or place.

And then you also have people who are local leaders at the level of their individual practice, their individual pharmacy or service, who are thinking systemically at that level, and entrepreneurial, in terms of the things that they're trying there. 

So, I think that is going to be the texture, particularly of the development of neighbourhood health. When we think about the complexity of introducing change in this area, it's going to need that very adaptive entrepreneurial aspect to change, perhaps more so than other aspects of transformation that's ahead of us. 

I was also struck actually by how on the last episode that we recorded, we were talking about the shift from analogue to digital and ended up speaking to people about neighbourhood health and community co-production. And then in this episode, we have Heather saying how actually the thing that would most help neighbourhood health development is the governance around new technology that would keep pace.

What really struck me from that is the capacity for local leaders to be thinking like a system in terms of how all the three big shifts, how all of the different imperatives to change kind of weave together at a local level, which absolutely has to happen. But when you look at it at a national level, these things start to come siloed in ways that are perhaps less overall kind of coherent.

Matthew Taylor

Well, that was brilliant. That conversation with Heather, we're going to build on it now with an equally fascinating conversation with Catherine Heffernan. And Catherine starts by highlighting the opportunities that the ten-year plan will provide in her neighbourhood.

Catherine Heffernan

This is an opportunity really to bring high quality care to people's doorsteps. And it's a really, really good opportunity because we're also seeing the rise of digital health as well. And there's an awful lot there that can actually help improve access to healthcare as well. So it's combining that into bringing it to the people. There is like a really good opportunity here for that better connection, that better working. 

So, it's enabling, I think, community pharmacists who have a very central role to play in their communities to work better, not just with general practitioners, but also with social care and doing that personalised packages around patients. One of the big things that time and time comes across in my public health work is that actually those people who live in our most deprived communities are actually those who are least likely to access healthcare. 

And indeed, we've even had people who live next door to hospitals and aren't accessing outpatient appointments or aren't accessing emergency care in a way that you think that they need to or should do. 

So, this is a way to of looking. So very, very key, I guess, the starting point in all of this and pulling it together is understanding who that local population are and availing of the technology and the tools such as population health management to better understand who are those patients, what are their risks and what are the interventions that we can do to help them in managing and preventing illness. 

So I think there's an awful lot of opportunity going forward, but it's also building on work that's already happening. 

Another thing that we have found is that within general practice, of course, they're so busy. Appointments are particularly limited periods of time.

But actually with things, for example, like with vaccinations, you do need to take that time to talk through with people, any questions they have, any hesitancies they have, and help them come to an important decision. And this isn't something that's easily done in general practice, but there are other healthcare professionals, like community pharmacists, who can take that time and have that conversation. 

So, we have been doing quite a bit of training up across our patch. We also found it was very, very useful to train up our community pharmacists to talk to older people about staying fit and healthy during winter. So we did a pilot of the proof of concept of winter fit, we called it, and there was ten different things that the community pharmacists and their staff could touch on, included things like dementia. 

Did they know about where to go for winter or warmth? Did they know about what they were entitled to? And you know what? In tight ones they had for social care in their homes and also how to prevent dimension falls, et cetera. And then depending on what the customer talked about, be something as simple as, it's very cold at the moment, isn't it, Mrs. Jones? And Mrs. Jones might said, my goodness, yes, my house is so cold. And that then could prompt a conversation to help Mrs. Jones keep her house warmer. 

And it proved very, very successful. And we had some tremendous feedback and we ended up winning a couple of awards for that. 

So what we're hoping is that with this integrated neighbourhood team's work, we can build on all of those elements and pull it together and have healthcare professionals and other care staff helping each other out in making sure that we have good packages of care around our patients, but also including that very important element of prevention and self-care as well.

Jen Morgan

What do you think is going to help us bridge the gap between now and the future? And what do you think the role of improvement is in helping us to make that transition to more integrated neighbourhood, personalised care, close to home?

Catherine Heffernan

That is the tricky question, isn't it? Because, I mean, let's face it, some areas are more dynamic than other areas. And a lot of the putting this into operation will be dependent on local leaders and people's appetite for change. It's not going to be easy. It is about winning hearts and minds and bringing people with us. 

So, I think we do have to be very, very good at sharing best practice and knowledge and particularly for people like myself working in an integrated care board, enabling those conversations to happen and to bring the information and to work with people and help enable them. It's not going to be something I think that's going to be magically set up overnight. But what we do have to build on is over the past number of years, we have had primary care networks coming together. 

And I know that, again, there are some areas where primary care networks work better than in others, but equally we have some GP federations out there who work really, really well. So there are building blocks there to build on. And I think we just have to make sure that we're sharing that learning and that practice into the areas that might be a little bit far behind at the moment to help them get up to speed. 

Also, we're doing it at a time too, aren't we, where there's a lack of resources in terms of financial resources. You know, the whole system is financially challenged at the moment. So there does need to be a little bit of rethinking of what can we do with what we've got. 

So yes, we have our ideal model where it's all singing and dancing, but actually, who do we actually have? What are the assets that we have within our local communities and not just in healthcare, what we have in our voluntary sector as well in our communities and how can we use those to push forth to help enable people to reduce ill health and to help improve their healthy life expectancy.

Jen Morgan

just a little question going a little deeper. Is there anything you want to share about improvement? Like what you value in improvement and how bringing an improvement approach or whether it's an improvement mindset, methods, processes? Do you have any thoughts about the role of improvement in this shift?

Catherine Heffernan

That's a good question because it kind of comes down to how do you measure improvement too. I mean, there are established tools for quality improvement of services and we do have metrics. I mean, we work in a system that's very good at creating metrics. So we do have that. Wherever we start, it is doing that baseline.

 It is looking at that population health management approach, making sure we understand our population, but equally setting up that we can measure that change, and perhaps taking that time to sit down because we can't do everything at once. 

Perhaps we, depending on the population need, for example, if you do an older population who perhaps their uptake of flu vaccine is not very good, or perhaps they're not having their annual checkups that they require for their various comorbidities. 

Perhaps it's taking something like that and starting with that and then seeing the improvements from where you are now to where you need to be. And there are standardised measures like we do have, for example, for people diagnosed with hypertension, there are targets for where we need to be in terms of their compliance with treatment. It might be just the big areas first and seeing where you can do your most change and improvement because we can't do everything. 

And if we do, we fall flat. And it goes back to, I think, knowing that and working very, very closely together, all of us in sharing what's the evidence of what makes a difference. But I think this is something that definitely will require quite a bit of thinking, particularly as we're gearing up to implement operating models across the country. 

This is something where are we going to add our biggest value and it will be different for each integrated neighbourhood team. So it's about sort of being pragmatic and perhaps not trying to do too much at once.

Jen Morgan

Maybe just thinking about this transition, we've got some ideas, the role of improvement. What would you say might get in the way of implementation progressing towards greater integration?

Catherine Heffernan

I think one issue is of course the lack of staff and perhaps the sort of inability to maintain and recruit staff. There are certainly gaps across London in different healthcare professionals. I mean, we're aware of the shortage of health visitors, the shortage of school nurses, the shortage of GPs. So we're not going to be able to solve that with the integrated neighbourhood teams, but perhaps we can think a little bit differently to make those roles more interesting and need to better retirement. 

There's also to some historical, I suppose, don't want to sort of create trouble, but there can be, I suppose, some hostilities sometimes, professional hostilities about different things. So, we'll have to try and overcome some of that too going forward. And already things are happening to enable that. 

For example, through Pharmacy First, pharmacies are able to upload information on patients that they've seen that then go straight onto the patient record that the GP can see. So that then can overcome any misgivings or any lack of transparency of what's happened to the patient. 

So, for example, if a patient was seen in pharmacy for some reason, the GP can then see on the record the conversation that happened. And that's really helpful. 

So, we do have these sort of traditional and these structural barriers, I think, would be challenges going forward. And there's no easy solution with that, but it's been being mindful of those.

Jen Morgan

Are there any particular skills or capabilities that you think are going to be really needed, again, to support the shift to neighbourhood health?

Catherine Heffernan

I think with anything like this, I've used the term ‘winning hearts and minds’ and that's very, very much part of systems leadership. And that's very much part of the skill set of leaders who work in organisations like ICBs or in the Department of Health and Social Care, because you do have to not just set the direction travel, but you've got to convince people to come with you. 

So, I think that's really, really important, but on the ground level, that needish-ness within integrated care teams or around that. There's going to be people who need to be very political savvy as well and making sure that people understand the movement forward and don't necessarily just attach it to a political party, but actually see this is about people working together and improving things and using what we have. 

I think it's very easy for people to say we need more money, we need more investment, but actually that's not there right now and we do have assets there. We do have a lot of really good stuff that's happening that we can continue going and making sure that we always advocate the patient's voice at the end of it and do what's best for our population.

Penny Pereira

What I really liked about this interview was that it gave some further really rich examples of how to build on existing good practice so that you build confidence, you help people see what things might look like in practice, and then you get more and more ambitious. 

So, the nice example of moving vaccinations to community pharmacy, but then actually expanding that to ten things that people could be doing, extending perhaps beyond what people might most obviously think of community pharmacy. 

Now you could try and work all that upfront and win the argument in the abstract. But what I got a visceral sense of was people like doing that in practice, working with people, showing that it works and then go on and win awards, then build confidence, not just at one area at a time, but across a large geography, start to kind of highlight what's possible.

Matthew Taylor

Yeah, and this maybe reminded me of conversations I had, Penny, when I was more involved in education, where there were sometimes divisions between people who talked about the importance of knowledge, people who talked about the importance of skill, and the people who talked about the importance of creativity. 

And what's interesting, I think, in Catherine's interview, the importance of all of those things, that you do need that kind of baseline of knowledge about good practice, about the way things work, about what's allowed and what's not allowed.

You need the skills that we develop, particularly around, for example, how we work with people, how we engage with the community. And then you need that creativity, that capacity to think, well, hang on, if we're having this conversation with patients, why couldn't we at the same time have another conversation with patients? 

If we've got a resource that we don't need, maybe one of our partners could use that resource. So you're bringing all the different elements together, aren't you Penny?

Penny Pereira

I love that way of talking about it, Matthew, it makes a lot of sense. And it really connects to what Catherine was saying about the critical importance of better approaches to sharing and learning between areas. Because if it was just about knowledge, then we could just publish some case examples, we could publish a blueprint, and we could then go and implement it everywhere. 

But because all of this work requires that mix of things that actually don't travel particularly well in print. They travel through people talking to each other, through space with your peers to have the creative sparks, which is, okay, you did this in some areas. That's not going to directly work, but actually it sparked a different possibility. 

Now let's think together about how we could use the skills that we've got or develop new kind of capabilities, connect with different people in order to make that happen in our area. So, I think that's why those kind of peer connections, the ability to be able to spread learning from one area to another has often been challenging and hard, maybe particularly in primary care, which has often not been helped by being a large number of smaller organisations where we're not often very good at having proper investment into them, having the headspace and the support to be able to learn from each other.

But it's not just those institutional factors, it's actually the nature of the learning that needs to be shared between places. 

Matthew Taylor

And I think that comes back for me, to what's been a recurrent theme in our conversation, which is the need to hold two or three or four different ideas together at the same time if we're going to make neighbourhood working succeed. 

I remember a comedian once writing, the world is divided up into those people who see false dichotomies and those people who don't, which is quite clever when you think about it.

And I think one of those false dichotomies can be in the neighbourhood work between people who want to emphasise a kind of idealistic view that neighbourhood working is about a different relationship, a different relationship with patients, a different relationship with communities, and those people who say, yeah, but neighbourhood working has got to be about some pretty kind of technical, hard edged financial stuff. 

It's got to be about how it is we can reduce unnecessary demand in A&E, how we can reduce length of stay, how we can reduce unnecessary admissions. And sometimes it can feel that there are kind of two camps here, but actually, great neighbourhood practice has to be about both, unless we have a different relationship with patients and with communities. 

We're actually not going to serve people better and we're not going to get onto a sustainable footing. But unless we can show that that neighbourhood working does release capacity and acute, it does bend the demand curve, then it's probably not financially sustainable. We have to work with both of these mindsets, don't we Penny?

Penny Pereira

These mindsets and also the associated methods that are best suited for the different types of change that you're describing there. Sometimes in the world of improvement and perhaps the kind of large organisations in the kind of acute sector or mental health sector, people talk about the importance of having one method that everybody shares and works to.

And, you know, I have some sympathy with that. There's some good evidence that it provides greater clarity. But I think it is problematic, particularly in these sorts of scenarios where neighbourhood health will both need community asset co-production methods and they will need methods like kind of process redesign, improving flow, some harder edged methods which come from a slightly different school and set of approaches within the improvement world.

It's actually going to require leaders, teams who are able to know when to use the right kind of tools and approaches and then know how to combine those so that it really makes sense as a source of development for neighbourhood teams. That's quite a sophisticated and challenging set of objectives.

Matthew Taylor

Well, that takes us back to where we started Penny. Because I'm sure that supporting improvement in neighbourhoods is going to be one of the areas where the Q network and Confed now working together will be wanting to explore. There's a real opportunity of real responsibility for us there. 

So look, that's all we have time for in this episode. Thanks again to our guests, Heather White and Catherine Heffernan and to our intrepid interviewer, Jen Morgan. 

If you liked what you heard, please share it with others or get in touch. Let us know what you think. Have you got great examples of improvement that you'd like us to be showcasing on this podcast? If so, do tell us. See you next time. 

And by that point, Penny, you'll have moved in and we'll be doing this from a more joined-up Q and Confed. Goodbye.