56. Becky Malby - Universal Healthcare National Inquiry

 Becky Malby - Universal Healthcare - Bookend 1 
Thu, Jun 13, 2024 5:40PM • 25:47
SUMMARY KEYWORDS
people, nhs, work, universal healthcare, poverty, podcast, community, universal health care, children, young people, waiting lists, places, measure, general, Whose Shoes, rationing
SPEAKERS
Gill Phillips, Becky Malby
 Gill Phillips  00:11
My name is Gill Phillips, and I'm the creator of Whose Shoes?, a popular approach to coproduction. I was named as an HSJ 100 wild card, and want to help give a voice to others talking about their experiences and ideas. I love chatting with people from all sorts of different perspectives, walking in their shoes. If you are interested in the future of healthcare, and like to hear what other people think or perhaps even contribute at some point, 'Wild Card - Whose Shoes' is for you. My podcast episode today is with the inimitable professor, Becky Malby. Becky is a well known mover and shaker in the world of healthcare, and I've been proud to work closely with Becky over the last 10 years or more. It's been a huge honour to be an associate of the London South Bank University Health Innovation Lab, and specifically to have worked with each cohort of Darzi fellows using the Whose Shoes? approach to coproduction and helping future healthcare leaders understand more about working with people and finding out what's important to them. So what are we up to today? Why am I introducing Becky to the podcast at this point? What are we going to be talking about? Well, I've always been a bit blown away by the work that Becky does, the common sense approach to working out what sits behind problems in healthcare systems, of finding radical and innovative ways to create the best care for people across boundaries. So today we're going to be talking about universal health care, health care that all people have access to when and where they need it. Becky has launched the Universal Healthcare National Inquiry Report, and we want a lot more people to be aware of this and to tell you more about the fabulous work that's been happening across the country as part of this initiative, I'm proud to be asked to do a mini series of podcasts in collaboration with London South Bank University and the Universal Healthcare network, there is a big synergy with Whose Shoes, for example, the report stresses the importance of seeing things from different perspectives, flattening the hierarchy and bringing people together to have open, honest conversations, to make change across the system. Start small and most importantly, start somewhere. There is also big synergy with the aims of my podcast in terms of seeking out exciting people, developing innovative healthcare solutions and sharing them widely. So it's a win win, and we're all excited to be doing this. So over the next few weeks and months, I'm going to be talking to four more special guests who will give us really practical examples of universal health care in action and the difference it's making in their communities. But first I wanted to start by talking to Becky to set the scene for the whole mini series and find out more. So what is universal health care? Why does it matter? What can we do about it? So without further ado, welcome Becky. Where should we start? 
Becky Malby  03:27
Hi Gill. Thanks so much for that lovely introduction. And the first thing that struck me about it was, was is it really 10 years?  
Gill Phillips  03:35
Yeah, it is.  
Becky Malby  03:36
It's amazing when you get over 60, but somehow everything's only been a short time, and actually it's been ages. So it's been lovely working with you, Gill over those years, and thanks for doing this podcast. You asked about universal healthcare. You'll know, Gill, that I and many others in the NHS are perpetually outraged, and during the pandemic, we were pretty outraged about the lack of equality of access and equality of service provision for people. So it looked to me like and to others like that some people were getting a lot more than others, and it was being tackled at sort of policy level around health inequalities. But actually, the NHS wasn't being entirely honest about how it was making things worse or contributing to it. And there are three things that we saw as we came out of the pandemic that worried us. One was that as austerity really bit and as people became phenomenally poor, they ran out of places to go with their problems, and so people have been turning up in general practice, particularly and in primary care in general, with health issues that stemmed from poverty, with nowhere else to go. So the first concern was ... actually, are you just medicalising poverty? Are we providing medical / clinical solutions to something that is actually about people not having food security, not having financial security, living in damp homes, being scared and frightened, and the stress of of deep poverty? So the first question was, if, if the NHS is medicalising poverty at one level, it's complicit in the problem that's causing people to turn up in the first place. And as honourable professionals, we actually need to be ensuring that the causes are tackled, not just sticking-plastering the symptoms. That's the first one. The second aspect of universal health care, where the NHS, I think, could be complicit, was that we were providing services that are not accessible to all. If you can't come to us, we can't come to you. And yet, during Covid, particularly the vaccine, we went absolutely everywhere. So it was very interesting. And I remember talking to a guy who was homeless, and he said, Well, I I really mattered to you during the vaccine when you thought I might kill you if I had Covid, but now I'm not going to kill you, you're not really that bothered about me and my health. And so I mean that really struck a chord with me that actually we have a duty of care to the whole population, no matter where they are. And so there are some lessons from the vaccine about, how do we find people and reach people? And then there's the phase after that, which is, and how do you help those people transition back into NHS services? Or what is primary care? is primary care just a session of appointments that people can and can't turn up to, or is it providing care to meet people's needs?  
Gill Phillips  06:48
Yes.  
Becky Malby  06:49
And the third question, and you can see these are pretty fundamental, was that we weren't being frank and open about rationing. So if you look at what counts, you know, you sort of measure what counts, don't you? We measure a lot about physical health waiting lists, the reportable data, and what politicians will talk about is how waiting lists are going up or down, and they mean physical health waiting lists. They mean people waiting for hip operations, but children, young people's waiting has been dramatic,  particularly ... It was starting before Covid and dramatic after Covid, as need has phenomenally risen. But we don't measure or count or pay attention to those waiting. There's no waiting list initiative for children, young people's mental health. There's a massive waiting list initiative for, particularly for adult people, more than children, to be honest, adult people's physical health. So we are rationing, and the NHS is putting those policies into action, and I think we need to be honest about it. So for me, universal health care is fair access, fair provision for all, no matter what their needs, no matter who they are, and that the NHS can in the way it delivers services, be more honourable about that fairness, and that's where we started.
Gill Phillips  08:06
Brilliant. And I think just to get that conversation out there into the open, and I've read the report and I've read the there's an executive summary as well, isn't it? Yeah, some very practical resources that go with your work that really help people understand these issues in a way that's accessible in themselves, I think so you started off just great there Becky, because you're picking up on a big theme of the podcast, which is curiosity. We've had curiosity. We've had people who are curious, which you are naturally, and that makes them furious. So you've gone straight in there with that, which picks up on, as I say, a theme that's running through, particularly some recent episodes we've had. And also, I'm really looking forward to talking to our first guest, Tom Holliday, and he's doing some fantastic work with children and picking up the theme that you've just mentioned, that children do get less. I'm working at the moment, one of my main projects is with Midlands Partnership Foundation Trust, and we've been doing some Whose Shoes? work around mental health of children. And it's been extraordinary. You know what I've learned, what people have learned, and absolutely bang on in terms of what you're saying. And these things just aren't measured, so it's so easy for them to just duck under the radar, and meanwhile, families are struggling so much, so that's why I'm excited to be working with you on this, on this project, and finding out more. 
Becky Malby  09:34
So Gill, it's lovely to hear you working with people who are trying to do something about it. And actually, I guess what's been really phenomenal about this work is that it has resonated. So actually, I haven't seen masses of defensiveness. I've seen masses of recognition. And you'll hear on the podcast series, you'll be talking to people who've really outreached from hospitals into communities, from general practices and prime care networks, working with faith groups and communities, really learning the lessons about collaboration, going to where people are. You'll hear stories of how they're trying to help those folks really get into the health services that they need to access them properly. You'll hear stories about general practice that are really trying to tackle and work and collaborate around poverty, are recognizing that poor people need something else, that are stepping up around people with complex needs, and that, you know, it really frames the work of integrated neighborhood teams, actually. Gill, so this could be a phenomenal start.  
Gill Phillips  10:34
Yes, I can really see the potential there.  
Becky Malby  10:37
So integrated neighborhood teams, on the whole, the policy makers think it's all about frailty. So the policy around them has been about frailty. But actually, if you look at where need is, if you start in particularly in general practice, it's a good place to start who turns up frequently, because if they're turning up in general practice frequently, they're probably turning up in the VCSE, the volunteering community sector, in hospital, A&E's, all sorts of places. But if you start looking at those folks, you'll find all sorts of people that you weren't expecting. So if you just point the collaborative effort around the historic story about where complex needs are, you miss the complexity of people's social and economic conditions, and actually, general practice can look after people pretty well with quite a severe level of physical and mental complexity actually, particularly physical, some degree mental, but where social complexity gets in, where those people have really difficult environmental contexts, that's when they need help. So if you, if you pointed integrated neighborhood teams just to old, frail people who have got, actually a phenomenal amount of wrap around support now, still much more to be done about coordination and shared skills, etc, you miss out children and actually, there are some children in our system who have really complex needs, who are living in very difficult circumstances. You miss out things like domestic violence.  
Gill Phillips  12:01
Yeah.
Becky Malby  12:02
We're seeing a real increase across the country. I'm a non executive on a integrated care board, and we talked about this recently, that we're beginning to see a huge increase in this. And what's the right response for that? I very much think any one service can't deal with it on its own. So when you're looking at looking at where we should collaborate, what's been good about this work is it's helped people think about actually, we can't do this on our own, and particularly if you're talking about people's context, yeah, but we do need social care, and you do need the voluntary community sector and for integrated neighborhood teams, the word is neighbourhood.
Gill Phillips  12:39
yes, indeed. 
Becky Malby  12:41
So you have to remember these place-based, local, community-based solutions, and they speak to the work that you and I have been doing over the years, which is 80% of of care happens in people's homes.  
Gill Phillips  12:52
Yeah. 
Becky Malby  12:53
People also need to contribute to be part of the solutions. It has to be collaborated and coproduced. You know, much that we know. So what people have done is they've not been defensive about these propositions. They've taken them on, and some folk are really trying hard to do something about it, very difficult in the current policy context. Let's hope, as we move through into a different government, no matter what colour or creed, that we have more generosity about these starting conditions, particularly around poverty, and particularly for our children and young people. 
Gill Phillips  13:06
And I think you're picking up Becky, the elephant in the room, big time. You know, things like the circumstances people live in, domestic violence, the work we're doing with Midlands Partnership now, we're doing a module specifically around children in care, and then the extra levels of complexity that that brings, I think these projects sometimes are dealt with as separate, you know, homelessness or domestic violence. But what I love about the work that you're doing about the universal healthcare approach, is it's people, and they're not in those little boxes. And the way that you're joining things up through multidisciplinary approaches. And I think we're going to have some very exciting examples to share through the podcasts. It was just that I'm picking up already,  
Becky Malby  14:12
yes 
Gill Phillips  14:13
one of the quotes that I love from the report, and again, picks up really well with the podcast series, and particularly an episode I did with Noreen Bukhari in Coventry, who's a long term mover and shaker in the voluntary sector, and get sustainable funding for voluntary organizations and community sector organizations. And the quote was, "so that they can focus on the work and not bidding for the work". And to me, that resonates so much just knowing how fantastic some of these organizations in the community are. But if you limp along with short term contracts, and by definition, can then only offer short term contracts, you're not going to be attracting the best people. You're not going to be keeping the best people. People can't plan ahead and do what we're going to do this year and next year. They're just limping along. So it is that kind of holistic approach that I love Becky. 
Becky Malby  15:11
So when we look at the volunteering community sector, I think this has been a, I guess, a harder one to tackle. So when we've talked about some of those other issues around medicalising poverty. You'll talk to George, and he'll tell you about how they've really tried to understand people are turning up frequently, those that relate to poverty. They've created collaborations with communities, codesigning solutions, really, really great neighborhood based solutions. So you'll see potential in that one, you'll see some potential around rationing. I think we're having more honest conversations now. For instance, at West Yorkshire ICB, we've created our dashboard, which includes children, young people's mental health, at least, making it visible where we're putting our money. We talk about it, we talk about trying to be fair in the way we deliver resources and funding, you'll see places like Frimley, really trying to tackle the fact that the Carr-Hill formula for general practice is flawed. So in wealthier practices and wealthier communities get more core funding than practices in communities that are deprived because Carr-Hill is skewed towards older populations, and actually most communities that are in poverty are younger, so there is general unfairness. So you'll see some places are trying to do something about it. We absolutely need policy makers to follow through on their promises. So NHS England promised it would review Carr-Hill, and it was make sure there's fair funding for all in general practice and primary care. And it just hasn't done it. So there are some real issues where local level people are trying to use their discretionary money as best they can, to make it fair, or trying to level it out, or there's some really amazing work going on, but it's very, very difficult. It's a real uphill slog, and you could just do with a better policy. And then you get to the issue around the VCSE, which is, we can't do this without the voluntary community sector. And I would say last year, there was not only appetite, but there was probably just about enough money to do that. So in West Yorkshire, we put aside funds, and we allocated that out to places, and we asked them to invest in the infrastructure the voluntary community sector this year. It's impossible, Gill, the money is so tight with phenomenal good intent, knowing that we're completely codependent on the VCSE, it's a real struggle in places to work out how you do it in a context where what you're measured on are not those sorts of metrics, where we're not required to do it, so we're not required, as an NHS to support and build the capacity of the volunteering community sector, even though, if that works, well, we know they'll be able to meet people's needs and support people. Yeah, you're looking at this general practice community services, I talk about GPs a lot, sorry, because I work a lot with them, and I have a lot of data on them, but Community Services will say the same. The referrals in are now absolutely phenomenal. So you have to say why, and you have to work where the why is, yeah, rather than keep on saying we've got to increase access with those staff. So this issue about collaboration, the voluntary community sector, the NHS role in shoring up and having that as a really good equal partner. Leeds did brilliant work with this under Tom Reardon and Mick Ward, really amazing. And their voluntary community sector that works in health is coordinated in Leeds as a really nice single point of access for the health sector into the VCSE, they're really good at bringing together and networking together across Leeds. It's absolutely phenomenal. And trying to build that some of what you're saying to that capacity around bidding, etc, but I wouldn't say that's common everywhere. So the VCSEneeds itself to begin to collaborate and to work out how it interfaces, and the health system needs to work out what it needs. And how on earth do we fund that in our current crisis? 
Gill Phillips  19:13
Yeah, it's just the same old, same old, isn't it? In terms of some things are easy to measure, so the things that are easy to measure, people pick up and measure, but things like prevention and early intervention just drop off the radar, because, you know, they're not statutory. I mean, we're seeing this ... the parallel with the work that we're doing with Midlands Partnership around, specifically the children with mental health problems, and then that holistic role, which I know comes through strongly in the report, in terms of no one person can solve this. It's it's families, it's school nurses, it's doctors, it's teachers, it's everyone. And I think the work that you're doing to try and join that up, and if the NHS are only responding to crisis and not measuring or aware of the things that sit behind that and prevent the crisis, then families are struggling, and the same problems are just perpetuating, aren't they, over and over and getting worse.  
Becky Malby  20:11
I think there's a really good case study for the NHS right now, which is around the obesity drug Semaglutide. So NHS England is requiring that every part of the NHS provides Semaglutide to people who on NICE guidance are eligible for it. It costs in terms of the drug 3000 pounds a head. That doesn't include the reorganization of resources and staff, because you have to do it through a referral pathway. And we don't have those referral pathways in every part of the NHS, so the cost of that, there is phenomenal amount of people eligible. And I'm just thinking, what? Why didn't we spend 3000 pounds a head as people are starting to get into trouble, and maybe what they need is, you know, is supermarket foo d vouchers for decent food and ... 
Gill Phillips  21:04
yes 
Becky Malby  21:05
and a life coaching and support. I know that's I'm o versimplifying it, Gill, I'm far oversimplifying it. 
Gill Phillips  21:11
But I love it. I know one of the things I absolutely loved about your work, the '10 leaps report' during the pandemic, and the hope there that the old system wouldn't bite back,  
Becky Malby  21:20
yes, 
Gill Phillips  21:21
and some of the initiatives that were there during the pandemic, in terms of helping people who were struggling, more community orientated, people obviously having having more time, and perhaps helping somebody with a slow cooker and meals that might be cheaper to prepare, that take a bit longer. But that kind of coaching and life coaching really isn't it, in terms of how you turn yourself around and also have enough money to buy, because healthy food is expensive. 
 Becky Malby  21:51
We have, you know, you have those sort of conversations, don't you, within the NHS around poverty and obesity, about, you know, the education system isn't teaching children to cook. Where can people access decent food? What do we do about what's on the selves in supermarkets? If you go into the Netherlands, you won't see rows and rows of biscuits. It's just not there. 
Gill Phillips  22:11
No.  
Becky Malby  22:11
You just don't see it. 
Gill Phillips  22:12
Or snacks. Just the culture of snacking doesn't exist. 
Becky Malby  22:16
So the entire system needs reworking. Our public health consultants know that Marmot knows that we've been saying it for years and and every time it's been said, it's unaffordable, it's unproven, and yet suddenly the money can be found. Suddenly, I think it's absolutely shocking.  
Gill Phillips  22:34
Yeah, I think just that. I mean, I didn't know that Becky. And I think that example it just sums up what we're trying to do here, doesn't it? Through this podcast series,
Becky Malby  22:45
yes, 
Gill Phillips  22:46
Something like that, that is medicalising poverty extreme.
Becky Malby  22:51
I mean, not for everybody. Obviously, there are obviously some people have got real difficulties. It's not poverty related, but you do need to understand where it is, and then you need to be working differently around that. And everybody is running around as if that's the hobby, if that's the you know, if that's just the sideline. And that, I suppose, is what worries me, and it worried me around the universal healthcare work. And what was so amazing about the stories you'll hear is people really, really adopting that and recognizing that these these sideline hobbies, nice to have around prevention, the nice to have around working upstream ... No, it isn't nice to have. It's absolutely essential, and we're going to try and do it. You'll hear some fantastic stories of people doing that and overcoming some enormous blockers to do that because they're great professionals. Whether it's Tom from the hospital system or Bill from the community system, you'll hear really great stories about it Gill. 
Gill Phillips  23:46
I'm really looking forward to that. Becky, I think this little I'm gonna call it a bookend with you. Okay, so we've got the four books, the main stories, coming along with our podcast guests, and this is the first bookend with Professor Becky Malby, setting the scene for what we're going to be doing and hopefully luring some people in to find out about it. Listen to the podcast. We're going to share some great links in terms of people finding out more about what's happening out there and how you can be part of it. And then, hey, Becky, we're going to bookend it at the end with us reviewing back on the series and seeing what we think's happened, and call for action. 
Becky Malby  24:23
Gill, I'm delighted you're going to talk to people who are absolutely passionate about doing something about this. There are great places you can start. You don't have to wait for national policy. I've, I've gone on a bit about how dire that is, but, but actually, people are doing some amazing things, no matter what, primarily by stepping into the problem, trying to find out what's really going on, rather than the fantasy what's really going on, talking with their communities and partners about it, and coproducing the solutions together, and that's what you're going to hear in the fantastic stories that are coming up. 
Gill Phillips  24:56
Brilliant. Can't wait. Thanks, Becky. 
Gill Phillips  24:58
Thank you so much for listening. If you enjoyed this episode, it would be fantastic if you would leave a review and a rating, as well as recommending the Wild Card - Whose Shoes? podcast series to anyone who you think might find it interesting, and please subscribe; that way you get to hear when new episodes were available. I have lots more wonderful podcast guests in the pipeline, and don't forget to explore and share previous episodes so many conversations with amazing people who are courageously sharing their stories and experiences across a very wide range of topics. I tweet as @WhoseShoes, thank you for being on this journey with me, and let's hope that together we can make a difference. See you next time