Bridging the gap: practical action on health inequalities

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Matthew Taylor

Hello and welcome to another edition of Health on the Line produced by Health Comms Plus on behalf of the NHS Confederation. 

Before we get into today's conversation, I want to let you know that you can now book for our fantastic Care Closer to Home Conference, which next year will be taking place on the 24th of February, in London.

Places are going really quickly. So book yours now at the NHS Confed website or go to http://www.nhsconfed.org/events.

Speaking of care, closer to home. Here at the NHS Confed, we've recently begun a new programme supporting our members in the area of ophthalmology. The aim is to help our members deliver care closer to where patients live and work now.

This is an exciting new programme of work. I joined the first session last week and it blew me away. Fantastic. When I joined, really interesting conversation taking place with a service user. But to help me explain more about the programme, its focus, how it's going to operate, I'm delighted to be joined by one of the Confed absolute stars, Sonya, assistant director of our acute network. 

So, Sonya, let's start at the beginning. A very good place to start. Why did we decide to put together the ophthalmology programme? What did we hope it would achieve for our acute provider members? 

Sonia Nosheen

When we put the programme together, we recognised that ophthalmology is one of the busiest specialties in acute care.

It has significant backlogs. The waits for patients are one of the longest waits for all the specialty areas. But also we recognised that probably out of all those specialty areas, it had quite a good infrastructure in the community and primary care setting to be able to safely transfer some of the patients from acute setting to the wider community setting.

So it made sense to explore ophthalmology in more detail. And we also know that it's one of the specialties that sees patients who are vulnerable, elderly, it has one of the biggest groups of 65 and overs within it. So being able to provide care closer to home for patients who really need it, was one of the focus points we wanted to start with.

Matthew Taylor

Great. And it's an issue I know also of concern to NHS England; they're, I think, concerned about the kind of patterns of care that there's a lot more money being spent on kind of lower-level needs of care, not enough, possibly on more kind of complex cases. So, there's work I think around how it is they can kind of change the patterns of care.

So this is an important area for many people at all levels. What do you think is the challenge, the biggest challenge in moving eye care closer to home? 

Sonia Nosheen

So, we know from all the teams who applied to be part of this programme, and we had a fantastic response. We know from them and the eight teams who are part of this programme that the absolute biggest challenge they are trying to work through is finance.

How can they ensure that by delivering care closer to home, the finance model is right, that the correct commissioning is in place, the funding models are correct, and that the sustainability for any payments that are needed to maintain these services in the community and primary setting is a significant challenge because we know that the acute sector in particular has got many financial challenges. And it's not possible to release money from the acute setting to the wider primary community setting. 

It's not possible to double run the costs as well. So how are we going to be able to deliver this care closer to home and ensure that the correct financial model is in place to sustain it? That's probably the biggest challenge that came back through the teams who are part of the programme. 

Matthew Taylor

Yeah, and again, this issue of how we align financial incentives with the aspirations of the ten-year plan is another one that I know so many people are thinking about it at, at so many levels in the health service.

Sonia, when we think about what we want to do in areas like this, good practice is, is really important. Not because it can be slavishly replicated, you know, everywhere is different. But good practice can help us understand key principles and see possibilities that we can then repurpose to local circumstances.

One of the things I enjoyed about the session that I joined the other day was hearing about good practice. Give us an example of a place that is doing things differently and doing them well. 

Sonia Nosheen

One of the examples that were shared for good practice in the first session was a Manchester Glaucoma Enhanced Referral Scheme, and we had Cecilia Fenerty, who was a consultant, ophthalmologist from Manchester Eye Hospital, come and talk about how they set up that service.

Now, there was a lot of great learning within how that was done, about having the right stakeholders, making sure that the correct digital infrastructure is in place to improve communication and sharing of patient records. And there were some conversations around how that business case was formed, the governance structure around it that's needed, and that feedback loop that was created to make sure that the communication and partnership working between primary and community settings and acute settings was sustained long term. That was a fantastic example. 

And just very quickly, we do have another example in our next session. Gloucestershire Hospital have been fantastic at the digital advancements that are really critical for care closer to home. Ophthalmology is quite complex in terms of the imaging that gets done, in all parts of different organisations. And being able to piece the full story for the patients and have all the images to be able to make correct informed decisions is vital. So having them come along and share with the teams how they have tackled digital infrastructures is really important so that other teams can learn from them. 

Matthew Taylor: 

Great.

And Sonia, I want to end with a couple of things that I gleaned from that first session. And the first is that in ophthalmology, as in other areas, there are kind of set of assumptions that people have, including people in the health service, which might get in the way of doing things differently. 

Talk a bit about how we need to address the way in which the public and other clinicians, other people perceive ophthalmology and what we need to do can change, challenge some of those assumptions. 

Sonia Nosheen: It's a really good point. In the first session we did take some time to think about systems thinking assumptions, different beliefs or experiences that people have that can help shape certain ways that people think. And there are a lot of assumptions that need to be addressed or understood. 

So, some of the teams that were part of the programme talked and shared how when we talk about care closer to home, will it be more cost effective? Is that an assumption? Because one of the things they recognised is that having parts of care provided in multiple locations in the system does mean significant financial investment in equipment or estates or workforce. So really trying to understand when we talk about care closer to home, where is the correct location and the right places to make sure that it's also cost effective is important, and it shouldn't be just an assumption that it will be cheaper to deliver.

There were some other assumptions that came through about how can they support the public perception on the great value and skills that the local optometrist and ophthalmologist are able to provide. Because there may be this perception that the public want to see more senior clinicians, ie doctors in an eye clinic, and how can we support that public perception that there is this really highly skilled workforce ready and available to provide the care that they need.

So these are some assumptions that they started to explore and think about how they can support and overcome. 

Matthew Taylor

And then the other thing about the session that was so powerful was to hear from a patient who gave really eloquent testimony, I think, as to the impact that the diagnosis had had on her, and really good experiences, but also much less good experiences in terms of the kind of communication to her, empathy with her. It is so important, isn't it, at the outset of these improvement programs to hear that patient voice. 

Sonia Nosheen

Absolutely Matthew. It really grounded the session and really welcomed the perspective and stories that were shared, and it was a great reminder how healthcare is a complex environment with hierarchical structures.

There's complex jargon, there is a lot of high workload and stress, but amongst that, we are trying to provide human-centred care for patients and people and the public. 

So it was a really honest account of the experience that she had, and it highlighted some good opportunities to reinforce some of the basics of care around simple things such as, hello, my name is, and describing what your job role is, being really clear about how you communicate, what different parts of the system, organisations or providers will do for patients to try and navigate through the complexities of healthcare.

Matthew Taylor

Yes, but because eye conditions are rarely life threatening, I think sometimes we forget that they are absolutely things that can transform your quality of life, your life experience, your employability, and all of this. And that's what we heard really vividly from the patient

In a sentence tell us where the programme goes next. That was the first session. It was great. What going to be happening over the next few months? 

Sonia Nosheen

So the next few months we'll be working with these teams to really understand the two biggest challenges, which is digital and finance. And through the teams working together, peer learning, having some experts come along and share some ideas and thoughts on how that can be tackled, will really help them with the next stages of being able to deliver care closer to home.

Matthew Taylor

Great. And it's just fantastic to see another example of our expanding improvement work at the Confed, and you've been absolutely essential to the growth of that work and the growth of our confidence as an organisation in helping our members to improve what they do. So thank you so much for talking us through that, Sonya.

If you'd like more information about this programme or what else we do for our acute providers, indeed all our members, contact acutenetwork@nhsconfed.org.

Now, we know very well that health inequalities is an area that needs urgent action. It's an area that is prioritised in the 10 Year Health Plan. So, this should be an opportunity for us as we think about the medium- and long-term future of the NHS to align with that goal of producing inequalities. Targeted action is going to be key. 

Now we know that respiratory disease and vaccine preventable diseases are great case studies of what's possible. For example, community-based respiratory programmes can improve early diagnosis and treatment access while expanding vaccine cohorts and raising awareness can help to increase coverage against vaccine preventable diseases.

So what practical approaches can help to bridge gaps, to improve health outcomes and to reduce health inequalities more broadly across, not just the health service, but the country. 

To answer these questions, I'm delighted to be joined by two charity chief executives. Firstly, Sarah Slee, CEO of Asthma Lung UK, a role she was appointed to in 2024. Prior to that, she was CEO at Crohn's and Colitis UK for five years and CEO at Celiac UK for 13 years. 

And Sarah's joined by Dr Tom Nutt, CEO of Meningitis Now the UK-wide charity that funds scientific and medical research. Prior to this role, Tom worked for an award-winning health charity that aimed to improve health and care services by capturing the voice and lived experience of patients, service users and carers.

And just before we get into our conversation, I need to add that this episode is non-promotional, sponsored by GSK and developed in partnership with the NHS Confederation. 

Sarah, Tom, welcome to Health on the Line.

So, Sarah, I'll start with you. Let's just ask the most basic question.

Sometimes we take the answers to these questions for granted, but it's a good point to start. Why is tackling health inequality as such an important issue for you, Sarah, and for your organisation? 

Sarah Sleet

Well, in terms of lung conditions, the biggest gaps in terms of inequalities actually occur in lung conditions.

So if you take a major condition like COPD, if you are in the poorest quintile, you’re five times more likely to die than if you’re in the richest. Now that's the biggest gap of all physical conditions in the UK and those kinds of differentials go across lung conditions. So getting to the root of health inequalities, dealing with them, is going to be fundamental to improving lung care in the UK. And we've got terrible lung health in the UK. We've got the worst in Europe, so it is time we did something about this. 

Matthew Taylor

Tom, ask you the same question. Why, is tackling health equality so important to you and your organisation? But can you just help me - sometimes when we talk about health inequalities, it feels like the issue we're focusing on is ‘equity’. It's the gap between the privileged and the most deprived. 

And sometimes we talk about it because it's really about improving outcomes because it's the poorest to have the worst outcomes. And so that's why you would kind of target things there. What is the kind of balance of these two elements, do you think in this story?

Dr Tom Nutt

Well, I think that's a really interesting sort of rider to that opening question really, because as you probably know, Matthew, and as many of your listeners will know, if you think about meningitis, it is a terrible and a devastating disease. It's relatively uncommon, thankfully, but when it strikes, it can kill within 24 hours. 

And around about one in ten people affected by bacterial meningitis will die. Others will be left with life-changing aftereffects, such as amputations, brain injury, sensory impairments, as well as the sort of psychological and emotional damage that the disease can cause. 

Now when our charity was founded, nearly four decades ago, there were no vaccines. So we set about funding the research that could help develop the vaccines with campaigns to get vaccines that could prevent meningitis into the NHS. We raised awareness about the signs and symptoms, the importance of timely diagnosis, and we've also worked really hard over those years to make sure people get the aftercare and support that they need.

And for many years that's great. And we, as a charity, often tell ourselves that that there's a great success story there. But actually, you look at the current situation, and this is to get to your point, you know, vaccine uptake has been falling for over the last decade. It's clear that people are still not aware of what to look out for, for meningitis or indeed other forms of acute deterioration.

And when we talk to people about how they access aftercare and support, it's clear that the lived experience is highly variable between good and very, very bad. 

I think you can look at it in all sorts of different ways, but I think it's helpful to look at it in a broad-brush way, which is that this variation is unacceptable in terms of people accessing health and care appropriately.

But also if we do want to shift the dial. Get vaccine uptake going to the kind of levels where it needs to be. And we've got to ask ourselves, what is it that's stopping, you know, that 10, 15, 20 per cent of people from getting those vaccines? And I think health inequalities, the debate we're going to be having today and that the system needs to have and the nation needs to have, I think you can start to answer some of those questions.

You know, why is it that we don't have, if you like, optimal vaccine uptake and optimal access to health and care.

Matthew Taylor

Thanks Tom. So, Sarah, we are moving into the thick of a very challenging winter for the NHS. But one of our challenges for us always is that the short term always pushes out the long term.

But we have a ten-year plan and that encourages us, us to think about that long term, to think about the possibility of, to use Tom's phrase, turning the dial on something like health inequalities. When you look at the ten-year health plan, where do you see the opportunities there for practical, measurable action in relation to health inequalities?

Sarah Sleet

You are right about, as we go into this winter, there are going to be huge pressures across the NHS, and a lot of that is being driven by respiratory conditions. So we know that as we come to winter, emergency admissions are being driven by people with breathing difficulties. Those admissions have actually increased by about 23 per cent in since 2022. 

And we know that when people go into hospital with breathing issues, they may have a stay in hospital, they then get discharged and then they end up, up back in hospital. About 30 per cent end up back in hospital. And that's because they are not being dealt with appropriately in the community. They're not getting that basic care all year round, which will help keep them out of hospital. 

So in theory, the ten-year plan should be brilliant for people with lung conditions because you know that shift, those leftward shifts to prevention is essential for lung health. You know, keeping people, keeping the environment that they're in healthy, but also vaccinations, as Tom said, really critical for people with lung conditions to keep them out of hospital.

But the basic care packages that should be delivered in primary and community care are simply not happening. We know, for example, with something like COPD and asthma, the basic care packages have collapsed in the last three or so years. Few of them, one in ten people actually with COPD, are getting that basic package. And of course, it's correlating with the increase in pressures of people going into hospital. 

So if we can take the time of the ten-year plan to really make sure that those community and primary services are there, are being consistently delivered, are being supported with the right workforce in the right place, with the right treatments, with the right diagnoses, which isn't happening in primary care either, then this will really fundamentally reshape everything that's going on and going wrong, in fact, with the NHS. 

But the problem's going to be, can we do that? Can we shift the resources, the attention and the head space that you need to get this right in a very pressurised system. I think we just have to really grasp the nettle now because we've talked about this for years and we're at the point of collapse, I think if we don't take the move now.

Matthew Taylor

Yeah, that's fascinating. And you know, when I've gone out and visited colleagues in primary care, we have a really strong primary care network in the Confed. The thing that's always kind of struck me as being powerful is those primary care networks teams that are very much focused on being proactive, not waiting for the patient to contact them, whether in person or online, but getting out, using data, reaching out to those people before they reach kind of crisis point. 

But that's, as you say, that's not easy to do. These things run deep in the health service just as we have failed over recent decades to achieve the left shift, and actually we've achieved a right shift, investing more in acute care. If you look at primary care, one can understand absolutely why it is that Wes Streeting and primary leaders in the centre are putting so much emphasis on access.

Of course access is not going to do anything about health inequalities on its own unless you have also got that proactive outreach element to it. That's important, isn't it? 

Sarah Sleet

Absolutely. If you don't concentrate on where the really deep inequalities are and where the real need is, you are just simply going to serve a population and a way of doing things that is already disadvantaging those people.

Every single driver is aligned in the wrong way at the moment because these conditions have been sort of overlooked and they're sort of treated as a, you know, just let's just keep people out of hospital and let's deal with the emergency situation. Let's not deal with the stuff upstream because we don't have the time and the resources to do it. That means that everything in the system doesn't help support appropriate risk stratification because we don't have the data there; appropriate people in the right places because we're concentrating on people getting through A&E quickly or doctors being able to get lots and lots of appointments out, but maybe not for the right people.

You know, all of the drivers, and all of the rewards are not aligned with the deepest need and with these upstream issues. 

Matthew Taylor

Well, Tom, that takes me to my next question, which is when we think about health inequalities and their impact, where is it that this is most obvious? Is it in differential access? Is it in different kind of levels of awareness in different population groups? Is it the way that we design services? I'm sure you'll say all of that, but where do you think we ought to be particularly focusing?

Dr Tom Nutt

So I think that's a good question. And in many ways I think it's tempting to think of health inequalities around vaccines as being a special case. But in many ways it is a corollary of the wider issue in the wider system. And of course with wider social determinants of health as well. So I'm afraid I'm going to answer your question by saying it is all of the above because actually we often describe our immunisation programme in the UK as being world leading and I think that's because we looked at it from the point of view of the vaccines that you're available. And that's largely true, although there are some gaps, for example, in the adolescent programme, which we would like to see addressed.

But actually many ways problems around health inequalities are the kind of workaday things that Sarah's just been talking about that affect both awareness, access and people's ability to interact with services, which is your design point.

So for example, as a mum, say for example, or a parent of an infant, can you actually get yourself down to a GP clinic to get the vaccine if you have a different cultural or linguistic background? Do you understand the letter that you've received that's asking you to come? Can you take time off work to go and get the vaccine?

We know that, for example, when we tried to vaccinate the NHS workforce, you'd have problems of people just not being able to get time off from their shifts to be able to get across town to get to the clinic and so on. So actually, unfortunately I think it is the case that the impact is felt across the board, but I don't think vaccines are necessarily a special case.

I think if we can address some of these issues at the root, then I think we can make progress. I think we should be optimistic. I would hate for listeners to this podcast to go away feeling gloomy about the state of the world because I think, the opportunity to change things and to address the impact as it's felt as a lived experience, is definitely within our grasp.

Matthew Taylor

Sarah, that again is a great prompt for what I wanted to ask you next because, and clearly the issue of health inequalities is moved in and out of the spotlight over the years, and it was the Covid pandemic that put it back in the front of our minds because we saw so starkly those differences.

When we think of respiratory diseases like asthma, COPD, and we see they are so strongly linked to social inequality. How do we need to understand what lies behind that? Again, one of these kinds of dilemmas we talk about health inequalities is should we focus on ourselves in the NHS because in the end, that's where we have agency and we can do something? Or should we be focusing on the kind of social determinants because in the end, if we only focus on doing the health service, we're kind of caught in the hamster wheel because of the amount of damage that's resulting from other factors that are driving demand. 

Sarah Sleet

Yeah, I think it's particularly pertinent with lung conditions because we know that those social determinants are really a big part of the picture.

If you are living in mouldy, cold, damp homes, it doesn't help. If you're living in an area where there's air pollution, you are more likely to have asthma, you are more likely to suffer from flareups with asthma. So I think the hope is, potentially, if we can get it right in the approach to the ten-year plan where ICBs act as strategic commissioners, but in doing so, they really look at population health and they really understand what's going on in their area and all of those different factors that are affecting the population health, and they're working with the public health experts in their area, the local authorities in their area, the voluntary and community sector organisations such as ourselves in their area, and talking about how the whole package can be looked at. Now, the NHS can't solve everything that's wrong in our society, but what they can do is be a kind of a convener of people who are determined to do something about health and bring those parties together and see what part everybody can play.

And I think there is that mood music in the ten-year plan to make that a reality. So I know that in areas like Liverpool, for example, there's a lot of work going on. There's an example where there is paediatric respiratory service, loads of problems in Liverpool because of poverty, because of air pollution, et cetera. The guys that are running a respiratory service there, they're not just treating the kids that are coming through their doors. They're thinking about the homes that those children are going back to once they leave hospital. And then they're thinking about what can we do to help change that scenario and prevent them coming in in the first place?

So they will talk to the local authorities. They're doing a project where they're putting in essentially dehumidifiers into those homes to make the indoor air pollution a much better-quality environment for the kids, and they are showing that you can reduce those kids coming back into emergency conditions.

So it's having that kind of doctor’s, healthcare, clinician’s thinking, yeah, actually I can do something beyond the patient in front of me and finding that time to do it, and working with their commissioners to make that a reality as well. 

Matthew Taylor

Really interesting and a couple of points come to mind as you're speaking.

So, one is, this is an area where we have managed to engage the public and change public attitudes in powerful ways - there is the huge decline in the prevalence of smoking, for example. More recently, the example of ULEZ in outer London, where there was overwhelming hostility. But since the data has started to come through, that’s shown improvements in air quality and shown reductions, for example, young people suffering from asthma it's interesting public opinion has really shifted. I think now a majority of people in those outer London boroughs are in favour of a policy they were very hostile to.

So I think one part of this story is if you really work at it, you make the case, you are willing to be a bit brave. The public will come round when they can see a clear and direct health benefit. 

The other thing is the importance of the NHS being part of a broader public service offer. I remember, a couple years ago actually, visiting a small town in Norfolk where they had outreach workers who were jointly badged from the local authority and the integrated care board, and that was partly so that when they knocked on the doors of people, they could deal with whatever problem they saw. If the problem was a medical problem, they could refer people onto the GP or another part of the health team. But if the problem was, exactly as you say, damp, they had the relationship to be able to contact the local authority housing department.

So it's important, isn't it, that the neighbourhood offer is not just an NHS offer, it is a kind of wider public service and voluntary sector and community sector offer. 

Sarah Sleet

Oh, it's so important. And again, there are sort of little seeds of hope there. 

There's something that's called ‘diagnosis connect’, which is going to be trialled later on in 2026. And the idea is that somebody gets diagnosed with a condition in primary care, pilots are going to start next year, they will be offered contact with the relevant charities for that condition. And what that will do, let's say it's Asthma and Lung UK, the person with a lung condition, we get in contact with them. We talk about what kind of support, wider support, those people might need. And of course we can then sort of signpost, help people into other services. 

So it's not just about dealing with their symptoms. We would start to talk about what is the home environment that you're in? What are the challenges that you are finding in terms of accessing healthcare, but also accessing benefits? for example

There's a huge ecosystem that is out there that has potential to support. The issue is joining up the bits of that ecosystem around the person who has the need. And that's what we haven't got quite got right yet. But I think there is a recognition that we've got to do that and there is hope that we can do that.

Matthew Taylor

So Tom, I was just talking about the case that we make with the public. And you would've felt, wouldn't you, that vaccines was an area where we really could win an argument with the public. 

But the picture is mixed. We know that vaccines are the most cost-effective way to improve public health, drive economic growth as a consequence, but they're kind of under prioritised in funding and policy. 

And when it comes to public support, understanding, while there are crosswinds in some cases, the public just don't know, in other cases there is active kind of vaccine resistance. 

So what steps can we take across government, NHS and the commercial sector, private sector to strengthen investment in immunisation and see it as being really integral to health strategy and to the strategy to reduce health inequalities.

Dr Tom Nutt

I couldn't agree more with everything you've just said really. And the phrase I had in my head as you were talking, and as Sarah was talking, was that we need to, if you like, kind of elevate the conversation about vaccines. It's almost as if vaccines have been taken for granted for too long for.

In fact, what we need to do, and in practical terms, it sounds a bit abstract to talk about ‘elevating the discourse’, but actually I think what we need to see is what I would call kind of leadership from the top down. I think we need our health leaders, and even our political leaders, to be saying that actually vaccines are integral to making the shift from sickness to prevention, which is what the ten-year plan says. I think we need to be looking with a forward vision about the role that vaccines can play, and then I think what you then see is in this kind of tiers below that, you can see action being driven collaboratively, which is probably something we need to sort of talk about in a moment, but also then thinking about how that then actually makes difference at the grassroots.

And the evidence is actually pretty clear. When healthcare professionals are empowered and enabled and given the time to talk about vaccines, then that can make a difference to uptake. When community groups and charities are involved in the delivery of vaccine programmes, then we know that that makes a difference. 

But of course, we've got a very complicated system. So we need to navigate that complicated system. And as I say, what confirms to me is that one of the sort of tragic ironies of Covid is that we all spent a lot of time talking about vaccines and, and those of us who, who care about vaccines in this world, probably naively thought that this was, you know, we were ushering in a golden age of vaccines. Everyone was talking about herd immunity and so on and so forth. 

But actually, what we've seen is probably something resembling, kind of fatigue setting it. Whereas actually we shouldn't take them for granted. They, you know, they're safe, they're effective. Investing in them has a huge multiplier effect.

One of the problems, I've mentioned the sort of system-level problems, is that vaccine cost effectiveness, when it gets assessed by the JCVI, by government in other words, it fails to take account of some of the social and economic benefits that preventing ill health can bring. You know, this is not just about resources within the health and care system, although that is critical, we should take account of the broader socioeconomic and for individuals, the psychologically emotional, the traumatic consequences of either preventing or not preventing ill health. 

So I think there's all sorts that can be done practically, but for me it is about, as I say, shaking us out of a bit of complacency about vaccines and putting them centre stage in the shift from sickness to prevention.

Matthew Taylor

And do you think, Tom, as part of that, that we now need to move away from what is, by kind of episodic approach to vaccines, which is, most of the time don't think about them. And then when you get to a certain age, you might have to think about the flu vaccine or if there's a pandemic, you have to think about the Covid vaccine, or actually children now at school will be vaccinated as part of their everyday kind of development through the school journey. More vaccines are coming online. 

Do we need to kind of get to a stage where citizens just think well vaccines is just part of my day-to-day life. Not that you're being immunised day to day, but that it's just something that will always be with you. Just like you have to get an MOT for your car every year, you have to kind of top up those vaccines that are relevant to you. Because it feels that this can episodic approach means that you have to start all over again each time, rather than just kind of embedding this in people's kind of day-to-day sense of what you do as a citizen.

Dr Tom Nutt

Yeah. I think culturally that's what we need to achieve this sense that vaccines are just part of what we do. I think there is a paradox of vaccines though. The more successful they are, the less we worry about what they're trying to prevent. The paradox of vaccines is that we're all much healthier, therefore, why do we need vaccines? 

So I wouldn't want to ditch a sort of episodic approach to vaccines management. But what we need to do is make it easier for people to interact episodically. So again, one of the sort of positive aspects of the ten-year health plan is to think about how we digitally enable people to access their own health records so they can know what vaccines they've had. 

And you know, why can't we use the NHS app, as I think is being promised, to ensure that people get called at the right time. So I'd actually say I think we need both. 

We need to sort of make that episodic interaction easier and more straightforward. But culturally, I couldn't agree more, we should just be thinking to ourselves that the way to have being healthy individually, the way to be healthy at a societal level is to be having that culture of vaccines that says, you know what, this is just what we need to do to make ourselves healthy and to treat health as an asset that's important to us for all sorts of reasons. 

Matthew Taylor

Thank you. And we're kind of drawing towards the end of our conversation, but a couple more questions I'm really keen to explore. 

So Sarah, obviously you focus on respiratory care, but participate in all sorts of other conversations about health policy. When you look at what kind of works in respiratory care, what do you think are the kind of lessons that could be, should be applied to healthcare more broadly? 

Sarah Sleet

When it's working well, I think that respiratory could be a real poster child for the ten-year plan. 

So when it's working well, that kind of sense of getting diagnosed early, whether it's through a screening programme - we have lung cancer screening now, but we're not taking full advantage of that because you go along for your lung cancer screening and if you have another finding, you haven't got cancer, thankfully, but you have another finding such as COPD, that's not actively followed up on, you think that it would be, but it isn't currently.

But if that diagnosis piece was dealt with well, and in some cases it is. Then the basic care stuff is dealt with and is valued actually by the NHS. So that there is, again, you know, I talked earlier about drivers and getting those aligned, so where people are taking the effort to provide that basic care in a consistent way, close as possible to the people that need it. Thinking about what kind of interaction can those people achieve? If you've got lung conditions, it might be hard to get to the local hospital, so the community pharmacy might be really closely, physically, geographically to where you are. Is it better that actually we're delivering our vaccinations or we're delivering smoking and cessation or something like that in a community pharmacy? 

So those are happening in pockets across the NHS. And then getting that into a kind of rhythm where that’s a consistently delivered package of care across the year, not reacting to crises, you know, as they happen.

It is happening in certain places, it is being dealt with well, and we can provide that as an exemplar to many, many other conditions that need that kind of approach in the NHS, whether it's diabetes, sometimes it might be heart conditions, it might even be anxiety-based conditions as well.

Get it diagnosed early, get it managed consistently over time, and then you are onto a winner. 

Matthew Taylor

Yes, and we've been doing some thinking in the Confed around how we can support local leaders to do things differently. And I think one of the insights we've had is you have to have a conversation, which is kind of dialectically moving between a conversation about the operating model in how do in hospitals and other services relate to each other, neighbourhood models, different funding mechanisms and all of that. But then you've got to bring that into a conversation about specific pathways and changing the models of care along those pathways. You have to have both conversations at once to make a difference.

Now, Tom, you mentioned a few moments ago the importance of, or you hinted at the importance of, kind of collaboration. When we think about health inequalities. What kind of partnership do we want to see? Do we need to see between government, industry, patient groups, communities? How can we create a united front in trying to reduce health inequalities?

Dr Tom Nutt

So I think for me this is about recognising that there is a common imperative. Vaccines are safe, they save lives. It's important that we drive up vaccine uptake and that we have a good conversation about vaccines in order to save lives and to prevent  illness and ill health. 

Now, of course, lots of us deeply care about this, whether we work for the NHS or the UK Health Security Agency, whether we work in the third sector like me and Sarah and others, whether we're community-based or indeed, whether we work in industry who actually produce the vaccines, the therapies that we need, and yet all too often it feels like we're all still operating in our silos. 

And you know, I mentioned at the beginning Matthew, didn't I? that as a charity, Meningitis UK is hugely proud of what we've achieved over 40 years. But actually I also acknowledge that vaccine uptake is falling. So, we can't sort of pat ourselves on the back on the one hand and then say, yeah, but it's not looking great, is it?

So, I think the way forward is collaborative. I think that can take many different forms. I've talked a lot about the need for a vision for vaccines in this country, which needs to bring together industry with the decision-makers in government and across the health system with people who can, charities like us who can connect, if you like, to people's lived experience of ill health and lived experience of vaccines. 

You know, there's a winning formula there to make sure that we do tackle the stubborn inequalities. And as we've been saying, sometimes inequalities are cultural, sometimes it's social and economic, sometimes it really is just workaday stuff of difficulties in accessing systems. So the solution for tackling that might vary. Place to place. That's why it's great that we're talking about neighbours. That's why it's great that we talk about local systems. But at the same time, there needs an overarching vision, which has to be born out.

Collaboration, recognising there's different strengths that we can all bring to the table, but as I say, the unifying part is that common imperative. 

Matthew Taylor

Thanks, Tom. 

So last question for both of you, which is this is a complex area, lots of different elements to it. But if there was one thing starting with you, Sarah, if there was one thing that you think if we'd managed to achieve it in ten years would demonstrate that we really had, back to that phrase again, turn the dial. 

What would be the one thing that you think would be a symbol of a shift or would be the biggest kind of facilitator of that shift? What would be the most powerful? 

Sarah Sleet

That's a tricky question to answer and this might be a bit of a weird answer in some ways, but one things I worry most about when I talk to people about trying to tackle issues around respiratory, and often I'm making the case that if you don't tackle respiratory and you're not going to achieve closing the gaps in terms of health inequalities because it's where the biggest health inequalities are, you are going to get hospitals falling over because people are going to end up in hospital. But if we think about people just in terms of managing flows through the system, I do sometimes wonder whether we are really doing the right thing by them. 

So if there was one thing I could do I think it would be, say, what is it in terms of the people that are living with these conditions that they would most want to happen? Is it for them about keeping out of hospital? Maybe, but it might be that it's about being able to engage, backing more fully with a society. It might be about engaging, backing with their families.

So I wonder whether we've got to think about the metrics that we're using for whether the system is achieving what it needs to achieve. And if we have changed the dial on just looking at waiting lists, just looking at free inputs in the hospital and we're looking at bigger, more meaningful metrics from a human being's point of view, not even a patient's point of view, I think that would be a really fundamental change. 

Matthew Taylor

Yeah, that's fascinating. Of course, we know that health is the single most important factor in people's sense of wellbeing. So how do we make an argument that's not just about the absence of illness but is about wellbeing and flourishing? 

Tom, what would be your kind of one big lever that you'd pull or one big shift that you think would demonstrate that we are on a different road here?

Dr Tom Nutt

Yeah, well, I mean, the idealist in me Matthew, says that the ultimate measure of success is when we are no longer having conversations about health inequalities. But let's think more practically. I mean, look, Sarah, you've already talked about metrics. I couldn't agree more about sort of person-centred metrics to drive change.

But actually, if we're talking about vaccines and preventable disease, we've already got a decent set of metrics. And that's around vaccine uptake. So, you know, a true measure of success will be to reverse that long-term decline that we've seen around vaccine uptake, making sure this sort of culture and the conversation around vaccines is a positive and a healthy one.

And then we'll see less disease, and ultimately that's what drives us as a charity. And it's what I think drives many of us as human beings, isn't it? You know, we want to live healthy lives. We want to be able to go about our day-to-day work. We want to be part of a family life where we can, which we can enjoy.

And as you say, Matthew, that's what you need to underpin. That is your health. So yeah, let's make sure we keep people healthy for as long as possible, and save lives

Matthew Taylor

Well look, Sarah, Tom, it's been great talking to you. I'm going to, following this conversation, turn the TV on and look at the cricket score, which is a terrible strategy in terms of my own personal wellbeing. But there you go. Maybe by the time people listen to this, it'll all have turned around and we'll all be dancing. 

Sarah Tom, thanks so much for joining me on Health on the Line.

Well, that's all for this edition of Health on the Line. Once again, thank you so much for listening.

We're always keen to share great practice, great ideas around the health service. So if you have an idea, if you have some, uh, interesting work you're doing, then do tell us about it. You can contact us at Health Comms plus@nhsconfed.org. So until next time, goodbye.