Caring for people and our planet: Dr Dominique Allwood on health inequalities and climate change

Key:

• JV:       Jo Vigor

• DA:     Dr Dominique Allwood

JV:    Hello and welcome to The Kings Fund podcast, where we explore the big issues and ideas in health and care.  I’m Jo Vigor, assistant director of Leadership and Organisational Development here at the fund and for our final episode of the year, as we head into Christmas and the New Year, I’m thrilled to be joined by a fantastic and special guest.  My guest today is someone who’s career to date, has spanned a number of different areas, Population Health, Public Health, Quality Improvement, Clinical Engagement and Leadership to name just a few.  This person is Doctor Dominique Allwood, Chief Medical Officer at UCL Partners and Director of Population Health at Imperial College Healthcare NHS Trust.

So welcome, Dom, what a list of accolades and titles there, so welcome to the Kings Fund podcast, we’re getting in the mood today wearing Christmas hats and jumpers and trying to stay out of the snow because it’s pretty chilly down here in the south.

DA:    Well, thanks Jo, thank you so much for having me, it’s lovely to be here with you and I’m delighted to be joining you for the festive edition.

JV:    Dom, your CV is really impressive, can you start by giving our listeners a flavour of your career so far and if you were to summarise, what’s been the most important steps in that journey?

DA:    Gosh, there are so many things, I’ll need to pull up the Linked In profile, just to re-remember all the stuff and I hope you’re not just about to appear through some door with a book that says, This is Your Life.  So yes, thank you, I think the things that I’ve really enjoyed about my career so far has been the variety and I am somebody who really enjoys spanning boundaries, organisations, issues, people, colleagues, teams.  So, I’ve been really privileged to be able to do that in many of the roles that I’ve had, I guess there has been a few formative things that have really shaped where I’ve got to and they start early on in my career.

So, one of the things was really at school, deciding what to do when you grow up, I remember being unclear about what I wanted to do, I knew I wanted to go to university but at my school, not everyone went to university and they definitely had had many people that went to be doctors.  But I had someone notice me, it was a sixth form head, who noticed in me, I guess a talent and ability and potential to be able to go and do that and suggested that I think about medicine and up until that point, I thought I’d wanted to do a career in designing.  So, I had done graphic design work experience but I was also doing science A-Levels and she noticed in me, something I think that was really helpful and gave me lots of mentoring around how I might apply for medicine.

I guess that’s the first time I really had somebody who took an interest in me and my life and helped provide me with some guidance and that has shaped my interest in mentoring others, definitely going forwards and as I progress through and into clinical training, I realised that I loved the practice of medicine but was less interested in some of the clinical aspects of it and more about how we change services to help people.  That has been why I’ve gone into quality improvement and Public Health, one of the other big things that shaped me was the Darzi Fellowship in Clinical Leadership at that point, when I did it, it was run by The Kings Fund.

I was selected to do a leadership fellowship and I found it completely transformational, there was so many things about that, that were amazing but one of them was understanding this question about what’s it like to be on the receiving end of me, thinking about what’s my role as a leader with others.  Until that point, I hadn’t really considered that other people are different and work differently and have different preferences and experiences and I really enjoyed learning about things like personality types and how you build teams and how you lead with others.  So, I guess the experiences of actually being mentored and understanding leadership has been really important.

JV:    I love the messages about the importance of mentorship, especially from a young age as well because many, many people don’t get that, so it’s great that you’re taking that experience on and really keen in your mentorship of others as well.  You’ve done so much in your career, what has that journey really been like because you’ve achieved a lot but if you look back, are there somethings you’ve had to put on the backburner or challenges you’ve had to face along the way?

DA:    Yes, so I guess there are a few things in that to unpack, one of them is a sense of confusion early on about my own personal identity, growing up as a person of mixed ethnicity, background, I’m half-Indian, part-Greek but I grew up in a fairly, I guess white area of Essex and didn’t really understand what it meant to have different coloured skin and look different to other children and that sense of feeling like you’re not sure ow you belong and I never really felt like I was completely comfortable in my skin, so to speak, until reaching university where I met so many different people with huge amounts of diversity of all different types.

But I guess that has really shaped my interest in understanding what it’s like to have experiences through different lens that include ethnicity and gender and I’m somebody who I’m blessed with, I guess some people would say, good genes.  So, I think I look probably somewhat younger than I am, I hope that’s something that will stay with me but it’s also a curse as well as a blessing because you can turn up looking young and female into rooms and there are stereotypes around people and for many, many times that I’ve been in meetings, I’ve had people say to me, oh tea with two sugars love.  The post-its are over there if you’re going to take the notes, thinking I’ve turned up to do the administration of the meeting and actually it’s, I’m here to chair, this is my role, I’m somebody who is in charge here or senior and leadership.

So, I guess the gender has played out for me, somewhat as well and there have been many experiences that have really shaped who I am, one of them was living and working in New Zealand for a few months and really learning much more about what it’s like to have health disparities and see things through the perspective of different populations including their indigenous population.  So, a lot of experiences have driven me to really think about inequalities and that partly steered me into wanting to take on Public Health work but also through the lens of quality improvement, thinking about what does equity mean.

Yes, lots of things have shaped me, my childhood, my experiences at school, university, the different places that I have worked, to help me really understand how to land and place myself in the work world and I don’t think you get taught that much about that when you’re going through your life.  So, it has definitely been a lot of experiences that I’ve learnt as I’ve gone and Public Health has been an amazing specialty and profession to learn a lot about some of those things as well.

JV:    What advice would you give to young people or young women coming through the health and care system in leadership roles, your point about two sugars love, is an experience that I’ve had myself, as we’ve gone through but what advice, one piece of advice would you give to people that are experiencing some of those inclusion challenges?

DA:    I think one of the things that I’ve done is, struggled with how much to mention these things, when you’re a junior in your career, you often wonder how much to speak up, speak out, the worry that the impact that might have on being known as a trouble-maker, or trying to be confrontational.  But I’ve got a personality type that likes to, not have conflict all the time but I’m the opposite of let sleeping dogs lie.  I like to process things; I like to have things out in the open and so I had some mentoring once about the fact that you don’t have to always call things out in a way that is threatening to people.  You can do what I learnt, which is about call it in.

So, you can say something to somebody without having to do it necessarily publicly or in a confronting way but I have wanted to make a point to people when that happens about the impact it’s had or whether they’ve realised because I think if you do leave things unchallenged, people will carry on often with types of behaviours that we do need to say something about.  So, seeing it as feedback in a constructive polite, kind way, I think is really important.

JV:    Thank you, some great advice to some of our listeners there, so I just want us to move onto your experiences during COVID, during the pandemic, some of which we’re still going through, you were seconded twice to the Nightingale Hospital in London, the first part you led a quality improvement project capturing staff feedback from the frontline and your second stint, you went in as medical director.  Can you tell us a bit about those experiences and the impact it’s had on you?

DA:    I think the first thing is that I guess, it felt like a lot of things that I’d done, up until that point had really helped prepare me for doing that and that sounds strange because who thinks about being ready for a pandemic before it arrives.  But the fact that I’ve done Public Health training, we learnt a lot about emergency preparedness, I’ve done various different leadership programmes and learnt about different styles of leadership which include command and control and where that is valuable.  I’ve worked a lot in quality improvement and learnt how you can use those skillsets in a way that helps to rapidly test and change and learn.

So, in many ways, this collection of skills and experiences that I’ve had, I think really helped me to contribute during the pandemic.  So, I had two roles, one was associate medical director in my hospital Trust, where I led some large and quite rapid things that included setting up a big staff health and wellbeing helpline and setting up this ethical decision-making support service to support colleagues who were having to undertake really difficult decisions.  But I guess this call to go and help at the Nightingale was one that I’ll never forget and I felt a real privilege to be able to go and serve and do that and as you’ve said, I was able to both work in a quality improvement and learning role.

Then the second time round, unfortunately we had a second time round but for someone who prepares, trains and improves the second opportunity is often the one that you relish more because you’ve had a chance to hone what you’re doing.  I was able to take all of that learning from the first Nightingale and implement it really fast, into the second one and had a lot of help and learning through working with military colleagues and others who were able to come back and help a second time.  But it was, I guess a chance to really exercise my clinical and medial leadership skills, also I was really keen to try and capture and evaluate that impact.

So, we did a lot of work, particularly the second time to think about what was the impact as an anchor institution of the Nightingale, working there, giving jobs to local people, really understanding what’s been the quality and learning impact of trying to set up a service in a field setting and manage through a crisis and how did we learn what outcomes patient and staff experience we had and how that compared to other settings during the pandemic.  So, I have this critical evaluative lens on things too, so in many ways, it was an amazing, whilst difficult experience to be able to put a lot of skills and knowledge into practice very quickly.

JV:    Thank you, I mean it just sounds, like you said, as tragic as the whole context was around this, the way that you all pulled together, that you were using people from across different sectors including the military, to get it set up and run, just sounded like a fantastic opportunity and to take that learning elsewhere.  What would be your one leadership takeaway from that experience?

DA:    I think the biggest thing that I saw, which felt important and it’s been well documented but I definitely agree, is the importance of clarity of mission and people felt like they really understood what they needed to do and get on with, I think, in many settings, it wasn’t just at Nightingale but you get a lot of the noise out the way and the pebbles in the shoes out the way and people can really focus and deliver amazing things when they are focused on what needs to happen.  I think in the current system that we have and the current context, there are so many distractions, money and lack of workforce and other things that just help to distract people away from the core purpose of what we need to be doing to get on with things.

During COVID, leadership really helped to drown out a lot of that noise and so I think there is a real provocation onto leaders at the moment to think about how do they provide that clarity of mission and purpose when there is so much going on around us and are we all aligned on what that is and for many people, that will be getting patients out through the system more quickly.  For others, it will be about how do we really try and prevent them from getting there in the first place but are people clear on what the mission is and how our leaders are doing something to help people really ensure that they are laser-focused on that mission.

JV:    I couldn’t agree more, very wise words.  I’ll just move onto the connection, the thread through your work around health inequalities, you’ve mentioned earlier on in this conversation that you’re really, really keen and central to you as a person, the concepts of fairness and equity.  When we reflect on all the different roles you’ve held through your career, it often looks like there is a focus on health inequalities.  I mean is that right and what inspired you to go into that direction and that focus in the first place., what was going on for you?

DA:    I think one of the experiences that I had, which made me think about variation which is of course important in thinking about inequalities was when I was a junior doctor, working clinically and I remember being the most senior clinical person in the emergency department in the resuscitation room and we had a number of big, major issues with workforce over that point.  But we also had a number of very sick patients that culminated at one time, overnight, so we had road traffic accidents, a stabbing and a shooting and I remember thinking, I don’t feel like we’ve got enough resources to look after all these patients really well and I don’t know how to deal with this.  I don’t know how you make choices about what you do when you can’t do everything.

The fact is, that some people will suffer and often the people that suffer in situations where we are resource-deplete is those who have less voice, less agency and many of those experiences that I saw about variation in care and why certain people get things and other people don’t stem back to equity and inequalities and it made me start to think that I wanted to do more to start changing some of the causes of that, rather than just patching up some of the effects that we saw as a result of those systems and issues.

I started to then learn much more about health inequalities and through the work of many people like Sir Michael Marmot became very familiar with that work and decided that Public Health was a speciality that I wanted to go into to help understand and act on the things that cause those inequalities.  Coming full circle, I’ve had the absolute privilege of just last month, releasing a paper that Michael and I and another colleague wrote around equity and around this concept of anchor institutions where you think about what organisations can do to tackle health inequalities and equity through the work that they do.

So, it’s been amazing to work in that space for a number of years now and it’s taken me into this new field for me, which over the last few years, has been around anchor institutions.  I think inequalities and equity can feel like such a big topic and particularly for those in the health service, I think, well how can I possibly tackle that through the way in which I’m working and the part of the system I’m working in and this concept of the anchor institutions about who you employ, who you choose to work with in terms of your organisations that you partner with, etc and how you work with your communities differently, is a really important part of that story.

JV:    With that work and with the research and conversations you’ve been having, what are the biggest challenges facing the health and care sector that threaten to hamper progress on reducing health inequalities, from your perspective?

DA:    I think that one of the biggest ones at the moment is this urgent verses important, so we’re getting very consumed with the things that are right in front of us at the moment around flow and resources, workforce shortages which are all really important and should warrant our time and attention but many of the things that cause those require a lot more long-term and preventative thinking.  When you’re in the midst of that, it’s very difficult to pull yourself out of it but those will be the things that get us out of it.

So, how do we take a long-term view but also a view that starts to be more system-focused, so the things that we might do in one part of the system may not give us the benefit immediately and there it might be in another part of the system and it might be further down the line.  So, how do we take an approach that is more long-term and more system-focused to help tackle these issues and I think that is a real challenge at the moment for healthcare organisations and leaders.

JV:    And that’s where to put your energy from the sounds of things, from what you’re saying there as well, where people should put their energy.  How do people get into some of those conversations about the urgent verses the important and interest in joining ideas up across a system rather than purely in terms of what’s in front of them, what’s the one or two things you would say to people?

DA:    I think one of the ways that I’ve seen that’s been helpful is actually thinking about improvement, quality improvement.  So, many people will be learning that through their training in healthcare or the people that they’re working with, doing quality improvement projects and they’re likely to be things that lots of people have started learning skills in but I guess it’s about trying to expand that view.  So, if you think about trying to improve patient experience or access or did not attend rates in your particular clinic, there are many things that you could do to slightly expand that view.

So, starting to think about, well what are some of the causes of why those things have gone on and how do we start to think more upstream or how do we expand our quality improvement views, so that we start to think about the people who aren’t showing up or the gaps in the data of people we don’t have, so starting to bring and equity lens in or when you’re doing an improvement project, thinking about how do you bring sustainability in.  So, that you start to think about what some of the bigger issues, health pieces are that start to move you into more of the prevention and social determinant space.

There are lots of ways you can do that through a quality improvement method and a quality improvement lens and then in terms of how to start thinking beyond your ward, your clinic, your team, there are lots of connections to be made and I think starting to explore those through the organisations that you work in, speaking to leaders, both within those organisations but beyond those organisations and understanding how you can get involved in work that starts to span outside your usual purview is really important. I guess the final thing would be, probably getting some mentorship around that, if you’re struggling to see how to do some of these things, mentors can be really helpful and powerful in helping to showcase opportunities for you or open the doors for things.

But I think, those pieces about starting to connect with people outside of your usual setting and starting to think a bit more in terms of how you might use some of your projects that you’re working on, your improvement work to start thinking a bit more in the lens of social determinants or prevention or equity or green, feel like places to start.

JV:    Thank you and you’ve recently wrote a fascinating opinion piece in the British Medical Journal about sustainability in the NHS, can you tell us a bit about how climate change is affecting people’s health and, in your article, you argue that any efforts to tackle climate change must avoid further widening existing health inequalities.  Is it possible to effectively combine these aims and find solutions that tackle both of these issues.  So, quite a bit question there.

DA:    Yes, it’s a huge question, so I guess just the piece on inequalities, it’s well-known but perhaps not often talked about the fact that the environment often has an axis that seems to see the biggest impacts of climate change on those who are the most vulnerable in our population.  So, for example, we see many of the impacts of climate change in some of the poorest countries around the world and those people are the most affected and least resilient and able to cope with those impacts.  I guess though for many people, they might think, well that all seems like that, I understand that but we’re living in the UK, one of the most affluent countries in the world, etc.

There are many examples of where health inequalities and climate intersect within the UK and one of those is air pollution.  So, you’ll see many examples of where some of the poorest schools and the poorest people live in places that have the lowest air quality and have some of the worst health impacts as a result of that.  That’s really a problem that we all need to be thinking about addressing and indeed many organisations, including healthcare are, for example, Great Ormond Street has done a lot on clean air frameworks and has done a lot of advocacy work and working with the Mayor across London on these issues.

So, I think there is a real role for healthcare professionals and healthcare organisations to both lobby and have advocacy roles.  I guess for me, what I was trying to do in the piece in the BMJ was to start to help people to think, both how they might do things in a tangible way and also start to do things differently.  So, the innovation pieces feels really important to me, that there are many sectors out there, beyond healthcare that have started to tackle the net zero challenge really well.  What can we learn from them about how they’re doing that and bring some of that learning and approaches into healthcare.
The focus of a lot of the work that I’m doing at UCL Partners, we’ve developed a climate collaborative with our provider organisations and UCL Partners is an academic health science partnership at innovation and focus on bringing things in from discovery, research and industry and innovation into practice quickly and evaluating that impact.  So, we’re focusing on the three I’s, innovation, implementation and impact, really thinking about how we can add to this agenda, along with many others.

JV:    What are a couple of the leadership principles that you think will be essential in delivering a sustainable NHS and a sustainable health and care system in the future?

DA:    So, I think one of them is definitely about collaboration, in the past, we’ve felt very competitive in the NHS and it’s not surprising, given the policy landscape that was about markets and competition and we’ve moved much more into a collaborative space and the advent of integration has really helped that integrated care system is a really powerful part of that.  But I guess often in some of our clinical spaces, we still see people feeling like they’re going to be having to fight over patient and activity or some sort of innovation that can be … I invented this here, I’m the first one to have done that.

I think people are moving away from that but what I’ve seen in the environmental work, environmental sustainability and climate change is that there is a huge amount of potential to collaborate.  It serves no-one well to be in competition to tackle climate change, there can only be benefit from doing things in a collaborative space.  So, I think it’s really incumbent on leaders to do that, to make sure that people feel like that the imperative is to collaborate, learn and share across pace and scale and the best leaders are really doing that.

I think the other thing is about being courageous and having courage to say, this is a really important part of what we’re going to focus on and then divert energy and attention and resource, particularly when we feel so constrained in the system at the moment and we’re so challenged, operationally, if we think about what’s the point of having healthy patients on a sick planet, it’s not going to … those two things just don’t add up.  So, some of these big challenges like sustainability, like equity take a lot of courage from healthcare leaders to say, I’m going to focus on this really heavily and that’s what we need to do as organisations, as systems.  So, collaboration and courage, I think are the two things that I would point out as the key leadership behaviours in some of these big issues.

JV:    Brilliant and I think The Kings Fund would be right behind you on those two as well, Dominique, on that note, I’m just going to move us onto our final question which is, we’re coming to the end of 2022, so if you had one thing you could leave behind in 2022 and one thing you could take forward into the New Year, what would those be?

DA:    Oh, okay, so I think mine might be a bit stolen from a good friend and colleague, Bob Claver, who talks about language, so the thing I would like to leave behind is the language that is around some of our big issues at the moment, if you think about what this language really says about the problems, I don’t think it serves us well.  So, things like flow, discharge, those things just conjure up such horrible images around what we’re trying to do.  So, I think language is really important in culture and culture change, so thinking differently about some of those issues and how we describe them, label them and tackle them, would be one of the key things for me.

Then I guess taking forwards, I talked a bit about mission and clarity, about what we’re here to do within healthcare and I think that word, ‘care’, is often missed off, we focus heavily on health and I’m a Public Health person and that’s in my title but actually about care.  Caring for patients, caring with patients, caring for and about each other, caring for and about our planet and I think this notion of care, what did we come into healthcare to do, why did many of us join the mission, so to speak, when we all decided to come and be part of it.  It was about care and I think we need to bring that forwards into 2023 and leave behind flow and discharge.

JV:    That sounds fantastic, Dominique, thank you so much for your time today, it’s been a real pleasure and a real delight talking to you and just some fantastic insights into your career and what you’re doing now and the importance of that work.  Well, that’s all we’ve got time for today, thank you so much, Dominique for joining me, you can find the show notes for this episode and all our previous episodes at www.kingsfund.org.uk/kfpodcast and you can get in touch with us via Twitter, our account is @thekingsfund.

This episode was edited by Bespoken Media, thank you also to our podcast team for this episode, Beth Sutherland, Sarah Murphy and Jen Thorley.  Don’t forget to subscribe, share, rate and review this episode wherever you get your podcasts and of course, thanks for listening, we hope you can have a relaxing holiday and New Year and you can join us for our next podcast in 2023.