What is the role of the NHS in tackling health inequalities?

Key:

• HM: Helen McKenna

• BO: Dr Bola Owolabi

HM:       Hello and welcome to The King’s Fund podcast where we talk about the big issues and ideas in health and care.  I’m Helen McKenna, I’m Senior Fellow here at the Fund and I’m going to be your host for this episode.  Before we jump into our conversation today, just a quick reminder that if you enjoy our show, please do subscribe, rate, and review us wherever you get your podcasts as it really helps others to find us and helps us to improve the show.

In today’s episode, we’ll be exploring some very big topics with our guest, including what the NHS’s role is in tackling health inequalities and the progress being made on the COVID-19 vaccination programme and to help us explore these topics, I’m really excited to be joined by Dr Bola Owolabi, the Director of Health Inequalities at NHS England and NHS Improvement and also a practicing GP in the Midlands.  Bola, welcome to the podcast, it’s great to have you with us today.

BO:        Thank you so much for having me, it’s great to be here.

HM:       Fantastic, I want to ask you a bit about your leadership journey and your career journey as well, but before we get into that, I just wanted to ask you how you are because it’s been a long year, it’s been a long difficult year, you’ve been working on COVID-19, I’m sure in your GP role and you’ve also had big responsibilities at NHS England, how has it been going for you?

BO:        I think it’s been a truly inspiring year, just to see the tremendous effort of so many of my colleagues, whether those working in the national team at NHS England and Improvement, people in our regions, people in our local systems, in communities at large, GP practices across the land, hospitals, vaccination hubs, you name it.  For me it has been an inspiring year, just the humanity and the dedication and commitment to genuinely making a difference in people’s lives, for me that’s how it’s been, it’s been inspiring more than anything else.

HM:       That’s amazing to hear Bola and it makes me think you must have great energy and positivity because I know it’s also been, I’m sure a bit of a slog, so great to hear that it’s been inspiring and that you’re able to see the inspiring bits within it.  So, I wanted to ask you about how it all started for you, I know you’ve worked in a number of different roles across your career but when you were a child, what did you think you wanted to be when you grew up?

BO:        That’s a really interesting question and I think for me, it started when I was aged nine and I had a terrible case of chicken pox and ended up being admitted to hospital and I was looked after by the most amazing doctor, a young female doctor.  Although at that age, I didn’t quite understand the ramifications of what it is to train to be a doctor, but I knew I wanted to be kind, I knew that I wanted to be understanding, in the way that she was and, in many ways, I think I was just in awe.  She made me feel really comfortable, like I was the most important person in that hospital.  I guess I made up my mind, actually during that hospital admission that I was going to be like her and what that meant was being a doctor, then that’s exactly what I was going to do.

HM:       That’s amazing and amazing that you stuck to it and also fascinating because it sounds like you were drawn to her qualities, her being kind and her being understanding and then that translated into then choosing that profession, which is incredible?

BO:        Absolutely, I mean yes, it was just … so my friend and I were both unwell at the same time and most of our chats in between ward round was about this fabulous doctor and my friend went on to become a doctor as well.  She’s a general surgeon and I think we both made some sort of an interesting pact to be like our doctor and yes, you mentioned sticking with it and of course there were times over the years that followed, it wasn’t plain sailing by any stretch of imagination but what’s really stayed with me though, was the fact that you could make people better and not just necessarily in terms of the medicines you prescribed because for me, I can’t remember what it was that I was given, medication-wise, I just remember how I was made to feel.

I’ve tried and I strive for that to be the hallmark of my profession and my practice, just to make sure that in addition to the technical element of medicine, that the way people feel, when they’ve consulted with me, leaves them knowing that I genuinely do care about them and their concerns.

HM:       Wow, it makes me want to register at your GP practice, but I know it’s actually nowhere near my house.

BO:        You’ll be very welcome.

HM:       Thank you.  So, you were appointed to the role of Director of Health Inequalities at the end of 2020, but you were already playing an important role already at NHS England and NHS Improvement prior to that, in your role as national speciality advisor for older people and integrated person-centred care.

BO:        Yes.

HM:       So, I just wondered, what then drew you to the inequalities role?

BO:        So, I’ve always worked in the ex-mining villages of North East Derbyshire.  These are villages often in the most deprived parts of the country, they have a life expectancy gap, sometimes up to eleven years, compared to the national average and then I’ve worked as commission lead for children, young people, and maternity and even in that role, my concern was primarily people with learning disabilities and making sure that our GP registers were correct, that we had the right data.

Whether that’s also in my role working as Deputy Medical Director in a Community Provider Trust again, I found myself drawn to the learning disability part of the Trust, even though it’s a very large organisation that delivers many other services.  When we were called upon to, as it were, lead the turnaround of failing GP practices, again in a very deprived area, challenged for many years, I just found a sense of purpose in leading that effort, this is a population that at the best of times, is under-served and by not having a strong General Practice offer, they were doubly disadvantaged.

So, if I look back over the course of my career, you could almost plot health inequalities throughout, whether as a GP, as a commissioning lead for children, young people, and maternity, in my role as National Specialty Advisor for older people.  Again, my focus was particularly older people as they experience disadvantage in terms of health outcomes.  So, I can’t really say this was a moment where health inequalities became so important to me, it’s just what I’ve done throughout my career.

HM:       That’s so interesting that it’s everything added up to this point, but you didn’t quite know it when you were on the journey.

BO:        That’s right, exactly.

HM:       As a frontline GP, to what extent is it frustrating, you’re seeing those inequalities very live and up front in your consulting room, but it must be quite hard to do a lot of stuff about some of those wider determinant inequalities?

BO:        That’s a really insightful question, I think it’s about spheres of influence.  So, when I’m at the surgery and somebody is in front of me and maybe they’ve presented with what appears to be a clinical issue, but as is often the case, there is a strong social element to it and then being able to refer that person, whether it’s to a debt counselling service or a befriending service, that kind of thing.  Then scaling right up to the national stage, where one then begins to think about the roles of the NHS in tackling health inequalities.

It’s true, in the long-term plan, that we did say that we can’t treat our way of health inequalities, however the NHS does have a powerful role to play in tackling health inequalities and I tend to describe those roles across four domains.  There is a role, as a commissioner and provider of services, so we are able to influence people’s ability to access the services that we commission and also to insist that they have an excellent experience once they’ve crossed the threshold and that their outcomes are as optimal as they can be.

So, that’s the first draw, then in terms of the wider determinant, the NHS does have a wonderful role as a key partner with being the integrated care system.  So, as we work with our local authority partners, as we work with our communities, as we work with people, we have an important contribution to make in those wider determinants within the ICS and of course the role of the NHS as an anchor institution because in many communities, the NHS is the abiding presence, the biggest owner of estate, just that anchor.

Finally, the role of the NHS, as an employer, so the 1.3 million people that are employed in the NHS are a microcosm of the wider community.  As we look after our staff and address their health inequalities, actually that is us putting our house in order as we then look after the rest of the community.  So, it’s ways of influence is how I look at it.

HM:       That’s a really helpful way of presenting it, Bola, and I guess what I’m hearing is, that as a frontline GP, it’s not necessarily frustrating because you do have a sphere of influence where you can make a difference to some of those inequalities but then obviously, as you move up the different levels, you’re now in this role where you can work at a different level with a different sphere of influence.

BO:        That’s right.

HM:       I wanted to ask as well, we talked about you were previously National Speciality Advisor for older people, how did that work impact on the lens that you are taking now, to your work, in your current role on health inequalities?

BO:        So, when I was National Speciality Advisor for older people, I was leading on the anticipatory care element of the National Aging Well programme and I had lots of conversations with many voluntary sector organisations as well as teams and programmes across NHS England and improvement and the NHS more broadly and what emerged to me was, when we talk about anticipatory care, essentially your proactive way of looking after people, there was something about the need for it to be person-centred, the need for it to be holistic and not looking at people as the sum of their medical diagnosis but seeing people as whole individuals with lives and experiences that go beyond whatever medical diagnosis they happen to have.

Also being mindful that many of those conditions are impacted powerfully by people’s social circumstances.  So, in many ways, the time that I spent leading on the anticipatory care workstream for the Aging Well programme, gave me the opportunity to make extensive networks, extensive partnership, I met so many people and so many organisations that when I was appointed in December 2020 to the Director role, there was a ready team, if you like, it was literally going back to these individuals, organisations to say, and now we broaden the lens, to not only older people but to all the other groups who experience healthcare inequalities.  So, for me, it was an unplanning natural sequence from the National Speciality advisor role to the Health Inequalities Director role.

HM:       That’s brilliant, so I wanted to ask you a few more questions about some of the work you’re doing in your current role, and I guess starting with the pandemic and what we’ve seen because obviously in some senses, the pandemic means we’re living in unprecedented times, do you think what we’ve seen over the past year, creates the impetus for change or even you could say a burning platform in terms of us now being able to make faster progress in terms of tackling health inequalities?

BO:        I reflect on the pandemic and what I see is an opportunity for us to leave an indelible legacy and I often think about it in the context of the Second World War, we see the big institutions of state that have emerged, the NHS, our NHS, adult social care, all of the institutions that we come to rely on and depend on.  It doesn’t matter what report you look at whether that is Public Health England’s COVID disparities report that came out in April last year or the beyond the data report that followed that or indeed the publications by the Kinds Fund or other think tanks, you could draw a solid line through all of those publications and reports and you could title that solid line health inequalities.

So, for me, what is the biggest thing that we can emerge from this pandemic with, narrowing health inequalities, they’re not new but the pandemic has shown such a harsh light on them and given us such an impetus to accelerate our progress.  So, whether it’s the digital transformation that has happened, whether it’s the connection with people and communities, so I think of the webinars that have been on all through January, February, March, part of April, talking to faith leaders, community leaders, communities themselves, driving up confidence in the vaccine.

I might look at all those partnerships, all those relationships, those networks that have emerged from the pandemic and I see how we can absolutely now leverage all of those to tackle the wider health inequalities that predate the pandemic.

HM:       That’s really good to hear and such a clear message, Bola, I know that one of your interests is in using integrated care models to reduce health inequalities, so I wanted to ask you a bit about that because, particularly give the Department of Health and Social Care’s recent white paper, where it talks quite a bit about the role of ICS’s integrated care systems in tackling health inequalities.  Although, I guess in my reading of it, I didn’t see a lot of detail in terms of the specifics of how ICS’s would do that.  So, I guess my question to you is, how do you see that happening in practice and how do the changes, set out in the white paper help with the health inequalities agenda?

BO:        So, I think integrated care systems have a really important role to play because of that duty to collaborate.  I think the white paper, in setting out the four purposes of ICS’s, has actually been really important because if you look across those four roles or the four purposes of ICS’s set out within the white paper, you can see a very important message within those four, which essentially is around tackling health inequalities.  I think therefore, it gives us a very important frame of reference.

I think the duty, as it were, to collaborate is perhaps the most important thing because the NHS is not going to tackle health inequalities in isolation, neither can our local authority partners or indeed our voluntary sector partners, they genuinely need to be that combined effort, bringing the different expertise, the different experiences of those different organisations to the table.

So, I often would describe the voluntary sector as playing a really important role in advocacy, in insight, in building connections and so for me, I do see the ICS in its role as collaborating, in its role has having an in-reach into the community to be able to move the dial in the right direction in tackling health inequalities and we’ve seen it play out, even now, in terms of our response to the pandemic, the local resilience forums.  I think the pandemic, if we ever needed a demonstration of how a whole system approach is how you address health inequalities, well the pandemic is the worked example, whether it’s the support that we were able to give to shielded people, whether it was the rollout of the vaccination programme, whether it’s the work we needed to do in terms of the various interventions put in place to reduce transmission.

We needed the collective effort of all of those institutions of state, working together, to be able to get us to a place where we’re now seeing the horizon.  I don’t think any one organisation is able to say in isolation that it has unilaterally or independently been able to get us to this place.  I do think it’s the NHS, working with the voluntary sector, working with the local authority, working with communities, community leaders, faith leaders and that’s what the ICS is.  There is now an opportunity, in a way that we probably haven’t had before, for all of these organisations to coalesce around a common cause.

What we have now is the permission to act and the permission for leadership to act and that is just so exciting.  I really cannot wait to see, I’m genuinely excited to see how the ICS’s are going and they already are, that’s the exciting thing, we have health inequalities system responsible officers and executive leads who are already bridging the gap and building bridges and making connections with other parts of the system.

HM:       So, I hear your point on the duty to collaborate and I think that is important, reading through the white paper, it was quite quiet on how we hardwire the need to reduce health inequalities explicitly, but do you think the bill presents us with an opportunity to actually go further in terms of strengthening the accountability and reporting arrangements for reducing health inequalities and is that something you would like to see?

BO:        I take the view that structures are important, like the bill but the thing that has made the difference and I keep using the pandemic as a frame of reference because it’s the thing that is most alive in all of our consciousness, we collaborated because we could come around the common cause and we didn’t wait for the piece of legislation to drive us to do that.  So, I see the bill as an enabler, but I see our natural instinct to actually address health inequalities as the thing that is going to move us forward.

We say it a lot, that culture eats structure for breakfast, we can have bills, we can have laws, we can have the structural things in place, and they are important, don’t get me wrong, they are important because they give us a context and they give us permission.  However, the thing that makes a real difference is the cultural transformation that happens in people’s minds.  That cultural transformation has already happened because now we all know that when we work together, we make greater progress than we would otherwise on our own.

That is now indelible in everybody’s minds and so for me, I think the hard yards that we have to cover in terms of integrated care systems is the cultural transformation, it is the move from competition to collaboration, it’s the move from organisation to system.

HM:       I agree with you, Bola, about the role of culture, I guess what I’m wondering is, as we see the backlog, the huge backlog of treatment, people on waiting lists and governments, the government, sorry, we can expect to see them focusing very much on driving down those waiting lists.  How do we make sure or how does the NHS make sure it’s able to continue to hold to that belief and renewed focus on tackling inequalities as part of that work to reduce the backlog, as opposed to an either/or and those things being in conflict when a political target comes along?

BO:        This is not a binary choice to be made, this is absolutely a yes/and scenario and I’m really heartened that when you see the NHS operational planning guidance that was published on the 25th March, you can see the very strong commitment throughout that document to tackling health inequalities, whether from the point of view of primary care or personalised care or population health management or in relation to specific specialities, MSK, cardiology, ophthalmology, cancer, there is a very strong theme throughout the NHS operational planning guidance that speaks directly to tackling health inequalities.

Beyond that, within the elective recovery fund gateway, health inequalities is one of the gateways and for me, there can’t be a more powerful signal of commitment from the NHS that as we restore our services, as we recover our services, we will do so on the basis of narrowing health inequalities.  The other thing is when you look at the five key priorities set out within the operational planning guidance, number one, restore services inclusively.

We’ve put this grand commitment throughout the document that is guiding our recovery effort and we’ve not only set it out as a list of priorities, but we’ve also put it within the gateway where the funding for the recovery effort comes in.  I really recommend those documents to listeners who may not have read them yet.  So, this is the NHS operational planning guidance and the implementation guidance as well as the elective recovery fund gateway.  Health inequalities is just hardwired through every layer of those various publications and for me, I really do think having that, so clearly and emphatically, gives us a solid platform upon which to do all the other things I was talking about in terms of culture and relationships, absolutely.

HM:       So, just thinking about the vaccine, Bola, I know you’ve been involved in media and video efforts to encourage people to get the vaccine, there’s been a lot of coverage in the news about vaccine take-up and vaccine hesitancy among some groups.  Then I’m aware that in some quarters, there’s been pressure to make the vaccine mandatory for staff in particular and the Department of Health and Social Care is consulting at the minute on requiring care home staff to have the vaccine.

So, I just wondered, what’s your take in terms of making the vaccine mandatory for staff, is that something you think we should be avoiding and is there a better way to encourage vaccines?

BO:        So, I will draw on my experience over the last several months.  When I’ve respectfully listened to people’s concerns and addressed those concerns, as well as appealing to people’s deep drive to do the right thing for their patients, I find that that message has connected more deeply with people.  So, most people who work in health and care, have come into it, driven by a sense of duty, to do the right thing, a desire to help and to protect.  When I speak to that deep driver, it actually leads to a much more productive conversation and so that is my take, is that as we go forward, clearly as you said, the consultation process is ongoing and it’s not my role in any way to pre-judge that.

Whatever other structural parameters are put in place, my experience is that speaking to people’s innate drive to do the right thing, to protect their patients, to protect their communities, listening to their concerns with respect and being prepared to address those concerns in a way that is authentic.  That’s the other thing, that’s the thing that I’ve seen shift people and shift their position and I hope that as we go forward, I and others will continue to have those sorts of conversations because that is the sustainable way of taking people with us, on this journey.

HM:       Thanks Bola, okay final question.  I know you’ve pretty much only just begun in the role, so December 2020, five months, so this might feel premature but what do you want to have achieved by the time you leave.  Have you defined any personal success metrics for yourself?

BO:        So, I’m proud to share this vision statement with you because it’s the distillation of the voices of many.  So, I started in the role in January 2021, and I spent my first 90 days having multiple conversations with individuals and teams and organisations and they’ve helped me to come to this vision that for me, for us to get to a place where we have and are delivering exceptional quality healthcare for all, but ensuring equitable access, excellent experience, and optimal outcomes, that is the marker of success for me.  To be able to look back and see us having made massive advancements in that vision, will tell me that we’ve done well.

HM:       That’s a very clear vision statement and great to have you share that with us.  Thank you so much Dr Bola Owolabi for joining me today.

BO:        It’s been a pleasure.

HM:       Well that’s it from 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, either @TheKingsFund account or my account, @helenamacarena and finally, thanks as always, to you for listening but also to our podcast team for this episode.  Producer Ian Ford, Researchers Jonathan Holmes, and Charlotte Wickens and also thanks to David Buck for his advice and assistance.  We very much hope you can join us next time.