Speaker1: [00:00:00] Hello, I'm Suhail Mirza and welcome to this episode in season three of Voices of Care. My guest today is the NHS England's regional director for London, Caroline Clarke.

Speaker2: [00:00:10] Voices of Care, the healthcare podcast.

Speaker1: [00:00:14] Caroline, welcome to Voices of Care. Thank you for giving us your time today.

Speaker3: [00:00:17] Thank you very much for having me.

Speaker1: [00:00:18] It's a pleasure. I've known your name for many, many years from so many people in the health ecosystem here in London. I'm a proud Londoner myself. I want to see if I can start actually to unpack the role of a regional director, because we've heard that title. What does that mean?

Speaker3: [00:00:35] Yeah, it's a good question. So, I think there are probably 3 or 4 things that we do in NHS London on behalf of NHS England. So we're a regulator. So there's a statutory responsibility to make sure that organisations are, you know, regulatorily performing. We're kind of performance improver. So we try and help people improve. We want to transform services, so we work with our partners across London, London councils, GLA and others to make sure that we transform services. And I think probably the fourth thing is that we kind of commission certain services. So we commission specialist services on behalf of Londoners. We commission some prevention services and justice services. So we actually make sure that things are appropriately kind of bought and managed. 

Speaker1: [00:01:25] You come with a, I remind you too much. But it might be 1991 when you started your journey.

Speaker3: [00:01:32] Thanks for that.

Speaker1: [00:01:33] Sorry, I'm older than you so but you come from a background obviously in the acute setting, Royal Free. London is very much in your blood. You've worked at numerous trusts. Homerton. ChelWest.

Speaker3: [00:01:45] Yeah, yeah. Not ChelWest actually. So I've been much further east. So my last job was I was the CEO of the Royal Free Group Hospital. So sort of between 10:00 and 1:00 in North London, that population, those hospitals. And I was at the Royal Free previously as the CFO. So I'm an accountant and an economist, and that's either good or bad, depending on. But I mean, I hope it's useful and I believe that you, you know, as a taxpayer, I think it's important that we manage resources. And as a patient, I think it's really important. So I think it's a good thing. But I started my career actually, I started my career in Hampstead. So I went 1991, I was a regional trainee. I was really lucky. I was on the graduate training scheme and I started in Hampstead Health Authority. So I kind of felt when I went back there in 2010, it was like a sort of really nice journey. And I live in North London. It used to be able to walk to work. My kid goes to a comp in Camden, you know, so I feel and in fact, in the last year since I've been doing this job, I've spent much more time in South London. I've spent much more time in out-of-hospital spaces and mental health organisations trying to really understand how the whole system works, because it's a long time since I worked in primary care and in mental health. 

Speaker1: [00:02:51] Well, let's look at that. I mean, that's a vast tapestry of London, very varied. Can you just give us a little bit of scale in terms of the London health economy? It's substantial.

Speaker3: [00:03:04] Yeah. So first thing, how many people are in London. Right. So it's somewhere between 9 and 10 million. There are more than 10 million people registered with London GPs. But it's a very transient population. So actually you usually hear people say sort of nine, 9.5 million. That's a lot of people squashed onto not very much land. So one of the defining things about London is it's only about 700mi². So it's quite dense. So it's also one of the most diverse cities in the world, probably not the most diverse, but, you know, 300 languages. It's up there. It's also one of the cities with the most variation in income. So the top 10% of households are ten times richer than the bottom 10% of households. That's a very big variation. We see that in all the health stats as well. So whether you're talking about child obesity or cardiovascular disease or cancers. You see that impacting people who are in that bottom 10% much more. And that is why people in the NHS get so exercised about wanting to reduce health inequalities. You know, I'm sure lots of people listening to this will know about Michael Marmot and the social determinants of health. It's all absolutely there in the data.

Speaker1: [00:04:16] And that's one of the priorities of course.

Speaker3: [00:04:17] Totally, totally. So you know, in 2019, the London NHS and the mayor's office, GLA and London local councils signed up to a vision to try and make London a healthiest global city and the best city in the world to receive health and care in. That seems very ambitious, doesn't it? But actually, having gone through the pandemic and seen what's happened in other cities, actually, I think it's absolutely the right ambition for us to have.

Speaker1: [00:04:44] And it's an extraordinary ambition. Sorry to interrupt you, because the impact of Covid on London in terms of excess mortality was extremely severe.

Speaker3: [00:04:53] I mean, urban areas generally and particularly areas with houses. Houses in multiple occupation. You can really see that in the stats as well. But I think coming out of Covid, the way to get to that vision is probably threefold. One is big emphasis on prevention and that sort of shift left. People talk about big emphasis on moving care from hospitals into out-of-hospital space. So primary community social care and a really, really big shift on tech. And that's the big thing that we want to do in London to make sure that actually we can offer Londoners, if they want it, a sort of digital-first care experience. 

Speaker1: [00:05:29] Well, I'm very keen to explore those in a bit more depth. Just one final tarry. Just taking a snapshot of London. I could be wrong here. It's definitely over 30. It might be 38 trusts right across the board, ICBs, primary care. You've talked about public health. It's huge, 33 local authorities. 

Speaker3: [00:05:50] 32 and the City of London, over 40 trusts. I mean, some are kind of merging and changing, which is why we're sometimes a bit loose with those numbers. There are five integrated care systems, so they're cut geographically. So North, central, northwest, southeast, southwest, and northeast. And if London covers 10 million there's sort of 2 million each. Northwest is really quite big. Yeah. And effectively my organization, NHS England kind of works with the ICBs to make sure that their systems are working effectively. And, you know, it's a real debate, isn't it, about how much you do centrally and do once for London or once the nation, versus how much do you want to deliver locally? And we think about that a lot actually.

Speaker1: [00:06:32] And there's no silver bullet answer because until recently some of the trusts have had joint chairs. And is that going to be something that's been reversed a little around that? You talked about financial stability. I just want to touch upon that. The National Audit Office produced a report in July 2024 talking about its financial sustainability, etc. Background as an accountant, just we're not going to go into detail about that. We don't have the time, but just intrigued. I read somewhere on your journey. One of the big lessons that you learned was that you can't know everything, and humility is quite important.

Speaker3: [00:07:06] Totally, totally. But there's something in there around, you work in a team, you're as good as you, as good as your team. So you surround yourself with people who are better than you. There's a big issue for me, actually, in London around the scale thing and about variation. And how do you address that? You know, most people that work in Western health economies say the biggest issue we've got is actually unwarranted variation, and outcomes of our patients are often adversely impacted because we do stuff really differently. So big thing I learned at the Royal Free was actually we can use technology to try and get more consistent process, to try and actually give the people that we serve a better, more standard service, you know, and actually their outcomes get better and their costs are driven down. So the more you standardise and take waste out, the better you can control your costs. And I'm pretty sure that's the case for out-of-hospital services as well as in-hospital services.

Speaker1: [00:07:58] And that's going to be an imperative given budgetary constraints and the ability to break even. Let's dive into that digital-first strategy and give some examples of how that's actually working because there's been some tremendous advances in terms of policy from NHS nationally federated data platforms. Et cetera, et cetera. Great promise. Some poor results in the past. Just unpack what you've seen on the ground in terms of digital-first.

Speaker3: [00:08:22] So I suppose the first thing to say is in countries where their geographies are more remote, they've been at this for a bit longer because they've had to be. So, I met a man from Lapland recently. This was the first person that I'd met since Father Christmas. And he was nothing like Father Christmas. So he destroyed my stereotypes of Lapland. But serious point. He was running a big part of their system and was describing their approach to both remote diagnostic, remote treatment and remote access for their patients who had to travel literally thousands of miles to get somewhere. And then actually, if you look at the Nordic countries, they're in a similar position, actually, parts of Australia parts of the States. So people are doing this. So it's not kind of London's thinking of something odd. It's just that we're trying to learn from other places. There are parts of London that are offering fantastic services to their patients. So, you know, you'll hear people say, well, my GP allows me to access their services by the internet. I get triaged, I get asked a set of questions, and then they'll signpost me to the right place and I'll get seen really, really quickly. I think our job, my organisation's job is to make that the case for everybody. So that's the first thing. So it does exist, but it's not everywhere, right? And actually the types of digital triage that I've seen and the types of just quick access in other countries is something that I think is utterly achievable. It's not going to happen overnight, but I think it is absolutely the journey that we're on now.

Speaker1: [00:09:41] And there's some examples you talked about, I think Moorfields Hospital.

Speaker3: [00:09:44] Oh, yes. So, for a number of conditions where you're not dealing with a patient who's quite complex and carries a lot of risk. So thing number one, actually, you need to understand the risk of the population and have that done fairly consistently across the city. The thing number two then, if I've got if I've got something wrong with my eye. The technology now exists for me to actually go quite quickly to somebody who knows about eyes and have that looked at and then get sort of streamed into a really fast service. And we're seeing this, you know, Moorfields and a number of other providers in London are doing this. So again, our job is to try and get that standard of service for all Londoners. Similarly, the technology now exists for things like diagnosis of skin cancers. So you know, very soon your phone, the camera on your phone will be good enough to read the image of your lesion mole on your hand or wherever it is and then and then give that to an AI-assisted piece of software, which will then be able to tell you very, very quickly if it's benign or malignant, and you need to go somewhere else. Now for the number of patients that have skin conditions that get really anxious, that's great. So this technology now exists. And our job is to really harness it and scale it and kind of sort of get the trust and confidence of the public so that they're kind of up for it. I mean, those are only two conditions. Others are available, ears, of course, MSK and we've been running a series of, we call them deliberative engagement events across London. So we're right in the middle of one on primary care. But we did one last year on urgent care, and we did one on a kind of use of data where we take a group, 100 representative Londoners.

Speaker1: [00:11:26] That must be an extraordinary room.

Speaker3: [00:11:27] It's amazing. You walk in the room and it's like, oh my goodness, this is London. It's like, well, you know, every type of group and characteristic is represented. It absolutely makes the little hairs on the back of your neck stand up and we talk to them about kind of, you know, we give them sort of input onto kind of the issues that we're discussing. So at the moment it's primary care. So what do we mean by primary care if we want to change access, what do we mean. And talk about the risks and the benefits. And of course Londoners want to engage in this. And they're really interested. When we did this with urgent care last year. You know, most people are much more savvy about digital, more than you'd realise. 

Speaker1: [00:12:04] It might be a heuristic, but you think digital inclusion is important and an issue, but people are much more open than perhaps anecdotally.

Speaker3: [00:12:14] Yeah. And I think, you know, in the healthcare profession, we get a bit lazy about talking about digital inclusion, you know, and I visited a practice out in Bromley last week and 70% of this practice has a first-generation Bangladeshi family member. 90% of the population is using digital triage to get in, because, of course, it's easier than picking up the phone and having a difficult conversation, or they've got a family member that can help them. So I think when we talk about inclusion, we have to be really, really clear about what we mean. 

Speaker1: [00:12:43] Yes, absolutely.

Speaker3: [00:12:43] I absolutely get it. And when we talk to Londoners, they worried about it. But we need to look at what the data is telling us and what they're telling us, and then respond in a really kind of focused way. So I think I think this can help, but it won't be the only way you access health care, right? So telephones are available and you can still walk into a practice. So we have to make sure that's all still available. But with our very scarce resources, which I don't think are going to go up massively in the short term, we have to use them the best we can. And I think this is one way of helping us do that. 

Speaker1: [00:13:11] And the deliberative engagement exercises, you said cover data as well.

Speaker3: [00:13:15] We did one a couple of years ago on data. And that was, you know, how far would you go in letting the NHS use your data for research, for providing better health care? You know, and it's a bit more nuanced. And of course, that debate is very big in the sort of public sphere anyway, isn't it? We get asked about data all the time.

Speaker1: [00:13:33] But encouraging.

Speaker3: [00:13:33] Yeah, it's really encouraging.

Speaker1: [00:13:35] In terms of grasping it.

Speaker3: [00:13:36] And I think, you know, there's something about we mustn't infantilise the public. You know, these are really sophisticated individuals who have views and we have to elicit them and engage them.

Speaker1: [00:13:43] No. I'm glad you said that, because sometimes it can appear rather condescending when people say, well, actually, are they really going to be engaged? But this is hugely encouraging you at the outset. You also highlighted out of hospital, community-based primary care. I hate to remind you, it's ten years since the, unless my memory is rusty, the five year forward view. In terms of primary care, this has been trailed a lot. Percentage of NHS budget towards primary care nationally hasn't quite got to where it ought to. Just broaden that out because that's where the policy narrative is. What's the practice on the ground?

Speaker3: [00:14:19] Spot on. So you know I remember Healthcare for London and Ara Darzi leading that.

Speaker1: [00:14:25] And the name returns.

Speaker3: [00:14:26] I know, I know. Yeah, yeah. We talked, very wise man. So this is good.

Speaker1: [00:14:29] Absolutely.

Speaker3: [00:14:29] We talk a lot about polyclinics then. I mean, you know, that was a physical thing as well as a group of people working effectively in integrated neighbourhood teams, which I think is most recently what Clare Fuller has recommended that we do. And I think she's spot on. And again in parts of London it's working really well, but in other parts it's not. I think there's definitely something for us to think about. In kind of sort of loose policy terms around what would give that an extra push and can we kind of think about different financing mechanisms? I mean, I can go into kind of NHS Bureau speak, but you know, effectively you've got to make the money work for everybody and you've got to give people a bit of time to get their workforce out into the community. You've got to give people time to get used to working with each other in a different way. And also we've got to stop thinking about buildings all the time. I mean, London's got a lot of estate. It's not all in the NHS. Some of it's in local authorities, some of it's, you know, in other public sector parts of the city. And we've got to think about how we use the assets.

Speaker1: [00:15:26] There has been some, there have been a few. Just to go off on a tangent. We won't go into the detail giving you a background, but London does have an estate, the NHS, and I think it was Bob Naylor. It wasn't that long ago that we were coming up with a very iconoclastic set of proposals. They were quite brave. 

Speaker3: [00:15:42] I know, and we've been working. So some people in my team work with the GLA colleagues and London local councils on what else could we do across London to really unlock some of that estate and make sure that we're kind of using it much more effectively in a much more integrated way.

Speaker1: [00:16:00] The Fuller review talked about a number of enablers. It talked about the estate, it talked about data, which you've already touched upon. And the other one from my memory is the workforce. And I want to touch upon that if I can. Hugely diverse population that we serve. There are a number of initiatives to ensure that it's an inclusive workforce. Can you sort of unpack that for us? Because that's a challenge from cost of living people being able to work and live in London, to making sure the workforce represents the Londoners that they serve.

Speaker3: [00:16:33] Yeah, I agree. Actually, there's some work we've been doing in the London region on an anchor program. I don't know if you've explored that, but you know, effectively how to become really, really good local employers. And how do we do that with partners and how to become good local buyers of services and support local businesses and all that stuff. So that's really, really important. And I think, you know paying people the London living wage. All that stuff is really important because actually then you'll have a workforce that wants to stay. I can remember when I was at the Royal Free and looking at the geographies of where our staff lived, and over a ten year period it really changed. So, kind of between 10 to 20% swing out of London into sort of Hertfordshire and, and you know, and that goes further and further and people kind of commuting more and all that stuff. So we really do have to think about that. London is becoming a very difficult place to live. You know, there is a housing crisis in London and we see that in our statistics because sometimes we find it difficult to get patients out of hospital.

Speaker3: [00:17:29] When we talk to local authority colleagues, it's the same for them. And so we have to really think about both that side of it. And then what does that mean for our staff? So I think paying people well and then just making it easy to work here. You know, you want you want to kind of bring your heart and soul to work in a way, don't you? And just have and enjoy it. And so what are the things we can do as employers, really good employers, to just take the pebbles out of your shoe and other aphorisms are available. But, so things like, is it easy for me as a junior doctor to move between different hospitals? Have I got a license to do that? So we work on that stuff, which never sounds very exciting, but actually it's really important when you talk to junior doctors and they're flipping about in their training, it's like, you know.

Speaker1: [00:18:10] And I think that taking the broader view, looking at it London-centric, we've of course, had the seminal Long-Term Workforce Plan back in January 2023, a month or so after you took office, a great vision, huge increase in numbers potentially. That's also going to require perhaps a different approach, a digital approach to training.

Speaker3: [00:18:32] Yeah, totally. So there's a guy called Eric Topol that wrote a report quite a few years ago now for Health Education England. And effectively was around here are the kind of major technological advances we're going to see. And this is the impact they'll each have on the workforce. So anything from, you know, what are the advances in genomics going to do for us in science? What are the advances in big data going to do or AI? And what does that mean for each of our professional groups? London has got 40 universities, 17 of whom we work with directly. We've got five now, six medical schools. So if London can't do some of this work together with our higher education institutions, it's not going to happen. So it's on us. I feel that quite deeply, and I know my team do as well. So we're really trying to work with the educators on what are these new roles. You know, some of them are quite contentious, you know. So the stuff in the media about physicians and anaesthetic associates at the moment. But on tech specifically, yes, I think there are two issues. One is what does it mean for people existing in now in the service? And how can we, you know... 

Speaker1: [00:19:35] Upskill perhaps.

Speaker3: [00:19:35] And then also what are the new roles? Things that we can't actually see. It's quite difficult to articulate it because I don't even know what it's going to be like in five years time. 

Speaker3: [00:19:45] But I do know that a technology like ambient voice technology, where you and I could be sitting, having a clinical consultation. So you're my doctor and we now have the technology. And this exists in quite a few areas in London. It exists in hospitals and in GP practices. So technology is recording our conversation. It's weeding out the nonsense. So it might be a quite short conversation for us. And then it's putting it into a structured form into the electronic software. And then in some cases, it's actually guiding you as to what you should do next with that patient, given what it's heard and that's existing now. And that takes out so much admin, it stops the, you know, the junior doctors having to do loads of coding. The clinician becomes the editor rather than the actual creator. But they're different skills. And it also has quite big implications for junior doctor training. So these are huge and they're here. And so I think our job is to really responsibly try and work. On something like ambient voice technology, we're working across a number of sites in London, just making sure we pilot it and doing it, trying to, you know, don't run before you can walk, all that stuff.

Speaker1: [00:20:48] But those slightly, dare I say simple, they're not easy, but simple steps technologically to transform primary care, community care services. They can make a big difference to that big puzzle. As an economist, as an accountant, you alluded to earlier, squaring the circle of productivity because that's what it's based on, isn't it?

Speaker3: [00:21:10] Yeah, yeah, that will really change productivity for sure. But again, it's you know, I've been put in quite a few big clinical software systems or been sort of part of the leadership group that's done it. And the classic thing you always end up with is, yeah, we did it. We had a really successful implementation. But you know, like only half the staff are using it, that thing. So, the thing for me is about, you know, we've got a lot of this functionality. We're just not using it. And, you know, if you go back to sort of the digital-first, I want patients to have the opportunity to, you know, get triaged and kind of go to the right place, which may or may not be the GPs. Well, we've got a lot of that functionality already, and it's just that we're not very good at using it.

Speaker1: [00:21:49] So it's an advocacy piece. Engagement piece

Speaker3: [00:21:51] That's right. And I think, you know, I think I hate to say this. It's not rocket science or exceptional. What we're trying to do in our strategy, it's just making use of what we've got, it's really hard.

Speaker1: [00:21:59] Behavioural change isn't easy even if it's relatively simple, says someone who's only just beginning to understand some of the functionalities of my iPhone. Staying on this primary care, community-based care and broadening out just a little, if I may. You've talked about, of course, local authorities, you're working with many different stakeholders. I just want to broaden the ambit. I know, of course, NHS England to make sure you have a voice to say around social care because that's extraordinarily important, particularly in an integrated system. I think we're now two years into the ICSs.

Speaker3: [00:22:38] So we work kind of with and through the five ICSs in London and they're great. They're doing great work. And of course, they work very closely with the 31,32 local councils. We also work with there's an umbrella group, the London Councils Group, who represent and then we work with the GLA as well. And actually that work is really important. And you know, I've been really surprised at how much, how much time I've spent over the last year thinking about housing, about complex patients, adults, and children around, you know, some of these really difficult issues which require multi-agency response. And we're trying to do more and more jointly so that we can because when the money gets tight, each organisation retreats into the bit that it can, you know, it can influence and partnership just becomes harder when it's stressful. And so as a region, we're trying to be quite thoughtful about how do we, you know, how do we facilitate good partnerships and how do we really try and get maximum use of resources in the place and even at PCN level, so that, you know, both social and healthcare resources are kind of maximised and you know, there's that old adage that, you know, if I'm going to have a bath, I don't care if it's a social services bath or a health bath. I just want a bath. You know, patients don't care. They just want us to really behave in a more seamless way. And I think that's what integrated care is really about. So I think our job is to really just try and facilitate that.

Speaker1: [00:24:05] And going to the bigger point, you've mentioned it before. All of this sits in the context, the wider context, and not just an NHS thing at all around health equality driving a reduction in the variability. Now, you mentioned Michael Marmot, of course, earlier at the Institute of Health Equity I think. 

Speaker3: [00:24:23] North London right. Yeah. Central London, UCL.

Speaker1: [00:24:26] Absolutely, UCL. There we are. We're back at London University. Now, they produced a report a couple of years back looking at health inequalities in London. And it was stark the impact of Covid. 2 in 5 children in poverty. Just want to set the scene, if you can, around the variability and what's concrete that we can do. You've got the mayor's office. This is a huge issue. 

Speaker3: [00:24:45] Yeah. No I agree, I agree. And so I think we all agree, and in fact, that London vision set up a number of pieces of work that we're doing jointly in all the areas that you've just described, actually. But the big thing that I think we all agree now that we can do next is a piece of work on cardiovascular prevention, because the people that are most impacted by cardiovascular disease are in all those groups that are less well-paid and have protected characteristics that we're not looking after properly. So, in the next couple of months, you will hear about our Million Hearts, Million Minds campaign, which will be something for all Londoners. Of course, a lot of the work that you do in things like measuring blood pressure and looking after your cardiovascular health actually doesn't take place in healthcare at all. It takes place in the library or in local authorities or, you know, you know, on the bus, so there's something for me around that's a kind of all-play public health initiative of the highest order. And I think it will make a real difference. And the idea is that we can really impact a million people's health by making sure they have the right checks, making sure they're taking their meds, you know, making sure they're exercising.

Speaker3: [00:25:58] You know, it gets us into the conversation about childhood obesity. It gets the mayor into the policy areas. Actually, the team's been in already around kind of sort of tobacco and sugar and, you know, kind of the licensing laws around schools. You know, so I think, this is something that all Londoners experience and it's something that we have to get into. And to the point about inequalities, if we can really tackle the causes of cardiovascular disease and get upfront early. Actually, we will be really making a big dent on health inequalities.

Speaker1: [00:26:54] A million hearts.

Speaker3: [00:26:55] A million hearts, a million minds. Because of course, it affects your brain health as well. And there's more and more evidence about that now.

Speaker1: [00:27:02] And we're going to hear about that later in 2024. And we will definitely look forward to that. But just speaking about the wider determinants, I mean the mayor's health inequality tests were, you know, we're very familiar with those. And there was a report from the Nuffield Trust a while ago looking at the idea that actually we need to broaden some of the work, not just look at the Equality Act, which is about protected characteristics. It goes beyond that. I think you've touched upon that. You said you were thinking a lot recently, over the last year about housing and these wider determinants.

Speaker3: [00:27:35] Yeah, housing and education, you know, transport. Did you know that there are 16,000 care leavers across London? So kids that have been in care and stuff.

Speaker1: [00:27:45] Up to the age of 16.

Speaker3: [00:27:46] And they don't have access, they find it harder to access health care. They find it harder to get around and get free prescriptions. So, you know, the colleagues across London have done a really good piece of work to actually just get those 16,000 young people, some of the obvious things like free transport, like free prescriptions, all that stuff. And so it's a small example, but actually you have to come at this at that level in order to really do something rather than just commentate. So I suppose I'm in that space of like, what else can we do and how else can we, you know, really make a difference at a, you know, meaningful level. And I suppose on housing and education, the work that we want to do with local government and with the GLA are absolutely in that space. So what do we do? And of course, you know, the mayor will be announcing at some point in his third term the detail of his manifesto. So, I guess, you know, we want to work really closely with him because generally we're really aligned on, you know, we want to say more about child health, more about mental health, as well as all these other issues around digital health and prevention.

Speaker1: [00:28:59] Yeah, you read my mind, actually, because I was just going to finish off, if I may. We've talked a lot about physical health, you know, million hearts, million minds. Mental health. I mean, it's a well-worn, hackneyed phrase. It's become such a huge issue. There's so many reports, but confining ourselves to London, it's a top priority for you. What have you seen that's given you some encouragement? What more do we need to do? Because it's going to be a societal impact for generations.

Speaker3: [00:29:24] So when I see local government and health service working together in, you know, and they do generally we do. And that gives me hope that people still want to collaborate, work in partnership because we're all in service to this wonderfully diverse population. The rise in acuity of patients presenting with mental health issues is alarming, really alarming. And, you know, it's in double digits over the last few years in London. And our emergency departments are finding that hard to cope with. I think we have a better model of care now with the police, inasmuch as we're trying to provide health workers to look after people in their hour of need. But none of this comes without a cost, right? Of course. But we've got to do more and we've got to do more to make sure that people are supported at home and in the houses. So it's back to that. This is the housing issue here.

Speaker1: [00:30:21] And the nexus you support, it's interesting as you're pointing to the nexus. Mental health, it can't be seen as a silo, mental health, and inclusion. I mean, Professor Kevin Fenton, of course, you know very well has been leading some great work, which I think you've been very closely involved in.

Speaker3: [00:30:35] Well, I hope you get Kevin on your podcast because he's very, very good. Kevin, if you're listening, you must do this.

Speaker1: [00:30:42] Thank you. That was unbidden by me. It was unbidden by me.

Speaker3: [00:30:46] Uh, but I, you know, we understand that most of the health issues that we're confronted with are not issues that can be dealt with solely by the NHS. And all the ICB teams and leaders all understand that. And of course, local government understands that. And our issue is, as ever, one of scarce resource. So collectively we need to decide what our priorities are and what the things are that we're going to try and fix first. And you know, one of my favourite meetings every six weeks, it's called the London Health Board, where we meet with the GLA and London councils and various NHS people and ICB colleagues, and we try and kind of problem solve some of these wicked issues. And that's where you get a kind of strategy that you can lock partners in on and really try and do good work. So I think that's you know, and Kevin of course is big in those meetings. So all part of it.

Speaker1: [00:31:40] I'm going to end off and if I may, with reference to a four-letter word you've used a couple of times, which is hope. 

Speaker3: [00:31:48] That was really alarming. Can I just say, I thought I'd done this with no swearing.

Speaker1: [00:31:52] No, you had, you had. We're in the new phase of a new government. There's going to be a new long-term strategy or there's a review, etc., if there's a couple of things that give you hope for London's health economy, where do you pin yourself there? 

Speaker3: [00:32:07] Well, I say hope springs eternal. So actually what's the data telling me? And actually, in parts of London, we are genuinely making improvements. So I see parts of primary care working really effectively. They've invested in technology, they've got multidisciplinary practices. They're working with social care and community services. That gives me great hope. It gives me hope that Londoners want us to help. They want to help us do this. And so the deliberative engagement work.

Speaker1: [00:32:33] Co-design.

Speaker3: [00:32:33] Really a proper co-design. Yeah. That's that is like just amazing. And then I hate to end with tech because actually this is all about people, right? The technology is just an enabler. But if we get the implications of tech right for our workforce. And think about being a patient in all this and who, you know, actually, that does give me a lot of hope. The thing I can't see is what it's going to look like in ten years, because this could be, you know, it's very difficult to see beyond a few years in terms of what technology is going to do for us. But my hope is we will respond quickly and agilely and all be in it together and realise these are common issues and we'll solve them together.

Speaker1: [00:33:11] Well, on that inclusive and hopeful note, Caroline Clarke, thank you for your time and your wisdom.

Speaker3: [00:33:16] Absolute pleasure.

Speaker1: [00:33:17] My pleasure. If you've enjoyed this episode of Voice of Care, please like, follow, or subscribe wherever you receive your podcasts. And if you want to find out more about how we're turning the dial on the health and social care debate, please visit newcrosshealthcare.com/voicesofcare. In the meantime, I'm Suhail Mirza. Thank you very much and I look forward to seeing you on the next episode.

Speaker2: [00:33:37] Voices of Care, the healthcare podcast.