People who identify as LGBTQ+ experience disproportionately worse health outcomes and have poorer experiences when accessing health services. Three years on from the Government’s LGBT action plan, Helen McKenna sat down with Dr Michael Brady, National Adviser for LGBT Health at NHS England, and Michelle Ross, Co-Founder and Director of Holistic Wellbeing services at cliniQ to explore the health inequalities LGBTQ+ people face and what needs to happen to make sure health services are inclusive.
- What are health inequalities? (explainer)
- Supporting LGBTQ+ NHS staff (blog)
- LGBT health (reading list)
- Transgender health (reading list)
Thank you to the people from the LGBTQ+ community who were interviewed for this podcast episode and who generously shared their experiences with us.
- HM: Helen McKenna
- SU1: Service User 1
- SU2: Service User 2
- MB: Michael Brady
- MR: Michelle Ross
- SU3: Service User 3
HM: People who identify as lesbian, gay, bisexual, transgender, queer or questioning, as well as other gender identities and sexual orientations, are more likely to experience worse health outcomes than the general population, find it harder to access services and they have poorer experiences of using services when they do access them.
In today’s episode, we’ll be exploring the health inequalities that LGBTQ+ people face, as well as asking what needs to happen to make sure health services are inclusive for these groups.
SU1: You know at some point, you’re going to have to go, “By the way, I’m gay,” and you’re, kind of waiting for it to happen.
SU2: She asked me whether I’m man and I said, “No, I’m non-binary,” and then she asked me whether I’m a woman. I said, “No, I’m non-binary,” and this conversation went on for a while.
SU1: It made me feel really unseen, just really, sort of invisible and not really understood.
HM: I’m Helen McKenna, Senior Fellow at the King’s Fund. I’m joined on today’s episode by two brilliant guests, Dr Michael Brady, National Adviser for LGBT Health at NHS England and NHS Improvement, and Michelle Ross, Co-Founder and Director of Holistic and Wellbeing Services at cliniQ, a holistic wellbeing and sexual health service for trans, non-binary and gender diverse people.
Before we get started, just a note about terminology and language. In this episode, we’ll be exploring some of the issues affecting people who are lesbian, gay, bisexual, transgender, queer or questioning, as well as those who identify as non-binary and gender diverse. So, we’ll be using the acronym LGBTQ+ to signal this throughout.
It’s also important to recognise that the LGBTQ+ umbrella encompasses a diverse range of experiences. There are differences in access, experience and outcomes for people of different gender identities and sexual orientations, and we’ll be exploring this where we can in the episode, and as always, do subscribe, rate and review us, wherever you get your podcasts. It helps others to find us and helps us to improve the show.
So, Michael, Michelle, before we get into our discussion, it would be great if you could each just briefly explain your roles.
MB: Hi, Helen, I’m Michael Brady. I have a few hats. I’m the National Adviser for LGBT Health at NHS England and NHS Improvement, and I’m also a sexual health and HIV consultant at King’s College Hospital in South London.
Broadly, my remit is to address, highlight and improve the inequalities experienced across healthcare for LGBT+ individuals. So, focussing on improving access, improving experience and improving outcome.
MR: I’m Michelle Ross. I’m a psychotherapist, and I’m founder of cliniQ, which is a holistic sexual health and wellbeing service, and we’re in partnership, a very wonderful partnership, with King’s College Hospital, where we deliver a service together on a Tuesday.
At CliniQ, we have fourteen therapists who deliver sessions throughout the week for therapy and wellbeing, and we’ve been delivering services coming up for ten years, which seems to have gone so quick.
HM: Brilliant, thank you, and it’s great to have you both with us. So, research has shown that LGBTQ+ people experience quite striking health inequalities. Michael, can you tell us a bit about the types of health inequalities that LGBTQ+ people face?
MB: Yes. I mean, I think the point to make is that we see inequalities wherever we look for it. I don’t know of any data that shows that LGBT+ people fare better than their heterosexual or cisgendered peers.
I think one of the challenges is that we don’t actually ask the questions often enough. So, we’ve actually got huge gaps in our data because we don’t routinely ask about sexual orientation and gender identity and trans status in every setting.
We do ask about sexual orientation in all of our national NHS patient experience surveys. We’re starting to get better data in mental health services, but to summarise, where we do ask the questions and we see inequalities, I think one of the main ones is in mental health. Patient experience is worse across the board in every setting. Substance misuse, alcohol misuse, smoking is much higher in LGBT+ people. We have some data to show that some chronic diseases are more common.
Screening is less likely to happen. Cervical screening is a really good example. Lesbian and bisexual women are much less likely to go for smears compared to their heterosexual peers, and accessing smears is particularly problematic for trans men and non-binary people assigned female at birth, with major barriers to accessing and much lower rates of cervical smear.
So, that’s probably a snapshot. As I say, wherever you look, you find the inequalities, but we do need to get better at data collection across the board.
HM: Thanks, Michael, and really interesting, the point around the data, because you were saying, you know, where we have the data, it shows significant inequalities, but obviously, I think you’re suggesting there’s a point there around the limitations of the data as well.
MB: Absolutely, and I purposely always say ‘where we have the data’, because one of the things certainly that I’m working on at NHS England and with colleagues across the country is to improve the collection of data, our data monitoring, which is really about getting to a stage where, systematically and robustly, across the system, we collect information on sexual orientation, gender identity and trans status.
Until we have data in every setting, we won’t fully understand the breadth and the depth of the inequalities, we won’t have anything to benchmark against when we’re making improvements. Collecting data or asking those questions is a way for services to demonstrate that they’re inclusive of LGBT+ people and that they are welcome and recognised and their needs will be met in services.
So, I mean there’s many reasons to get better at collecting data, I mean not least that I think we have a legal and a statutory duty, and we have a duty under the Equalities Act to address or prevent discrimination for the nine protected characteristics in the Equalities Act. So, in this sense, we’re talking about sexual orientation and what’s called gender reassignment in the Act, but essentially is trans people.
I think as public health services, we are not discharging out duties under the Equalities Act, unless we’re collecting this data because we don’t know the proportion of LGBT people in our services and we don’t know what their experience is.
So, I would encourage all services to, if they’re not already, collect this information on sexual orientation and gender identities.
HM: Thanks, Michael, and, of course, we need to be clear that there are different identities within the LGBTQ+ population, and that access experiences and outcomes will sometimes differ quite significantly between them.
So, Michelle, coming to you, thinking about the groups that you work with most closely, and that’s trans and non-binary populations, are there specific challenges that these groups face?
MR: Oh yes, and in a way, it, kind of, follows on from what Michael was saying around that data and the collection of those questions and around a broad range of identities. There’s something I often say, wherever it is, if we’re not counted, we don’t count, and data is not just about numbers, clearly. It actually really looks at the details that people face, the different lifestyles that people have as well.
When I’m saying that, I’m talking about LGBT people, but trans people specifically. You know, there are some trans people that are privileged and can access mental health services that they choose, which might be privately-led. However, there is no data on mental health services, mental health issues for trans people.
Well, let’s just say, in those NHS services, we have got the data. About 84% of trans people have thought about ending their life, just under half of trans people have committed some kind of act of self-harm or attempt of suicide.
Now, if you think about almost half of the population of any population, that is huge. Trans people are seen as a vulnerable population and a small population really, but if you think, if that was half of the whole country that have attempted suicide, there would surely be an outcry, and there’s not an outcry on these issues.
Historically, and presently, trans people have to be diagnosed with a mental health condition really, gender dysphoria. That really doesn’t help people have a sense of self. It should be really in primary care, so that, you know, the services are much more easier accessible, because still, we see mental health as a stigma.
Now, trans people in and of themselves, don’t have mental health issues because they’re trans, but it’s the system, the way that it’s systemic and the culture around being trans and the harm that that can do. They’re not able to access services that are inclusive, aware and delivered in an appropriate way. It really is a vulnerable population in many ways because of lack of access to those informed services.
It really needs to change. I think it’s getting to a crisis point, especially the way that things are happening at the moment with the huge attacks on trans and non-binary people. We see it in our mental health services at cliniQ. We see the impact. You know, getting 90 referrals in a month is quite overwhelming for us, and I think it would be for any, and it’s all about the mental health and they’re not able to access services and trust, if they do go to their services, that they’re going to get met in a way that respects their identity.
HM: And, Michelle, I’m really struck by what you said around, you know, if you're not counted, you don’t count and just how dispiriting that is, and also highlights how important services like yours are that are, kind of, focussing on specific communities and their needs.
I think just thinking about taking an intersectional approach, obviously, sexuality and gender identity are only a part of our identity. So, how do other characteristics, such as race, ethnicity and disability, play into this?
MB: You know, we are none of us walking around with just one characteristic or one experience. We’re all a richly diverse mix of our ethnicities and sex and sexual orientation and gender identity and our religion or whether or not we have a disability and where we were born and where we live and what jobs we do and our disposable income. All of those create complex pictures which means that, as much as possible … and this is difficult sometimes when you’re think of it from a large-scale national point of view or even from a service point of view, but it’s about really trying to always give thought to that individuality and not using too broad brush an approach around health inequalities.
HM: I’d like to move onto the LGBT action plan now. So, thinking about what’s being done to tackle these issues, the cross-government LGBT action plan was launched back in 2018, and it had over 75 commitments aimed at setting out how to improve the lives of LGBT people, and 12 of those were focussed specifically on health.
Before we get onto what progress has been made against the commitments, can I just take you both back to the launch of the report. Was this an important moment from your perspective?
MB: I mean, I think the LGBT action plan and the national LGBT survey that preceded it and informed it were incredibly important points in time. The survey was the biggest survey of its … well, it remains the biggest survey of its kind in the world, with over 108,000 responses from LGBT people talking about their experiences of living in the UK, and as you said, Helen, with some specific questions around health which led to the forming of the action plan.
I think it’s important for a number of reasons. Firstly, just if nothing else, because it was a very visible statement of intent from the government. It was a really tangible commitment to ask the questions of the community, to listen to what they were being told and to do something about it by developing an action plan with specific commitments.
HM: And Michelle, thinking back to those three years ago, was it an exciting, kind of, optimistic moment for you?
MR: I’d like to say it was. I agree, it was really important for LGBT+ people, absolutely, and was needed, needed to be actioned, and when I say ‘actioned’, what I would like to see are goals set, timelines set. Not just an action plan, and when do we know when things are going to be set in place? Where are the actions? How do you then break that down and say, “Well, this is what we’re going to do then and this is what we’re going to put in place. This is what’s needed.” What is needed out of this most of all? What is the priority? Is there a priority?
I am someone that’s seen many action plans in my lifetime. You know, I think as a trans person myself, and I know I speak now from a community, but I also speak as a psychotherapist as well, that I get a little bit tired and a bit wary of seeing action plans. Now, that’s not taking away from the action plan we’re talking about, but I’m just saying it feeds into when is this going to happen? When is it going to make a change to people’s daily lives? Are they still going to be thinking about ending their life? Are they still going to be self-harming? Are they still going to be going to a mental health service that doesn’t recognise them or is really difficult to go to and being stigmatised within that.
There is a crisis in the trans community at the moment, and as I said, the amount of referrals we’ve received just demonstrates a small part of that crisis really. I mean, trans people, as far as I’m aware as a person from the communities, are not looking for anything special. Just equal rights to access to services that are informed across the country.
HM: And rights to their, kind of, very existence in some of the cases that you're talking about, Michelle. In terms of the action plan, you know, it’s been three years, that’s a relatively short time, but are you seeing a difference in terms of on the ground with the people that you’re working with as a result of that action plan?
MR: I think they’re going worse really, in the context of those attacks. I have seen changes in access to services in gender care. So, I’ve seen those making it easier for some areas of the country, for trans and non-binary people, to access some of those services.
So, if that’s part of it, then yes, I’ve seen some changes, but for me, that’s scratching the surface because there’s many people that don’t need those services and yet, those people still have needs, still have mental health needs, still have support needs, still have many other needs for their daily living. You know, so have I seen changes? Yes, but I haven’t seen enough.
HM: And it sounds like, to me, there’s a health, kind of, emergency within the trans community.
MR: Yes, I would say so, I would really say so, and if I don’t express this enough, I’m not doing something right. I’m not doing my job right.
HM: So, Michael, over to you in terms of, you know, it’s been three years. Obviously, we’ve had COVID as a pandemic during that period, but how have things changed from your perspective? How much have you been able to implement of that action plan so far?
MB: We have achieved some successes if we’re thinking about some of the specific commitments within the action plan. I think the other thing to remember about the action plan is that, like a lot of the things that we need to do, and this is sometimes part of the challenge, there isn’t often one single organisation that’s needed to deliver it. So, we do need a coordinated approach across the system that involves NHS England, it involves the community, it involves individual service providers and the Department of Health and sometimes with the Royal Colleges.
So, sometimes part of the challenge is pulling everybody together and getting that action, but certainly, there are commitments within the action plan that we haven’t achieved. So, my other area of work is as a sexual health and HIV consultant. So, there was a commitment around pre-exposure prophylaxis and we now have PrEP, the incredibly effective HIV prevention strategy, available on the NHS. We’ve still got more to do to make sure that everybody who needs it, who is at risk of HIV, has access to it. Having PrEP commissioned was one of the commitments, and that’s a success.
We’ve seen just recently changes to the blood donation rules. So, blanket deferrals for men who have sex with men. That’s gone, and now, everyone who donates blood will have an individualised risk assessment, irrespective of their gender or their sexual orientation. So, that’s been improved.
There’s been some work around surrogacy. The first commitment was appointing the national adviser, and so I’m pleased to say that I’m here and still here. So, that commitment has been achieved, but I think some of the other areas I would describe as works in progress, and they’re all areas that we’ve touched on already and Michelle has gone into detail. So, things around mental health, things around access to gender identity services, commitments specifically around LGBT+ people with learning difficulties, autism, issues around body image. So, there are some broader issues that we still need to work on.
I don’t think that means that the action plan is of no use. I think it remains a useful document, you know, and as I said, it’s very evidenced by the responses from the survey. It remains a, kind of, focus, I think, in terms of highlighting areas. I definitely think that there is scope to add more or to also focus in other areas. You know, as we’ve said, health inequalities exist across the board, but we can still keep working on those areas described in the action plan.
HM: Thanks, and in terms of where the action plan is at now, Michael, because a few weeks ago, I think I spotted some comments from equalities minister, Liz Truss, who seemed to be suggesting that the status of the action plan might be under question in terms of current government policy. Have you had any clarity on that, Michael?
MB: No is the honest answer to that. I mean, I am involved in discussions with government and, you know, the Department of Health and also discussions with NHS England about new areas of focus and where we should be heading in the future.
Certainly, you’ll probably have heard of and be aware that the government is running an international LGBT+ conference next year. I think that’s a real opportunity for us to focus on health priorities as well as within that key theme of that conference of ‘safe to be me’.
So, yes, there’s work ongoing still about, you know, as I’ve said, keeping going with the areas that were described in the action plan, and also adding more or expanding them. I think it also goes back to the point I was making before, is that there are multiple organisations that are responsible for delivering this work. I mean, clearly, the government sets policy and sets the environment and the culture within which we work.
So, that’s very important, and keeping a commitment to address these issues high on the agenda is as important as ever, but there’s certainly work, both at a national level with NHS England and the Department of Health, and frequently, I think, also we mustn’t forget at local levels. I mean, whilst those of us that work for national bodies have an important part to play, a lot of the changes, a lot of the really good work that’s been driven to address health inequalities is happening in individual trusts, by organisations, from the community, like cliniQ at a more, sort of, local or regional level as well. We mustn’t forget the importance of their contribution.
HM: So, we’ve talked about what the NHS is doing to try and address the health inequalities faced by LGBTQ+ communities, and now I want to explore a bit about the experiences of individuals when using health and care services.
To help us get a sense of this we spoke to some members of the LGBTQ+ community to find out what their experiences have been like.
SU1: You know at some point you’re going to have to, “By the way, I’m gay,” and you're, kind of, waiting for it to happen.
I had to go in for a small procedure and it meant that I had to get anaesthetic. I was just in and out. I didn’t have to stay overnight or anything, but I did need to bring somebody with me to take me back from hospital.
The nurse was, sort of, taking me back to the waiting room, to my waiting partner, and he said something like, “There is someone waiting for you, isn’t there?” and I said, “Oh, yes, yes, my partner is there,” and he said, “Oh, that’s really good of him to come in,” and I said, “Oh, actually, it’s a she,” and he said, “Oh, how does that work?”
I could see on his face that he, sort of, saw the penny drop and realised that he’d said something he didn’t really mean to say and he, sort of, apologised. He went, “Oh, have a nice rest of day,” and sort of threw me at my partner and ran away.
SU3: In my experience, from my particular situation, the care that I received over the years has been consistent and attentive. I’ve been HIV positive for 25 years. So, I mean, the fact that I’m a gay man was pretty central to that experience. So, right from the off, I mean, it was never an issue. It never has been an issue. I was never made to feel that my sexuality, as far as I can perceive, it’s never had any bearing on the kind of healthcare that I’ve received. It’s almost invisible.
SU2: I did have one specific negative experience. Essentially, I requested a referral to the Gender Identity Clinic. So, I met with her and she asked me whether I’m a man and I said, “No, I’m non-binary,” and then she asked me whether I’m a woman. I said, “No, I’m non-binary”, and this conversation went on for a while where she wanted me to pick between whether I’m a man or a woman, and I kept insisting that I’m non-binary. As a result, she said, “Oh, I think your blood pressure might be quite high.” Yes, because I’m quite upset by this point.
I come to speak to this person who is supposed to be a specialist and they just act like a barrier.
SU1: The one that, kind of, left me quite angry I suppose, it, sort of, stuck with me, I was in hospital. I ended up in A&E with what turned out to be a blood clot in my leg. By the end of the day, I had to go and see the nurse specialist to be given a prescription for the blood thinners. So, after you’ve had a blood clot, they give you blood thinners for up to six months, just to make sure everything is flowing properly again.
At the end of it all, she said, “Okay, I’m going to give you the prescription today, but you’re not to start taking them until I phone you tomorrow morning because we’re going to use the blood that you’ve already given us to do a pregnancy test.” I started to say, “Oh no, that’s okay, there’ll be no reason for you to do this,” but I didn’t get to get through my sentence before she said, “No, it has to be done. We do it for everybody. There’s no arguing.”
All I wanted to say was, “I’m gay. It’s very unlikely,” and I realise that there are probably protocols that they have to go through and I realise that there probably are exceptions and there are reasons why they have to do that, but really, all I wanted was to be able to put my situation forward and for her to say, “Yes, I’ve heard you.”
I just felt like she didn’t know who I was or understand anything about me, and just by not taking that moment to let me finish that sentence, it made me feel really unseen, just really, sort of, invisible and not really understood.
SU2: So, I can see the importance of especially the people who have the power to be the gatekeepers to be properly educated and to support the patients. It’s such a small change that could mean such a big difference.
HM: So, we heard a range of experiences there, including some positive ones, but also what comes across so clearly is that there is a lot more that needs to be done to ensure that the NHS is genuinely inclusive for everyone.
Various findings, including data from the LGBT Foundation and the government’s own 2017 LGBT survey suggests that work needs to be done with healthcare professionals, to improve their awareness of LGBTQ+ issues, so they can provide better patient care, and there are also issues for staff themselves. For example, the 2020 NHS staff survey showed that lesbian, gay and bisexual staff report worse experiences than their heterosexual colleagues, with nearly 14% reporting discrimination from patients or the public, and nearly 12% from their own colleagues.
So, Michael, Michelle, from your perspectives, what are the key things that need to happen next to make real and meaningful progress in tackling health inequalities for LGBTQ+ people and to ensure that health services are inclusive?
MR: Oh, that’s a big question because I think the NHS is, overall, wonderful, really, and I genuinely mean that. I think our health would be far worse without something like the NHS or actually the NHS.
Yes, I think there is work being done. I know from the work that I’m involved with within the NHS, you know, I see various departments. I see lots of activism within the NHS on changes. You know, you only have to look at all the badges that have come out within the NHS on it, the rainbow badges meaning LGBTQI, and also there’s now a trans badge.
So, there is work, but that needs to be right throughout, because I think it’s mostly within certain trusts that do that, and it’s not just about giving out a badge. It’s not just about this or a label or something. It’s about how do you help the staff, the front-of-house people, the people that deliver the services, the clinician? How do you help them be reminded that it’s not just a binary system, that there’s LGBTQ people who also identity in a range of identities.
That needs to change, and we spoke about the data and forms that people fill in, and I think that on a daily basis, using those, reaffirms that there is more. There’s not just male and female. There are people who have sexualities that are different to them.
I’d love to hear Michael’s point of view on this.
HM: I was going to ask you, Michael. You know, you’re obviously somebody who’s trying to drive change in this area and so many others across the NHS. What’s your view in terms of do you think the NHS currently sees the issue of providing inclusive, sensitive and appropriate care as enough of a priority, bearing in mind there are pockets of excellent practice and then potentially areas that need further development?
MB: I think we can certainly prioritise it more, and we certainly definitely need to do more, but also, as both you and Michelle have just acknowledged, there are plenty of examples of really great practice around the country, and I think it’s really important in these discussions. We do need to start with the ‘what’s going wrong’, but also recognise where it’s going right.
The whole concept of being inclusive, for me, it’s fundamental because I think it encapsulates everything else that we’ve been talking about. You know, an inclusive service will have really good training for its workforce, so they understand health inequalities and know how to address them and to support LGBT+ people. An inclusive service will collect data on sexual orientation and gender identity.
So, we’ll have addressed that data issue, but I also think when we’re thinking about inclusive services, there are things that individuals can do. I mean, sometimes when you look at the system, it all feels too huge and too overwhelming, but actually, every single one of us working in the NHS can make a change tomorrow, so that our service is more inclusive and our services are more inclusive.
You know, Michelle’s mentioned some of them. Signs and signals are really important. Rainbow badges, rainbow lanyards, posters for LGBT organisations in your waiting room, ensuring that the images on your website are inclusive, with same-sex couples, with trans and non-binary people. Ensuring that your language is non-binary and is inclusive of everyone, the language on your websites and your patient information and your health promotion.
These are all simple changes that we can all make tomorrow, and they’re all signs and signals that mean a huge amount to LGBT+ people. Simple things like asking about pronouns or using your pronouns in your email signature or having your pronouns on your badge. People see that. People from the community see that and it gives them confidence and trust that you are going to be somebody that is going to support them, and your service is going to be inclusive.
I know, because they tell me all the time, people tell me all the time, but LGBT+ people, particularly trans and non-binary and gender diverse people, they look for these things. You know, they will avoid services that don’t display these, and will be drawn to services, and have been shown to have a better experience in the services that do this.
So, that stepping back and thinking, “Is my practice is inclusive?” You know, “Am I an ally? Am I teaching myself about the needs? Am I calling out bad behaviour? Am I meeting the needs of my LGBT+ patients?” That’s something that all of us can do tomorrow, as well as service leaders, service providers, the system, thinking about that more generally.
HM: Turning specifically to the community Michelle works with, which is trans and non-binary people, a group who, as we heard, often feel very marginalised, there’s a good deal of discussion at the moment, Michelle, not least in health circles about transgender rights. We’ve talked about that earlier. Do you have a message for health services and staff listening to this about how they can support the transgender community and improve their experience of health services?
MR: Well, several messages, but I’d just say invest in trans people, and I don’t mean just give cliniQ loads of money so we can do lots of work. What I do mean is invest in trans people, making jobs accessible for trans. There’s huge unemployment. Making those jobs available. Making sure that when you put out an application for a job, that you are very aware of including trans and non-binary. Making sure that your websites are very inclusive of trans and non-binary people.
I think access to jobs is not the only thing, but access to fair treatment, and when I think about that, I don’t just think about gender care. That’s one of the main issues, yes, but I think all access to all health and not be scared, not having to feel that you have to explain what kind of trans person you are. Sitting there with a health provider saying, “Well, what kind of trans person are you? What are you? What have you done? Have you had surgery?” Those questions just drive people away and they’re unnecessary.
HM: Thank you, Michelle, and a really strong message there to services and all our listeners, and Michael, final thought from you.
MB: I think on that, what I would say is talk to trans and non-binary people, engage with the communities and ask them what they want and what they need. We don’t do that nearly enough. We assume that we have the answers when we don’t have the answers, and Michelle has very eloquently, as always, run through many great tips for services, but that would be my single biggest thing, and do it meaningfully. Surveys are great, but nothing beats sitting down and talking to the individuals who we are meant to be providing services to, and to the community organisations that represent them. So, meaningfully engage, that’s how we make better services.
HM: Well, that’s all we’ve got time for today. Thank you so much to Michelle Ross and Dr Michael Brady for joining me, and also to the individuals from the LGBTQ+ community who kindly shared their experiences of using healthcare services with us.
You can find the show notes for this episode and all our previous episodes at www.kingsfund.org.uk/kfpodcast. You can also get in touch with us via Twitter at the King’s Fund account, and thank you to our podcast team for this episode, Charlotte Wickens, Sharon Jones, Lynsey Hawker, Deborah Fenney and Sarah Murphy, and thanks to you as always for listening. We very much hope you can join us next time.