What’s the future of care closer to home?

Matthew Taylor: Hello and welcome to Health on the Line from the NHS Confederation, the organisation that represents members from across the health and care sector. Now, if you're listening to this podcast the day it comes out, then you are listening at the time when hundreds of our members, policymakers, stakeholders will be gathering in Birmingham for our National Care Closer to Home Conference. We're recording this a few days ahead of that conference, but putting it out as the conference itself unfolds. 

So the timing couldn't be better. Now, we all know, I think, that the shift from hospital to primary- and community-based care that Wes Streeting says is so essential to the sustainability of the health service requires action at every level. Up and down the country, leaders across primary care, community services are demonstrating how this shift can take place and how by doing so we can address many of the challenges facing the health service and build services that are better for the people that we care for.

So our conference is an exciting opportunity to bring together health and care professionals alongside national and local experts and inspirational speakers to look at the future of care closer to home. But here in the Health on the Line virtual studio, I have three people who are more than qualified to talk us through some of the key issues that we face now and particularly as we think about the imminent ten-year plan. 

So I'm delighted to be joined by Richard Kirby, Paul Sherriff and our own Ruth Rankine. Richard is CEO of Birmingham Community Healthcare NHS Foundation Trust. Paul is chief officer for partnerships and integration, Birmingham and Solihull ICB and plays a vital role in developing integrated working and primary care to support the delivery of the ICB's core aims. And Ruth is the Confed's director of primary care who set up our PCN network and now has expanded it to become our Primary Care Network, reflecting the need to engage across the whole of primary care. So Richard, Paul, Ruth, welcome to Health on the Line. 

Let me start by asking you to tell us why you think it's so difficult to achieve this shift. Of course, Wes Streeting talks about it, it'll be in the ten-year plan, but we've actually been talking about it for decades. But what's actually occurred has been a rightward shift. I understand the latest statistics show that the proportion of health spending going through acute hospital activity is higher even than it has been over recent years. Why is it so difficult? Let's start with you, Richard.

Richard Kirby: Well, I think there's probably two things to say. One is that so much of the way our current system works defaults to the acute sector in a way that causes real difficulties for colleagues working in acute care. And we've got to work differently with acute colleagues as well as colleagues in primary and community care to tackle that. But also I think we've not come together in the primary and community care sector with the structure the intent and the purpose that would really help us rise to this challenge. So I think it's something about the way primary and community services can work together, which is a lot of what we've been trying to do in Birmingham, to rise to the challenge we face.

Matthew Taylor: Great, and I want to hear more about what you've been doing at Birmingham because I'm a huge fan. But Paul, do you agree with Richard's kind of diagnosis there of why this has been so difficult?

Paul Sherriff: I do actually, Matthew. think that what Richard said is very true. I’d kind of add a little bit to it, I think specifically from a primary care lens or a general practice specifically, it's a very distributed model of care the way primary care set up and therefore it's quite isolated. And I don't think we've made it necessarily easy in terms of bringing services together, whether that's for community partners, but also for our acute sector partners. So there is a sense of lots of different views on how we should do things, which make it incredibly difficult to get to where we need to. So I think some of the work that Richard's just alluded to in Birmingham is about how do we start to address some of that isolation and bring people together so we can get a shared view and a shared purpose.

Matthew Taylor:  So Ruth, before I ask Paul and Richard to elaborate a bit more on what they've been doing in Birmingham, you've played a number of roles. You've been in the department at times when people were ostensibly committed to this kind of shift of investment. So you've seen from a variety of angles how difficult it is. So what's your account of why we're rightward shifting when we are committed to leftward shifting?

Ruth Rankine: So I think it is happening in small pockets. If we look at our members, you can see where it's happening in terms of, we've got federations who for years have been delivering services outside of hospital, often contracted by the hospital to do so, whether it's diagnostics, minor surgery, MSK. We've now got community services in areas being able to deliver chemotherapy at home. And of course we've got digital, which enables a much greater focus on self-care and self-empowerment. 

So I think it's happening, as has always been the case, in small pockets around the country, but we haven't got that sort of overarching strategy, drive and commitment to make it wholesale. I think part of the issue is because of the lack of investment over the years in primary and community we just haven't been able to build the capacity that we need in order to deliver more care closer to home and in out-of-hospital settings. I think it's harder at the moment because in previous years, we've been able to double run and we've had funding to keep services running whilst building for the future. And given the current financial climate, we haven't got that luxury.

So I think there's just a number of things that at the moment are making it quite difficult, some of which have been there previously. But to be honest, it is a bit of an enigma because we've talked about it for over 30 years and we still haven't really managed to make it happen in any big way.

Matthew Taylor: And that's why what's going on in Birmingham seems to me to be so inspirational because it's not just a small pocket, it's a commitment across the whole system. I visited East Birmingham a few months ago. I was kind of blown away and then went around telling loads of other people that they should visit. And I think there have been lots and lots of people visiting the area. So, my perception, Paul, I'll start with you, my perception of what is different about what you're doing in in Birmingham and Solihull is firstly, the way that you're engaging with primary. And I know, Paul, you've been absolutely at the heart of that. So I'm really interested in that. We've been pretty explicit in the Confed about the fact that if we do want this shift to occur, we are going to have to grasp the nettle of primary operating at scale at kind of place level. 

And then the second element that I think has been this point that Richard has made about bringing primary and community much more closely together. That doesn't always, it isn't always the case. And then I think the third element has been an explicit recognition that the system has to reduce the overall investment, the proportionate investment in acute, if any of this is going to work. Those are the three elements I've observed from the outside. But Paul, what's your account of what's enabled you to do things differently in Birmingham?

Paul Sherriff: I think, starting with that, it feels to me as though the pressure is there for all services across all sectors. And actually there is a kind of shared purpose about wanting better services and better care for patients and the professionals working together. So there is something that feels very different, which is I think is the pressure and the expectation is being felt by everybody. And I think we've moved away from a culture of looking to externalise and blame one another. From a primary care perspective, we just started with some very honest conversations and without getting into too much of the detail, we kind of landed on, we needed to come up with a very clear clinical leadership model that made it pragmatic for primary care to have their voice heard and to have some influence and impact, but make it accessible and consistent for our partners, such as the community trust and the acute trust and social care. And that needed some managerial support. So that was a really clear view for us. And we felt the scale, the population of about 250,000 was the right kind of scale. That's what you saw in a place called East Birmingham and Washwood Heath. I think that there is something really clear around everybody getting a shared understanding of one another's problems and one another's perspectives. So actually bringing partners together in the same environment, in the same building, actually the points of difference aren't that great. We all want to try and do the same things but we don't have that shared understanding. So I would agree with you around those three areas. That's where I felt we've started specifically from a primary care point of view. And that's probably where I pass over the baton to Richard to add to.

Matthew Taylor:  Yes, Richard, build on that. I'm really interested in the emphasis that Paul puts on investing time, organisational development. One of my observations about the health service is that we expect people to collaborate, which can actually be really difficult. Iy involves making sacrifices, going back into your own organisation and saying, ‘look, things are going to be even tougher in the short term in order that we get to a better place in the medium term’, but we often expect people to do that without investing that time and that organisational development to create the kind of relationships and trust that is necessary for that to happen. You've done that in Birmingham, so I'm really interested in your observation.

Richard Kirby: I mean, I think we're doing it, is probably what I'd say, Matthew, rather than we have done it and it needs us to keep working together on it. We have been lucky to have some really strong GP leaders with whom we have worked both in primary care network leadership roles and in some of the GP federations in the city. And that's really helped in the process Paul described. But these things take time and they take give and take. So we've been able to, for example, as part of the work of bringing primary and community care services closer together, make some changes to local wound care pathways that have in the short term required a change in the community services in order to support primary care, to get us all to a better place. But that kind of give and take really only comes when you've started to build, I think, the kind of relationships across primary and community care at a scale with the kind of backup of a, in our case, a specialist community trust that enables you to work through those trade-offs. 

Matthew Taylor: And Richard, you're an influential figure nationally, do you sense that national policymakers understand what the success factors - I realise it's a work in progress in Birmingham - are, how does this feed into the conversation about neighbourhood working?

Richard Kirby: I mean, think there's increasing understanding nationally around both the importance of the neighbourhood and integration in the neighbourhood in a way you'll be very aware of, Matthew, and the Confed's been a strong advocate for. I think the couple of things are key and hopefully will be increasingly part of the way everybody works together going forward. One is the ability to organise primary care at scale across a patch so primary care can be a partner alongside NHS trust providers and that's part of what we've been trying to do in Birmingham. And the other piece I think is the deliberate bringing together of primary and community services in a way that enables us to gear up to do at our end of the system, if you like, the part of this work that can only be done in primary and community care and it hasn't always been the tradition that those services work closely together, it hasn't always been the case that those services are structured across a whole system and some of what we've been putting a lot of effort into in Birmingham. 

Matthew Taylor: So Ruth, turning to you, I think, you know, we're really clear at the Confed that we're agnostic about, as it were, who leads in the space between systems and neighbourhoods. But I guess we have a slight preference for this kind of Birmingham model, which is around bringing primary community, social care, community mental health together, and in a sense, commissioning acute rather than the other way around, which is acute, as it were leading a kind of integrated model and overseeing the rest of the service. Although, that is a model that works in some places and it's clear that the preference at the centre is to allow that to happen where it will work. But if we are going to have that Birmingham model, it does involve challenges for primary. And we produced a report in February, the Confed produced a report in February on the future of primary care. 

Share with us Ruth a couple of the key recommendations from that report in terms of what primary needs to do to step into this opportunity and also what kind of reception those recommendations have had. 

Ruth Rankine: Yeah, so the report we did was intended really to inform thinking on the ten-year plan, specifically around primary care in terms of what we want to see protected because we know it works well and we know it adds value, not just to patients but to the wider system. What needs to change and actually what needs to be removed. So one of the things that we've been grappling with for a number of years is actually the funding formula that works out or that calculates how much general practice receives to treat its population. And 24 years ago, I was involved in the team that negotiated the new contract that brought in the funding formula. And at the time, it was the best that we could do because it's not easy when you're talking about funding and you end up, no matter what you've introduced with, winners and losers. So I think that it definitely is time to look at how we fund general practice specifically to do what we need it to do in terms of the continuity of care that Secretary of State talks about, but also to think about prevention. But then also what's their contribution to neighbourhood health service and wider system working? So one of the key recommendations is around a review of the funding formula. And I think everyone nationally recognises that it's an issue. It's just a really difficult thing to address because of the potentially unintended consequences of any changes. 

I think the second thing was around, we've always advocated for greater flexibility for primary care around the additional roles scheme. So when the ARRS scheme, as it's known, was introduced, it was quite heavily specified in terms of which roles people could employ, how much you pay them, job descriptions. And actually what we wanted to see was if we're really going to give primary care the autonomy to design services to respond to the needs of the population it serves, we wanted to give them the flexibility to say, ‘these are the services we need to deliver on the basis of what we understand about our population and therefore these are the stuff we need to employ to deliver those services’. 

So through this year's contract, they have relaxed the rules around those workforce roles. But again, as with everything, there are potentially unintended consequences of doing that. And the final piece is around Section 75 funding, which allows obviously NHS local authorities to pull budgets around specific services. That currently doesn't apply to primary care providers, which in the context of a neighbourhood health service is really important because so much of what we need to address through neighbourhood health service is not just within the gift of the NHS. So that's one of the things that we've called for reform of the Section 75 and we know that that's something the department's working on. 

Matthew Taylor: Well, it's interesting that you finished there and turning to you, Paul, one of the things that is really interesting in Birmingham is that social care is very much part of the integration story at place level. Anyone who knows anything about local government knows firstly that local government is very challenged at the moment financially, but also that Birmingham has faced particular difficulties. And I'm not just talking about the dispute in relation to refuse collection services. How have you worked with local government, Paul, particularly given the kind of challenges that Birmingham City Council has faced? 

Paul Sherriff: Yeah, I mean, as you quite rightly point out, they're well publicised those challenges. I think from the outset, in terms of the inception of the ICB, there was a kind of broader system reset where, despite those challenges at the city council, but also our relationship with Solihull Metropolitan Borough Council, it was very much seen as a health and care partnership. So the development of our local policy of our five-year plan and our ambitions for our populations were clear. So it needed adult social care, it needed children's services, but it needed the broader council partners at the table. And I think I would go on to say around the establishment of our priorities at place, place of Birmingham and place of Solihull. So at every step of the way, the city council and Solihull MBC have been part of that journey. And that I think has given, despite the challenges that you highlight and they're well reported, has given that senior leadership commitment, despite those challenges, to be part of the development of those services that we've discussed already, for example, at East Birmingham. So I think it's the investment of time in the relationships, it's that shared commitment once again, but it's at all levels, I think. And that's probably been the really key thing that I would highlight, making sure it's at all key levels, but working right down at a place level as well.

Matthew Taylor: So Richard, there are lots of kind of fuzzy boundaries, aren't there, between what social care does and what community trusts do in a whole variety of areas. Some of the most challenging areas in terms of policy like continuing care. How have you been able to work with the local authority in those kinds of fuzzy areas to achieve synergy rather than conflict? 

Richard Kirby: I think it's a really important point Matthew. I mean, at the moment, we've just done it by being ultra-pragmatic. So our teams are together, particularly in the kind of areas you've seen, and we're trusting the folk on the ground to make the best judgements they can within the kind of frameworks we're all working in. We haven't yet got to the point of making structural change across organisations, and it may be we don't need to get there. Maybe we can do the majority of what we need from within the current arrangements. And people have invested time and effort and energy and as Paul says, our social care partners have been an absolutely critical part of this and we probably couldn't have got to where we've got to without them with us. Now that's not to say there aren't points of tension and things we've got to work through together, absolutely, as you'd expect. But so far, we've been able to do most of what we're seeking to do without rubbing up against those structural and frameworks that might get in the way. 

Matthew Taylor: Well, that Richard takes me to this question of what we need from the ten-year plan, because what you've achieved in Birmingham, you've achieved kind of bottom up in terms of the relationships there. We do need kind of national, a different national framework, different national policies. But what we don't want, I think, is something that's going to squeeze out this capacity for local partnerships, which reflect local challenges, local relationships. Richard, as someone involved in national leadership, but also at the Birmingham level, how do you think the ten-year plan gets right the need for a strong national framework, but not one which closes down the scope for the kind of bottom-up collaboration that you've created? 

Richard Kirby: I suspect it's probably three things. It's being really clear that there is a national expectation that people take integrated models of care, the neighbourhood team, seriously. So it's not a ‘if you want to’, it's a ‘this is part of the standard national offer across primary and community services’. I think then it's about local freedom to let people work out how to do that in a way that reflects their population, their history, their structures.

And it's then being clear, I think, that systems and organisations are accountable for the impact that they have. In a way, we are used to being accountable for some of the big national access targets and some of those other things that we know are top of the list in terms of delivery.

Matthew Taylor: Well, that's interesting, Paul, that last, I mean, everything Richard said is interesting, but that last point in particular about how, in a sense, we need to measure and care about and be held to account for things other than the issues that tend to be the ones that politicians most focus on, which is fundamentally around elective waiting lists, what happens at the front door of hospitals. That's one element of it. What else do you think we need to see in the ten-year plan so that you can build on what you're doing in Birmingham and Solihull and more places can follow in your footsteps? 

Paul Sherriff: It's a very broad kind of question, but I think what I'm hearing and what I'm welcoming of is that the kind of bold backing of primary and community services at a neighbourhood level, that to me makes real, real sense. In terms of some of the specifics, I think again, I'm going to, for the danger of sounding repetitious, it comes back to a shared understanding across all providers and the whole part of the system. 

So where we've invested some time is for our GP colleagues to understand the pressures within the hospital. So I don't think it's about saying what are the measures necessarily just in primary care. I mean, I'm slightly concerned, and I have been for a little while, about just looking at access. We've touched on, I think, and you've spoken about in other podcasts around the increase in provision that we've managed to deliver, but actually perhaps expectation and satisfaction with services is not as good as it was previously. 

So I think it's about listening to some of the professionals. It's being really mindful about what some of the service users feel in terms of the satisfaction with services. And it's moving away from just sole accesses, whether those are elective care, waiting times, GP access times, and perhaps looking at, I think it's very difficult to do, but continuity of care is a good one, personalised care and kind of broader satisfaction. So again, very difficult to look at it just in isolation. And I think we have to look at it collectively as a group of services. 

Matthew Taylor: So Paul, I'm really taken by that point and let me ask you all this question before we start to wind up. And Wes  Streeting talks about three shifts, the analogue to digital, hospital to community, treatment to prevention. You know, I've reflected on this a bit and in the end, I've come to the view that there really is one shift, which is the significant one, that is to say the digital data biotech, well, that kind of underlies everything and obviously we need to see progress in those areas. Nobody is, when we talk about hospital to community, talking about simply picking up a service in hospital and plonking it down in the community in a kind of unchanged way. That would be a bit pointless, I think. It seems to be that fundamentally what we're talking about here is a different model of care, particularly for those people who have long-term conditions, complex conditions, the people who are going to be using an ever-greater resource element of the NHS resource, but you know, as a reflection of the demography of the country. And I kind of feel that at the heart of the ten-year plan, we've got to acknowledge that the model of care does not really work for that group at the moment. And we have to work differently if we're going to have a model of care that's more proactive, more holistic, more empowering. Ruth, do you agree with that, that that's where we that's in the end the critical thing here? 

Ruth Rankine: Yeah, I mean, I think part of what people are struggling with is what does ‘care closer to home’ mean? And it is, as you say, it's not just about shifting a service that was delivered in the hospital to just delivering it in the community. I think there's a massive opportunity here to look at pathways with a group of multi-professionals across sectors and say, how can we do this differently? 

And it's not just about how can we do it more cheaply. It is about how do we deliver a better patient experience? How do we deliver more of this outside of the hospital? And that comes back to Richard's point, and Paul's, about people understanding what each other can do. So hospital specialists understanding that actually there's a whole group of GPs with extended roles in primary care who can do more than just day-to-day general practice, they're already operating that intermediate space. So actually seeing specialists come out into the community, working with GPs with an extended role, so delivering some of those enhanced services in that intermediate space, which is about delivering it more cost-effectively, but it also is about improving the culture of how we work across the primary secondary interface, but ultimately the patient benefits. 

So I think we need to be careful that we're not just thinking about shifting something from one place to another, but we're really using this as an opportunity to completely rethink how we deliver care. But again, this is not new. I mean, we were doing this 20 years ago in terms of looking at redesigned pathways. And in a lot of those cases it was actually hospital specialists who were driving some of this because they saw the benefit of delivering care in the community.

Matthew Taylor: So Paul, when I came to East Birmingham, Washwood Heath, I think one of the things that you said when I spoke to you was that you had started from working with GPs who acknowledged and believed that the model of care wasn't really working. That was the kind of bedrock of everything that followed. Sometimes I reflect on how our language gives us a way, we talk, don't we, in the health service about flow, and our concept of flow is that it's how do patients flow through the kind of fixed rocks of the health service. It really ought to be the other way round. The question should be how should services flow around the needs of patients? So do you think that's what needs to be at the very heart of this ten-year plan?

Paul Sherriff: I do actually. I think we perhaps engineered the way we've constructed services to cope with our pressures and we may have kind of lost a kind of sight or feeling for how it is to be a patient. it strikes me as I've been listening to the responses to some of your questions during this morning actually, the work that we do with communities and with our patients in terms of this shift is going to be as important as the work that we do with our professional colleagues, if not of more importance, because it's going to take time to manage this transition. My expectation as a patient 20 years ago was I would see my GP. I might actually see a pharmacist now. I might see an extended scope practitioner who's a nurse. I might see a physician's associate. There were a whole range of different roles. So my expectations need to change. And I think that investment in that transition around how services are going to be remodelled is going to be important. And I think how we work with the public and with communities to do that is key. 

I think we need to not just go through the motions, but genuinely listen and understand how do services need to work for you? If you're a busy parent, if you're caring, if you're working, but you're caring for an elderly relative, our current services don't work. You know, I have that personal experience myself. I think as we go through this, it's not just what we feel are the right ways of changing it. And I think what I've seen in Birmingham and as Richard has pointed out, we're on a journey. Nobody's saying we've got to the end, it's building in that time to understand not what just it means and for the experience of the professional, but what does it mean for the patient and the service user? How could we make the access to our services better? What are the range of services that need to be available, which might not be our traditional one. So yes, I agree with you in short, Matthew, but those are kind of a few reflections.

Matthew Taylor: Yeah, thank you. And Richard, obviously community services are in their nature very relational. I was talking to Jim Mackey just yesterday at our Mental Health Network conference and I was suggesting to him that the kind of cultural shift we need in terms of what our responsibility is to the people we serve. I'm just giving you a small example, much less complex than the challenges that we face, I know, but many years ago, Barking and Dagenham local authority they had this shift with the people who worked in their kind of call centre and their enquiry desk. And they said to people, you must no longer just give people phone numbers or people's emails or tell them what department they should contact. You've got to actually take that person to the next person, you must only hand them over when you know that someone else is now going to take responsibility for solving their problem. And this was had a huge impact in terms of satisfaction, but also the satisfaction of people who worked for the local authority, but also the citizens. 

Do you think that, as I say, our challenges are more complex than that, but do you think that at the heart of the ten-year plan also needs to be this kind of cultural shift to how it is we, all of us, are focused on building services around the personal needs of our patients?

Richard Kirby: Yes, I think making this as personalised as possible. And of course there's challenges with doing that in a large complex set of services. It is, I think, really important. So part of the neighbourhood team model, we've been working on, like lots of others have, is a full holistic assessment from a key worker from the team who then acts as that point of contact for the person we are working with as we try to put together the package of services that help them. And I think that model that tries to really kind of understand for a particular person what it is that helps them most and deploy that. And it might not be a statutory sector intervention, it may increasingly be services from voluntary or community sector partners in a way that enables that person then to take greater ownership for their health, needs to be part of the shift we're all trying to pull off I think. 

Matthew Taylor: Well, Richard, Paul, thank you so much. Ruth, I'm going to ask you, but you've only got a few seconds to do it. This is membership time of the year when we're asking people, we know it's a big ask to join or to sustain their membership of the Confed. Listening to this conversation and thinking about what we're going to try to achieve in our out-of-hospital conference, bringing together primary community, local government, just say why you think that Confed membership is so important for folk in primary care in particular at this time.

Ruth Rankine: You know, our number one objective is that we see a really vibrant future for primary care and that we support our members to achieve that future for themselves at a local level. And that's not just about looking at primary care on its own. It is about working with community, mental health, acute networks, because this is about primary care's role in the system. So how do we put it on that equal platform with the rest of the system? So I think if you talk to our members, they will say we have a different conversation in our Confed groups, we’re with like-minded people who see a different way forward, who completely understand the benefits and the need to work at scale, because ultimately that will drive more investment into our hospital services.

Matthew Taylor: Well, Ruth, thank you. Richard, Paul, thank you so much for taking time out of your busy day. As I say, I'm a great admirer of the work that you're doing in Birmingham. Thank you for joining us on Health On The Line. 

That just leaves me to introduce the latest leader in our Leader in Six interviews. And this time I ask six questions of Helen Ray, who's the outgoing CEO of North East Ambulance. I spent a fascinating day with her recently. 

Matthew Taylor: First question, what's the biggest issue that you're thinking about at the moment? What's top of your interest? 

Helen Ray: Yeah, so top of my entry at the minute because I only have eight weeks left to work before my retirement is making sure that the transitionary period of handover to the newly appointed chief executive is as steady and stable as it can be in what is a very challenging financial and political environment. So that is the thing that I'm really focused on over the next seven or eight weeks. 

Matthew Taylor: And I'm sure your success is very grateful for that. What's, give us an example of an innovation or change that you're most proud of in the organisation. 

Helen Ray: So I'm really proud in this organisation of the way that we have developed our cultural approach to quality and safety, taking those two things together. So recognising that you do not and cannot be a stronger organisation from a quality perspective unless you are really focused on making sure that your staff are happy in their jobs and have the right tools that they need to be able to be successful. I don't think we're there yet, but we have and do talk about the green shoots of development within that frame. So I'm really proud that I'll be leaving the organisation with a very strong framework that'll allow them to continue to grow. 

Matthew Taylor: Yeah, and you've wrought a real cultural transformation here in your five or six years. Tell us about a leader that you really admire. It could be in some health service, anywhere in the world, but just a leader that you've admired. 

Helen Ray: Yeah, I mean, it comes in lots of forms, doesn't it, leadership? So I have lots of role models that I look up to. And, as a female leader, I really admire lots of the women who've smashed the glass ceiling. So if somebody had said to me in 1983, when I was starting off as a student nurse, that I would end my career as a chief executive, I would have thought that was ridiculous because I didn't think I spoke in the right way, I didn't think I had the right education and I didn't think I'd get the opportunity to do that. But here we are. And one of the leaders who helped me to form myself as a person in the NHS is a lady called Katie Wake, who no one else will have heard of. And she was a ward sister. She was a leader for me when I was an orthopaedic nurse. And what she taught me was that kindness was the hardest and strongest thing that you could be as a leader in the organisation. Because with kindness, which is a really hard thing to deliver day in, day out, comes confidence and trust from other people. And if you are a trusted leader through your kindness and compassion, that is how you bring your followers along with you. So I've never forgotten Katie for that. 

Matthew Taylor: That's really interesting isn't it, because we were talking earlier weren't we about how the more the ambulance service can talk about what it can do for other people rather than for itself the more powerful it can be so that's really interesting. You've carried that through your career. If you were king of the NHS or queen of the NHS for a day, what's the one thing you'd do?

Helen Ray: Give much more credence and we talked about this a bit didn't we, Matthew, I'd give much more credence to how we powerfully interface with our primary care and community care colleagues. I think we've lost touch in that respect and I think when I described earlier what I would like us to be able to do with a significant amount of freedom is almost turn our face away from the traditional boundaries or the traditional interface we have with acute providers and turn that around to think about what does that look like in the left shift for the people who are the iceberg under the water that are our primary care colleagues. I'd really like us to have the freedom to do that more. 

Matthew Taylor: Yeah, absolutely. Tell us something about yourself, Helen. There's nothing to do with your job. 

Helen Ray: Interesting. I mean, I'm so boring! So, I mean, I've touched on the fact that I'm retiring. I'm a very keen gardener, bizarrely enough. I love my garden. I don't have a very big garden, but I've got what is classified as my tiny little allotment at the side of it. And as part of my plans over the summer, I'm going to retract myself into being part of The Good Life and grow vegetables and, you know, be a little bit more self-sufficient and a little bit healthier. So that’s probably not a very interesting thing, but it's interesting for me. 

Matthew Taylor: No, absolutely. And then last but not least, tell us something that you've enjoyed recently, podcast, box set, film, book, something that you've really enjoyed that you'd like to recommend.

Helen Ray: I don't know if anybody's said this already, but I mean, obviously everybody has been talking about Adolescence and I'm not a huge watcher of TV, but my husband and I watched that whole thing on a Sunday and we could not stop watching it until we'd watched the whole bit to the end. And it was enlightening and frightening, I think in equal measure if you really paid attention to what that was telling me about the psyche of younger people and the way that we need to recognise how the social media interface is impacting on them. What I think has come out of it, which is fantastic, is that it has opened a dialogue between old people like me and, you know, the much younger generation for us to be able to ask more, rather than judge. I think we're very judgy as we get a bit older and I think it's opened up a channel where we can understand more and potentially be kinder to the teenagers, the young people who are growing up in what are very challenging circumstances that were set out in that series.

Matthew Taylor: Well, it's a powerful bit of television. Look, Helen, thank you so much and we all wish you a wonderful retirement. But I also hope that you might do some work with us at the Confed because I sense there's still quite a lot of change…

Helen Ray: There might still be a little bit in me yet!

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