What just happened? Health and care policy in 2021

Key:

• HM: Helen McKenna

• SA: Siva Anandaciva

• MW: Michael West

• Emma: Emma Sheffield

HM:       Hello, and welcome to The King’s Fund podcast where we talk about the big issues and ideas in health and care. As this is our final episode of the year it’s only fitting that we take a look back over the year that was in terms of health and care and also spend a bit of time thinking about how 2022 might shape up. As always, please do subscribe, share, rate and review us wherever you get your podcasts. It helps others to find us, and it also helps us to improve the show. I’m Helen McKenna, and I’m delighted to be co-hosting this episode with Siva Anandaciva, Chief Analyst here at the Fund.

Siva hosted our last episode on the health and care bill, which if you haven’t listened to you, and I listened to it last night, I would really recommend that you do. So, welcome Siva.

SA:         Thank you Helen, I’m glad to be here.

HM:       So, in order to summarise an entire year into a 30 minute episode, we’re going to focus in on five key areas that characterise the last year for the health and care system, or we see them as characterising the system. So, we’ve picked them out as COVID-19, waiting times and performance, the reform agenda, funding, and, finally, the people who work in it, AKA, the workforce. Siva, does that sound good to you?

SA:         Yes, sounds good to me. I was just thinking how on earth do you summarise a year that’s just happened. It would be easy to just do an entire hour on COVID.

HM:       Yes, 30 minutes is going to be a challenge. And then at the end, and this is the most exciting bit, we’re going to round off the episode and the year with a special bonus round prepared for us by our producers. And just to be clear neither Siva, nor I, have seen these questions, the producer’s questions, this special bonus round. So, this could either be very entertaining or fall flat on its face, so let’s see how it goes.

SA:         I think it could be career killers, but let’s see what happens.

HM:       I hadn’t contemplated that third option, but thanks for putting it in my mind. So, Siva, I’m going to start by asking you a couple of questions on the themes of COVID-19, waiting times and performance, some of your expert topics. It’s clear that the new Omicron coronavirus variant is now spreading pretty rapidly, but even before Omicron hit our shores, the numbers waiting for non-emergency hospital treatment were already going up, they’ve now reached six million, which is the highest number since records began almost 15 years ago, but I guess it’s important to say that the pressure in the system has gone up and down. So, as 2021 comes to a close, what are your reflections on the challenges the NHS has faced in terms of performance over the past year?

SA:         I think I’ll make a few different points. I think the first one is benal as it sounds, is just how serious the pressures are. A few weeks ago, I was with a group of clinical needs from the NHS in England and Wales, and you could just see that some of them were almost out on their feet, they were that knackered. And I found parts of the discussion with them, we were talking about healthcare policy, but I found parts of the discussion with them quite upsetting. Honestly, I don’t know how some of them get out of bed in the morning.

They were talking about the pressure they felt, the guilt they felt for not being able to do more for their patients, always thinking about work, never being able to switch off and some of the things they had sacrificed. Then we started thinking about their clinical services and talking about the clinical services. And one of the things that came through is when you’re under this much pressure, when the pressure is unrelenting and where everyone else is under pressure as well, it’s quite easy for you to lose your sense of what good care looks like, and the things that you start to accept is reasonable.

The second thing is, it’s been a battle on multiple fronts, hasn’t it? So, understandably, because the data is better in hospital services, that’s what dominates media reports. You pick up the newspaper, you’ll see six million people waiting for care. You’ll see record waits in A&E departments, but everything is under pressure, and everything is connected.

So, again, I was talking to a group of valid health professionals, and they were saying you will read a lot about people with COVID or other serious conditions going into intensive care, you get incubated, so they put a tube down your throat to help you breathe in intensive care. When you come out, sometimes you do need speech and language therapy, you do need to rehabilitate, so we’re seeing pressure too. Until someone mentioned it, and it seemed obvious when they did, I hadn’t heard of that, so I think a battle on multiple fronts is my second one.

And my third one is probably just repeating back what you said, which I think is the key point, it was up and down, the pressure over the year. And I’m getting really nervous that a lot of the narrative around, in policy circles, at least recovery, makes it sound like we had our COVID period, we’re coming to the end of it, now it’s a steady linear path up towards where we used to be. When actually I think it’s going to feel a lot more like three steps forward, one step back.

HM:       We have seen quite a lot of focus on general practice too. What’s your take on how general practice is feeling right now?

SA:         God, what a question Helen. To be honest, I don’t know, but if I were going to hazard a guess, I would say it feels like you’re trying to do about three jobs at the same time, three full time jobs. One job of delivering the care you need to do for your patients, you know, the patients in your local population, your registered list. Tracking chronic conditions, helping them live the best lives they can, one huge job.

You’ve got another job which is gaining your part alongside other parts of the health and care system in rolling out the booster vaccination programme. And any time I see a headline which is the biggest vaccination programme in history, you think well that’s great, unless you’re part of the people delivering it, in which case it’s a massive logistical challenge.

And the third one is a transformation agenda. Over the last few years, what you’ve had primary care networks, you would have changes to the contract, you’ve got all these new policy initiatives, federations, super practices that have changed how primary care practice is delivered. And, so, I think you put all that together and it’s understandable why some GPs are narked off.

HM:       Yes, the Prime Minister announced or has announced that we’re now moving into Plan B to help mitigate the impact of the new variant. So, looking ahead, what impact do you think that’s going to have on health system capacity, and what do you think 2022 will bring?

SA:         Helen, when we got the order to work from home in March 2020, I genuinely thought we would back in six weeks top. So, I would be foolish if I say I know what’s going to happen, but I think it’s more of the same. If you look at the big factors, the big pressures on the health service, unmet need, growing demand, and you look at the big supply constraints, not that much is going to change.

HM:       So, moving forwards, what’s the, kind of, underlying long term increase in capacity that the system is going to need, or do you think there will need to be a long term increase in capacity?

SA:         Absolutely. I think this is, you know, we can argue about how much. I think it’s pretty incontrovertible now that the health system in this country needs more capacity. Whether that’s basic acute services, so more staff beds, and that argument was one even before COVID, even though it hadn’t been implemented, because we saw the narrative change, didn’t we Helen? When we would have covered reports over bed cuts being planned in different parts of the NHS to suddenly seeing things turn in planning guidance towards well hold on a minute, stop taking beds out unless you’re very confident you don’t need them, and then slowly turning into we need more capacity.

And the second thing is capacity in different parts of the system. So, if you’re expecting massive increases in the demand for services for long COVID, then a lot of those services will be placed in the community. Some of the new diagnostic hubs that the NHS is trying to put in will be in the community. So, I think you’ll see a call for more capacity, but also capacity being placed in different places.

HM:       Yes, absolutely. So, final question from me to you on this bit, I just wanted to ask you if you think there are any particular parts of the health and care system that have had a particularly good or challenging year in delivering the care the patients need?

SA:         So, on the good year, there are certain clinical services whereby their very nature is harder to deliver during a pandemic, you know, anything where you’re operating near the ear, nose or throat or the mouth, it’s harder to do when you’re operating in an environment with an airborne respiratory disease, right. But I don’t think I’ve met anyone who hasn’t had one period in the last 20 months where they didn’t feel broken. I think they’ve had periods when they were broken, and often in surprising ways.

So, I’ve got a colleague who is a consultant ophthalmic surgeon, so I would say he is a tough cookie. And he was saying he went through three months where he felt completely purposeless. He just felt that he trained his entire career to be an expert at something and he wasn’t able to do it. And he was doing other things, he was, you know, volunteering in other clinical roles, but, essentially, he said I feel useless. So, maybe there have been parts of the healthcare system that have had a relatively good year, all things being considered, but they certainly don’t spring to mind.

So, Helen, I think the tables have now turned, haven’t they, because it’s your turn to be in the podcast guest chair. The questions are about reform, which is one of your specialist, one of your many specialist subjects. So, our last podcast episode was all about the health and care bill, which could be supporting one of the bigger shake ups to health and care policy and how the system is organised in the decade, but it’s not the only bit of reform.

We’ve also got an adult social care white paper, the folding of several bodies including Health Education England into NHS England, and this is before we’ve even entered what the Secretary of State, Sajid Javid, has dubbed the year of reform. So, let’s start with the bill. What are some of the main challenges the bill is going to come up against?

HM:       So, in your question you mentioned a number of different bits of reform going on. You’re right to mention them because there is a lot happening, and I think that is the first point I would want to make. In terms of the bill itself, the government has said it wants the legislation to come into force from April 2022, which means the timetable for getting the bill through its, kind of, journey through parliament is very tight now.

One of the things that I think is going to be particularly controversial, there are powers that the bill introduces for the Secretary of State to be able to intervene in local service reconfigurations. That’s something that lots of people aren’t particularly happy about. People argue that risks politicising reconfiguration and local service decisions in a way that’s really unhelpful. So, I think there is going to be quite a lot of pushback against that, and I don’t know whether the government will concede on that, but they’re going to be under pressure to.

And then the other thing that is a big issue is the, kind of, I guess, notable absence in the bill of anything significant enough on workforce. So, currently the bill will require the Secretary of State to publish a report at least every five years on the system for assessing and meeting workforce needs. And, you know, given where the system is at in terms of workforce, the huge scale of shortages, and the fact that it’s clear there has not been proper long term planning, we and others are calling for the requirement in the bill to be strengthened to mandate regular publication of independently verified workforce productions.

It's going to be hard for the government to resist that. On the other hand, that’s something the government is not going to want to support because it places a requirement to, kind of, set out publicly what workforce needs are, places the treasury in a bit of a bind, given then the Treasury is under pressure to fund those properly fund enough workforce in future years and workforce is a huge cost to the system. But, of course, if you want to deliver waiting times, targets, if you want to restore performance, if you want to meet any of these, kind of, ambitious government commitments, you need the workforce there to deliver them.

The other thing I would say is a, kind of, challenge that I would expect to see in 2022 to the progress of the bill is the social care cap change. The government introduced clause 140 to change the cap and floor model of social care funding. That change ultimately means that the main beneficiaries of the government’s reforms to the cap will be people with higher assets. Those people with low to moderate assets will get more of a marginal benefit, which is regressive and runs counter to the government’s ambition of levelling up.

SA:         I wanted to ask you a question based on something you said about the politics of it all. So, if I were a local MP, and I’ve got constituents lining up virtually to tell me about how long they’re waiting for hospital care, what is there in the bill that I could look at that screams vote for me, I’m a good idea, I will fix the problems that you’re hearing about?

HM:       Yes, that’s a great question. And I think it’s something that this bill currently suffers from. It’s incredibly technocratic. What’s missing is the, kind of, how is that going to improve ordinary people’s lives, and I think, you know, the challenges that the system is facing right now in terms of, you know, a backlog of care that pre-dates COVID. Workforce shortages where people can’t access services quickly. Nurses are under pressure.

While I think in a, kind of, indirect way some of these challenges will be helped by the bill, you know, integrated care systems can solve some of the things we’ve been talking about or help to around workforce passporting, being able to work across a system. Inequalities bringing different partners into play to solve local challenges. Yes, those are things that ICS’s and integrated care working can help to solve.

I think this bill doesn’t really deal with it, or certainly explicitly deal with the biggest challenges facing the system today. And I think that’s pretty obvious. I don’t think that means you shouldn’t do a bill, and I don’t think that means you shouldn’t go forward with integration and integrated care systems because they are an important solution for the longer term working of the system. But it’s slightly odd to be, kind of, pushing so hard on it right now when it doesn’t straightforwardly solve the biggest issues facing the system.

SA:         And what your answer is highlighting is there is a difference between a health and care bill and a health and care plan, and the bill isn’t necessarily there to be a cure for all the issues at the moment or issues in the longer term.

HM:       Yes. Some of the things I’ve spoken about just then can’t be solved in the bill or maybe shouldn’t be solved in the bill, but the absence of a narrative to explain how they are going to be solved makes it hard for the bill to pass in its current form. The narrative that’s missing, that helps to explain how these changes along with other changes, like you say, some policy documents, some guidance, you know, narrative that says how alongside these technocratic changes we will solve workforce and we will solve, you know, inequalities and we will solve backlogs. Without that, it just seems a bit out of place.

SA:         I think the thing that’s come through really strongly from you Helen is where is the narrative, where is the thing that brings together all the disparate elements of reform into one package.

HM:       Absolutely. Here is what the health and care system is trying to do, and here is it what it’s going to try and do for you and your grandma. Legislation on its own doesn’t actually necessarily deliver change. As we saw in some ways with the Lansley reforms, not all of it ever, kind of, really took off, and to some extent, Simon Stevens, kind of, ignored it. There is some reality to a narrative that means people buy into it and make it happen.

S****o, I’m coming back to you, Siva, now. I feel very relieved that I’m no longer answering questions. So, I wanted to ask you what your take is on the levy. The health and social care levy, which I guess was the big, probably arguably the biggest, kind of, funding development this year, but correct me if I’m wrong.

SA:         No, I think it was by a country mile the most exciting thing that’s happened in health and care funding in three years.

HM:       Exciting.

SA:         Yes, just exciting. It my small world, it was blockbuster. And amazing actually, it’s amazing that it was kept so well under wraps for so long. So, what would I say about the levy, oh so many things? We’re not a physical think tank, we don’t do that much work on different ways of how you raise money. So, we’re not a tax and spend think tank. It was still a big choice how they’re raising the money, and I think I would point you to the work of the Institute for Physical Studies Resolution Foundation because it is not a neutral choice in how this money is going to be raised by a hike in national insurance.

So, that’s one point, the levy reflects a choice in how the money is being raised. The second thing is I think people will notice the money. This won’t be one of those cases where billions are promised for the NHS, and then you don’t really see much material change, whether it’s getting your cataract removed in a new surgical hub, that’s a really small set of operating theatres that has sprung up in a new site, or whether it’s being able to get your x-ray or a more advanced scan in a new community diagnostic hub, which might even be on your high street. I think over the next two to three years, you’ll see more options for how you access care as a result of the funding that’s been put in through the levy.

The other thing is, you know, I think I and other people are already worried that is a health anchor levy that could end up being a health care levy. A lot of the elements that are there for reforms to adult social care, hopefully will be used to reform adult social care, but we’ve seen in the past that the NHS has this incredible gravitational pull when it comes to money, and the government might be sat there in two years’ time thinking waiting lists are still going through the roof. We’re fighting an election, why didn’t we use some of this levy money and things we can get our head around, like tackling waiting lists, rather than something like adult social care.

And the final thing I would say on the levy, this is a huge amount of money that’s been promised, £13bn a year for the levy across the UK. At the same time, it isn’t a bonanza, given the level of under resourcing for the health and care system, the thought went into the pandemic given the extra demands on the service. It can still be true that this is a phenomenal amount of taxpayer funding going into a health and care service, and it won’t be a bonanza. It certainly won’t be at the same level of the new levy years, so I think everyone is going to have to collaborate their expectations very carefully over just how much this money will achieve.

HM:       And I find that fascinating just, kind of, playing devil’s advocate, obviously, think tanks like us always say it’s not enough money. That tends to be the mantra, the policy response, the press release. I guess in my mind I’m just wondering now –

SA:         Whether it will be enough.

HM:       What would be enough? What would ever be enough?

SA:         And one of the reasons I like working in a think tank is if the evidence changes, we can change our response. So, I think there are times when we say if the system were going to be flooded with cash, we would raise questions over how well can you spend that money. And I know this is going to sound incredibly simplistic, but they’re all sorts of complicated models you can build to inform how much you should spend on health and care in the future. And I genuinely think those models play an important role.

My incredibly simplistic take is if you’re talking about 1-2%, or less growth in healthcare funding above inflation, you’re in trouble. The best you can do is keep the lights on, but you will start to see services and quality of services start to slip, waiting lists rise. 3-5%, you’re broadly in the level of, yes, you’re keeping the show on the road, you can transform some services, you can make some improvements, but you’re not going to see fundamental changes. 6-7%, you’re really turbo charging things, you’re starting to see transformative improvements. Anything beyond 7%, I think the argument flips to how on earth can you spend this money wisely without just paying everyone record salary increases, because there is just not enough to spend the money on.

So, I think if we’re ever at that stage, when you see a government promising 15% increases in health and care funding, we will change our approach and say oh hard on a minute, how much is there. And that was meant to be a serious answer, but the slightly more serious answer is I think the dynamic does change, doesn’t it?

There are periods where the system is saying to the government we need more money. If you want to see these improvements, and there are times when the government will say well just deliver more productivity, you know, get on with the job. The mode we’re in at the moment, is where the government has said, here is some record increases. We’ve changed taxation to provide these record increases. Your job is a system, yes, the context is difficult, please deliver.

HM:       Thanks Siva, and I think it’s really helpful to anyone in the Treasury or Department of Health spending teams there just from you to be clear that we’ll complain until it’s about 15% increase, so good to know.

SA:         So, Helen, I think now you’re back in the chair in which you answer questions rather than ask them. The topic we’re going to finish on is people. So, we know that the staff working in health and care services are the system’s greatest asset, but at the same time they have just been under unprecedented strain. And it wasn’t exactly a piece of cake for the years before that. Now earlier in the year you spoke to Suzie Bailey, who is our director of leadership and organisational development here at The King’s Fund and Professor Michael West on a podcast to explore the results of the 2020 NHS staff survey. Let’s hear some of what Michael had to say.

MW:      From the number of studies that have been done during the past year, we have seen increases in anxiety, stress, and depression amongst staff and in some groups of staff working in particular areas like ICU, there have been worrying increases in symptoms of post-traumatic stress disorder which bear unfavourable comparison with soldiers returning from combat zones. So, it is a real issue, we do need, I think, to be having a discussion about how we create some rest space for staff rather than just saying now you’ve got to catch up on the backlog. But we do have to recognise that’s it not just about taking care of staff at this moment to come out of the pandemic. I think how we treat staff at this juncture, this point in time, if we get it right, they will remember it for a long time.

SA:         So, that was Michael speaking back in March of 2021. He was followed in June by the Health and Social Care Committee who published their report on workforce burnout in resilience in the NHS and social care. Absolutely, the report showed that the pandemic had left staff physically and emotionally drained, but it also said that burnout workforce shortages had been a feature of the health and care system for many years before. So, I guess, Helen, have you seen anything change for workforce health and wellbeing since then?

HM:       I don’t think much has changed other than I think things have got tougher. We’re back with a new variant. COVID is really bubbling up quickly again. That’s going to place pressure on staff. We’re continuing to try to manage with serious levels of shortages. There are difficulties in retaining existing staff. People are continuing to talk about work life balance being a reason as to why they resign from the system. Significant numbers of health and social care staff died from coronavirus.

I think we also know that NHS staff are 50% more likely to experience high levels of work related stress compared with the general working population, and that’s not just bad for their health, but it also affects the quality of the care that they deliver and the performance of the organisations they work for. There is a recognition of the pressures that staff are under and the impact on their wellbeing.

The public recognise it, we’ve seen clapping for staff during the pandemic. Government talks about it. The government has made a lot of commitments about increasing numbers of staff. They’re struggling to deliver on them, and the system remains short staffed and under pressure. So, is there anything I can point to as a significant improvement, I’m not sure I can.

SA:         How bad do you think it has to get?

HM:       That’s a really good question, I don’t know. You would have thought that already would have been enough, and I’ve heard us an organisation describe the government’s attitude to the workforce issue as being somewhat of a blind spot. Is the reason that government hasn’t yet, kind of, really stepped up and thrown everything at it because it’s really hard, but that’s probably still not a good enough reason, but it is really hard to magic up new members of staff when it takes time to train them, but they still need a plan to do that and you can say, and then within three or five or seven years and we haven’t seen that.

Is it that the pressure is not there from the public and the electorate for it? I mean, yes, the public care about waiting times. If they remain bad and potentially get worst, that’s going to be a massive challenge for the government, and the government will care about that. But do the public associate those issues with lack of staff? Do they just settle for substandard performance? So far, that, kind of, pressure from the public on the workforce shortages issue hasn’t come up, but maybe it will now with waiting times becoming worst and worst.

SA:         There is a similar story on the evidence of inequalities and discrimination in the health and care sector for ethnic minority staff. What do you think will happen in 2022 that might address these issues?

HM:       The issue you’re highlighting has been going on for many years, but the pandemic has raised awareness of the need to, kind of, actively ensure that different staff groups aren’t made to experience, kind of, normalised discrimination and disadvantage. The type of discrimination we’re talking about has a significant influence on workplace stress and we’re seeing, kind of, year after year ethnic minority staff in the NHS reporting worst experiences and sometimes shocking experiences when compared with white staff.

And they also continue to be under represented in senior posts. And you mentioned social care, unfortunately we don’t really have equivalent data for social care. So, we know it’s a problem, but we don’t have, you know, the same, kind of, level of robust data. I think in terms of what I’d hoped to see next year, it will be great to see them acting on the concern that we did see during the pandemic for ethnic minority staff.

It would be great to see organisations developing, you know, really broad comprehensive strategies that are focused on equality and inclusion, but also it’s really, you know, strategies and interventions that can help reduce stress and burnout, and thinking about resilience in terms of underlying stresses, ways of managing those stresses and ways of mitigating those stresses.

So, I’m reluctant to do this, but Emma, I’m handing over to you. Not reluctant because it’s you, you know, I would love our producer to be on air, but just reluctant because I know you’re going to ask us some tricky questions. So, yes, over to you for our special bonus round, Emma.

Emma:    Thank you Helen. It’s a pleasure to be on this side of the mic. You can both be on the same team, there is no competition.

HM:       Can I phone a friend as well?

Emma:    Who would be your phone a friend of choice, Helen?

HM:       Health policy phone a friend.

Emma:    Yes.

SA:         So, let me just be clear, you could ask me for my opinion and instead you’re going to phone someone else.

HM:       It depends what the question is Emma.

Emma:    A very diplomatic answer, Helen. Okay, so I will jump in with the first question, which is what did Secretary of State for Health and Social Care, Sajid Javid, get attention for replying to a tweet about?

HM:       I remember the tweet, but I actually can’t remember what it was about. Oh, yes, it was about the vaccine. Somebody tweeted to complain that they had been given a different vaccine for their booster than they had been given for the first and second vaccinations. And Javid basically said so what get over it.

Emma:    That is correct, yes, excellent twitter memory there. So, next question, what data did NHS England’s national medical director call frankly disturbing in November of this year.

SA:         Ouch, god this is embarrassing, isn’t it? I was going to say the performance stats because that’s what he normally comments on. It could be the waiting list performance stats or the A&E performance stats.

Emma:    It wasn’t, no.

HM:       Was it NHS England’s FOI performance?

Emma:    So, it was obesity levels in school children. Data from NHS Digital shows that almost one in seven children start primary school obese, which is a rise of almost 50% in just one year.

HM:       Wow, and that is frankly disturbing, yes, absolutely.

Emma:    Okay, moving swiftly on to the next question. Who is leading the review into health and social care leadership? Bonus points if you can –

SA:         General Sir Gordon Messenger,  boom.

HM:       Hey, how did you get that first?

Emma:    Okay, well Helen, here is a bonus point for you. What is the name of the person supporting him from the NHS?

SA:         Dame Linda Pollard.

Emma:    Good job Siva.

HM:       Sorry, can I just throw some extra questions to Siva?

Emma:    Sure.

HM:       Because I feel so humiliated. So, tell me, Siva, so Gordon Messenger, who is he?

SA:         General Sir Gordon?

HM:       Yes.

SA:         I feel like this is going to be the same answer that George Bush gave when he couldn’t remember (inaudible 00.33.27), and he just kept calling him the general, because pretty much literally all I know is he was a general.

HM:       Okay.

SA:         But jokes aside, he has obviously not just had operational experience, but a background in leadership as well, and I think he is someone who is going to be one of these outside voices that’s brought into the NHS to look at culture and leadership without the history, without the knowledge to really hold the lens up to the NHS, but at the same time he’ll have Dame Linda Pollard who is a very respected chair in the service to almost be the, not just as support, but almost his translator for the health and care system. Sorry, I’ve completely dodged that, haven’t I?

Emma:    And then, finally, last question, who in the speech earlier this year questioned why the people of Rutland lived to such prestigious ages?

SA:         The Prime Minister, Boris Johnson.

Emma:    That was right, Boris Johnson, in his levelling up speech. And, so, that is the bonus round finished. You both performed very admirably. And I’ll chat with the other producers and there may be a slot on our regular pub quiz team for you both, but I’ll have to get back to you.

HM:       Does the pub quiz deal with health policy?

Emma:    Well, you can be our phone a friend. You can be our phone a friend for health policy.

HM:       Okay, great. Well, that’s it from us. A huge thanks again to you for listening throughout the year and we hope you have an amazing Christmas and New Year. You can find the show notes for this episode and all our previous episodes at www.kingsfund.org.uk/kfpodcast. Don’t forget to subscribe, share, rate and review this episode wherever you get your podcasts.

And you can also get in touch with us via Twitter. We’re at The King’s Fund. Thanks as always to you for listening, but also to our podcast team for this episode, producer Emma Sheffield and researcher, Charlotte Wickens. We very much hope you can join us next time.