57. Tom Holliday - Children get less

Here is the first episode of this special mini podcast series, in collaboration with London South Bank University and the Universal Healthcare Network. 

(You will remember that Episode 56 with Professor Becky Malby was our first ‘bookend’ to introduce this series and tell you why Universal Healthcare is important)

Dr Tom Holliday is my first guest to dive in and share examples of how universal healthcare works in practice, breaking down traditional barriers to deliver more personalised care in a more equitable and human way.

Tom, as well as being a great friend of mine, is a very forward thinking consultant paediatrician. He is also now leading the Darzi Fellowship programme, with which I work closely every year with Whose Shoes. 

Children Get Less. Not here! We have put them FIRST!

After all, they are our future.

Lemon lightbulbs 🍋💡🍋
🍋 Follow this series to learn ALL about Universal Healthcare - and why it matters!
🍋Children are often pushed to the back – so we’re putting them first!
🍋 Good healthcare should come to where families are, not expect people to visit lots of separate buildings and specialists
🍋 Integrated care is jargon. Best practice care is what we must aim for
🍋 It is about providing the holistic care a child needs.
🍋When you are passed on from service to service, important information gets lost through the gaps.
🍋 It’s all about relationships! Across care boundaries!
🍋 If you swap GPs, you shouldn’t have to start again with a new CAMHS referral!
🍋 The NHS incentivises and measures activity; it should focus on meeting need
🍋 if you meet need, the overall level of need goes down
🍋 Third sector organisations need sustainable funding to plan longer term
🍋 If you can tackle issues via primary care, people don’t need to come to hospital
🍋 Complex problems can be resolved through good multidisciplinary working
🍋 If you don’t know the answer, phone a friend!
🍋 Physical health and mental health are interconnected
🍋 Children get less - especially mental health provision
🍋 CYP mental health services might talk in terms of a waiting list
🍋 Families, waiting for mental health support, talk in terms of “this isn’t a wait, it’s a life on hold!” 😢
🍋 Prevention and early intervention make all the difference
🍋 It’s not rocket science. It’s actually quite easy!
🍋 The patient is the expert in their own condition and how it feels
🍋 It’s all about teamwork and learning from others – nobody is doing this work alone!

Links:
Universal HealthCare National Inquiry
Easy Read Executive Summary
10 Leaps Forward - Innovation in the pandemic
Bob Klaber - kindness matters
Gill's Universal Healthcare work with MPFT

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Please recommend 'Wild Card - Whose Shoes' to others who enjoy hearing passionate people talk about their experiences of improving health care.

Chapters

• 0:00 Gill introduces her friend, Dr Tom Holliday, a forward thinking consultant paediatrician in London who is working hard to join up care for children and families
• 2:40 Integrating care? Or de-fragmenting care?
• 3:30 Gill draw similarities with the work she is doing with Midlands Partnership Foundation Trust
• 4:12 Innovation in health care is not just about health tech and robotics, says Tom. It is about being more patient centred
• 6:00 “I want to be able to meet need in a way that the system doesn’t interfere with”
• 7:15 Healthcare should not be about providing appointments in different organisations and buildings. It is about providing the holistic care a child needs.
• 8:48 It’s all about relationships! Across care boundaries!
• 9:24 Falling through the cracks - #MPFTWhoseShoes and children’s mental health
• 10:21 The NHS measures activity; it should focus on meeting need
• 12:15 Relationships are designed out of the system – even worse for children experiencing the care system, where trust is even more critical!
• 13:07 Sustainable funding and the ability to plan long-term
• 15:00 Practical examples of addressing health inequalities in Northwest London - very large numbers and very diverse needs
• 18:42 Child health hubs - working more closely with primary care to avoid need for hospital visits
• 20:56 Horizontal integration and vertical integration – and jargon!
• 21:25 Multidisciplinary working - working across boundaries to solve problems rather than them on
• 23:16 Families are cheering to hear about joined up care! 💜
• 23:55 It works much better for professionals too – you just phone a friend in another service and sort it! Perhaps a school nurse.
• 27:45 Tom explains the Quadruple ( now Quintuple) Aim of healthcare …
• 31:46 Prevention and early intervention make all the difference
• 32:10 It’s not rocket science. It’s actually quite easy!
• 33:26 Joining up physical care and mental health care - it can be a gaping chasm - but the two are strongly interconnected
• 34:10 The scandal of young people in crisis and struggling with mental health
• 34:55 How can I help you? Practical examples of working together across physical and mental health – very rewarding!
• 38:00 Getting to the root of the problem. Three experts in the room!
• 40:48 Feedback from these early joint clinics is phenomenal!
• 41:55 Children get less - especially mental health provision
• 43:48 It feels hard enough for a huge organisation like MPFT to join up within their own service – but also reaching out across boundaries is key
• 45:25 🍋 💡🍋 It’s all about teamwork and learning from others – nobody is doing this work alone!

Transcript

Tom Holliday - Children get less

Wed, Jul 31, 2024 11:51PM • 50:04

SUMMARY KEYWORDS

work, Gill, care, integrated, primary care, system, meeting, mental health, clinic, relationships, physical health, year, universal healthcare, joining, Tom, paediatrician, families, young, patient, children

SPEAKERS

Tom Holliday, Gill Phillips 

Gill Phillips  00:11
My name is Gill Phillips, and I'm the creator of Whose Shoes?, a popular approach to coproduction. I was named as an HSJ 100 wild card, and want to help give a voice to others talking about their experiences and ideas. I love chatting with people from all sorts of different perspectives, walking in their shoes. If you are interested in the future of healthcare, and like to hear what other people think, or perhaps even contribute at some point, Wildcard Whose Shoes? is for you. So today is the first episode of this special mini podcast series in collaboration with London South Bank University and the Universal Healthcare Network. 'Hang on, Gill', I hear you say, 'we've already heard you talking to Professor Becky Malby about this' - and you're right. I recorded a special episode with Becky as a bookend to introduce this series and tell you why universal healthcare is important, so that we can dive right into these conversations and hear what the various special guests have been doing to make universal healthcare a reality, and today, I'm not only talking to someone I know, but a friend of mine, who I've been wanting to get on the podcast for a very long time. It's my huge pleasure to introduce Tom Holliday, a very forward thinking consultant paediatrician and also now leading the Darzi Fellowship program with which I work closely every year with Who's Shoes?. So, a provocative title for this first conversation today: Children Get Less. So we're flipping things and putting children and young people first here. After all, they are our future. So Tom, how should we dive into this important topic and make it make sense to our listeners? Who are you and what are you up to?

Tom Holliday  02:13
Brilliant, Thanks, Gill, it's real honour to be here. As you know, I'm always such a fan of everything you do. So, you know, it's a real pleasure to, to be invited onto your podcast. So yeah, my name's Dr Tom Holliday. I'm a consultant paediatrician. I work at London Northwest University Healthcare Trust, i've been there as a consultant about three, four years now, and I'm the integrated care lead there. That said, that I'd always worked in West London and Ealing and Northwick Park for almost all of my paediatric training. So I know the region, I feel very at home there, and people often ask me what my specialty is. I always say, I don't, I don't really have a speciality. I'm a generalist. I'm like a hyper-generalist. And you know, my role in integrated care is really going out and joining up parts of the system. And sometimes we say integrated care, but I think really it's about defragmenting care, because we've split that care up a lot over the, well, over the lifetime of the NHS. And then my other jobs, as you mentioned, I work at London South Bank University, and I'm an Associate Professor there in Clinical Leadership and Health System Innovation. And it's a real privilege to be the director of the Darzi Fellowship in Clinical Leadership there. 

Gill Phillips  03:29
That's amazing. Tom, thanks for that introduction and... Integrated Care Lead. Well, that's a big, big ask, isn't it, because I think, you know, I'm doing a project that I'm rather proud of at the moment with Midlands partnership Foundation Trust, and that is the holy grail, isn't it? Joining things up for families. They don't really care who provides this service or that service. They just know they've got a child with possibly complex needs who needs help, and they want that service to join up around the child and indeed, the family. And that's why I'm excited to be talking to you, because I think that's exactly what you're doing, and some really innovative ways of doing that. 

Tom Holliday  04:08
Yes, yeah, I hope so. I think it's very different. Because, you know, we say it's innovations in care. And I think lots of time when people talk about innovations in care, you know, they think about sort of like health tech and, you know, robotics and things that sound like very, you know, cutting edge stuff, virtual wards, but I think this is a very different, actually, in some ways, a much more necessary, you know, form of innovation. It's actually how we organize care in a way that better meets the need of, you know, both the people who are accessing the care and also the people providing the care in in lots of cases. And, yeah, it's a real honor to be integrated care leaders. It's what I'm I'm trained in. It's what my experience is in. And the funny thing is, I often, often find it quite a difficult term, though, because I think, you know, first of all, integrated care, the whole point of that is that it's much more patient-centered. And population centered care, it's a way to better address need, first and foremost. I was thinking, if it's such a patient-centered idea, then the word integrated care is very, it sounds very jargony

 Gill Phillips  05:13
Very! 

Tom Holliday  05:13
And lots of people don't really know what it is. And then the other thing that I think is always that, you know, we say integrated care, and, you know, I'm the integrated care lead, and it makes it seem like it's a special thing, or, you know, something extra, or like cardiology or respiratory and it's not. It's, I was just think it's, it's a term for what we should be doing anyway. We should be joining up the system, providing more connected care. It's just a term for, well, best practice care, really. But I think the risk is always, if you say it's integrated care, this is our integrated care system, this is our integrated care pathway, this is our integrated care lead, then it just makes it seem like another specialty. But it's not. I think it's like, it's hyper generalism. That's the point. It's defragmenting to provide better care.

Gill Phillips  05:59
That's a really good word, I think, defragmenting. And I think, you said then that it's important equally for staff. You said for people providing the care too. And I know when we spoke before as a sort of pre chat, Tom, I wrote down this quote that you'd said, I want to be able to meet need in a way that the system doesn't interfere with. As driving thing for good staff coming into the system. And you know, how huge is that really, that that the system doesn't interfere with? And that's the golden thread, really, isn't it? To try and actually join things up in a way that's just common sense without it all being over complicated. 

Tom Holliday  06:40
Gosh

Gill Phillips  06:41
Do you remember that nugget? 

Tom Holliday  06:43
Did I, I did I say that? Did I say that, Gill!?

Gill Phillips  06:45
You did. You did. I was impressed.  

Tom Holliday  06:49
Were you! 

Gill Phillips  06:50
I was.  

Tom Holliday  06:51
Gosh, I don't know. I'm wondering to what extent it's possible to ever do that without the system interfering, because whatever system you have is still a system, isn't it?  

Gill Phillips  06:58
Yeah. 

Tom Holliday  06:59
I guess, I guess, when we were talking, we were speaking a little bit about how the system has become quite siloed and quite fragmented. And very often, what that means is that for, you know, families, young people, populations who are trying to access care, they have to go to where the care is provided. They have to go to the organizations. Because, you know, people often do ask you know, what is integrated care? Then I normally start with what integrated care isn't, which is more or less a system we've currently got where the care is tied to organizations. And really, those organizations, most often than not, are sort of bricks and mortar buildings. Sometimes they're virtual buildings, these days, post pandemic, but more often than not, you know, those are buildings and organizations, and to access the care provided by that organization, the family has to cross that boundary to get the care there. So, that might mean they have to go to the GP to be seen. Then they might be sent to the hospital, to that organization, and then there's a wait there, and then the hospital might send them on to see another specialist or to see a community provider. And every time you're moving on to another service, you're losing information down the gap there. The information that you lose is the context of the family and the story and the narrative. So it means that you can't see the pattern, you can't really work on addressing that need. So I always think that integrated care is really just reconnecting lots of those people and those those relationships, really. And I think what it implies is that, instead of making the families come to you, we actually have to think about leaving our organizations and building the care more around them, making it much more patient-centered, and working together. You know, it implies collaboration. It's built in. So really, these days, when people ask me what integrated care is, my standard answer is that it's about relationships. 

Gill Phillips  08:48
Relationships, yeah. 

Tom Holliday  08:48
Yeah, it's about relationships. That's the center. That's what really makes it work. My standard answer to, you know, can I give a definition of integrated care these days is that it's about building relationships across a care boundary that's focused on meeting the needs of a patient or a patient group, because it's the relationships that really change the outcome, that's what makes it work. 

Gill Phillips  09:10
Listening to you talking there Tom, I mean, I know that access is a key theme of the Universal Healthcare National Inquiry. So that's going to be running across these various mini podcast that we're doing across different areas of the service. But an example, I'm actually finalizing at the moment some new Whose Shoes? scenarios around children in care. And we've actually got a scenario called 'falling through the cracks', and I'm discovering different levels of layers and layers of this stuff, so that, for example, if a child in care moves, you think it must be a big move in a child's life to move to a new foster family. Perhaps it involves moving to a new school, but as soon as, as I understand, it involves going to a different GP, they might need to be re-referred for, say, CAMHS support, and they might have CAMHS support that's going really well for them, and suddenly the whole thing gets disrupted, and even they might drop to the back of a waiting list again, somewhere else. Oh my goodness! 

Tom Holliday  10:12
Yeah, it's madness, isn't it?  

Gill Phillips  10:14
It is madness. 

Tom Holliday  10:15
Yeah, and you can only imagine what that's like. And actually, you know, the thing is, Gill, it's inefficient, isn't it? The system's set up the way it is, because there is a notion that it's more efficient, and it depends what you measure, really, because if you measure activity - which is what the NHS does measure - if you measure activity, and you measure stuff, the stuff that we do, then actually it is very efficient, because we do a lot of stuff for a lot of money. But in a much wider sense, it's hugely inefficient, because every time you are creating a new waiting list, every time you're going back through triage, you're adding in a step, and you're creating more demand for the system. And we know that the problem is, if you design a system around demand and creating capacity to meet demand, then actually it's very well, it's very well known that demand overall is only ever going to go up. It's built in. It's designed into the system. The insustainability of the current system is designed in. We organize around capacity and demand: demand goes up. We incentivize activity. So of course, you know, in a complex system, you get what you pay attention to. If you incentivize activity,  if you incentivize doing stuff, you're going to get more stuff, right, more stuff to do. And then we wonder why we can't do it all with the resources we've got!  It's absolutely built in. So the answer for me, in lots of these cases, is that you don't organize around demand, you organize around meeting need. Because if you're meeting need. It's quite simple. The overall level of need goes down, and the sooner you can do that by promoting access. If you can promote access, then the sooner you can meet need, closer to where people live and work, overall need goes down, and you get a much more sustainable system. You get a much happier, healthier population, and in general, you get much happier, healthier staff to do that with. So yeah, I agree with you. 

Gill Phillips  12:11
It's such a win/win, isn't it? And I know, yeah, you were talking about relationships, and that's key, isn't it, absolutely key. And the example that I came in and gave immediately smashes relationships. Someone started to, especially children, perhaps in care, who've got absolutely understandably issues around trust and attachment, and they start to get to know somebody and start to trust them. How damaging to smash that relationship?  

Tom Holliday  12:38
Yeah, no, I agree. I think that the issue is the relationships designed out in that system, aren't they? Like, the minute you've got multiple silos and fragmented care, you've designed out relationships, and you're absolutely right, Gill, especially if you've got children, families in the care system, who probably, in some cases, have have known very few stable, sustainable relationships.  

Gill Phillips  13:01
Yes! 

Tom Holliday  13:01
You can see why that doesn't work and why that's not a good quality system of care for those people.  

Gill Phillips  13:07
And I think funding, again, I'm sure that comes up in the Universal Healthcare National Inquiry, the idea of people having sustainable funding so that you're not limping along from one contract to the next. And again, relationships: if you know that you're going to be able to work with a child for as long as it takes, rather than wondering whether the number of sessions that have been commissioned or the block of funding to our community organization might end in March, it's all of these things, isn't it, because not only does that in itself stop things, but just the worry about it and the fact that people's attention is distracted to other things, rather than just the relationship and helping the child?  

Tom Holliday  13:50
No, I agree. I agree. And, you know, I think actually, even then, you can still bring that back to its effect on the relationships that it has, because if you have short term funding, you get short term relationships, they don't mature. They get broken, and relationships don't develop overnight. There's this lovely saying that change happens at the speed relationships form.  

Gill Phillips  14:10
Yes. 

Tom Holliday  14:10
So you need longevity. So all of those things like resource, funding, estates, personnel, you need longer timelines, and they facilitate a much more robust, resilient relational system, if you've got them in place.

 Gill Phillips  14:29
So Tom, perhaps tell us a bit more about your work in this context with children in London, which I find really innovative, and how other people might learn from this in some way.  

Tom Holliday  14:42
So I guess the first thing to say is that they are things other people can do elsewhere. And, actually that's that's why we're doing them. I think in the NHS, there's nothing new under the sun. 

Tom Holliday  14:53
And you know, when we talk about innovation in the NHS very often, what does that actually mean? Because it's, chances are it's been tried somewhere. And I always think as innovation is new to that context. So that time or place, yes, because the thing that you can't move is, you know, we've spoken about this a lot, the thing that you can't move is the relationships. So every time you're trying to set up a new integrated initiative, you're starting from scratch, really, it's a new complex change program, and it evolves in unpredictable ways. I think if you, if you can do it right, it evolves in a way that is much more suitable and suited to its context. So there's a little bit of variation there, but it's hopefully warranted variation so that it fits much more within what's needed in that place. But yeah, so two, two examples, and both examples are from my work - I say my work, but it's our work, it's a team effort, you can't do this on its own- our work at London Northwest in trying to promote a more integrated, joined up experience for our populations of young people around the hospital. Our context at London Northwest is that we have a very diverse population, it's a very wide catchment area. In fact, we look after more than 10% of all of London's young people. 

Gill Phillips  14:53
Yes.

 Gill Phillips  16:12
Really, wow. 

Tom Holliday  16:13
Hundreds of thousands of young people, and between our various sites -so we have Northwick Park, Central Middlesex and Ealing - we cover a huge part of northwest London, a really diverse group, lots of different languages, lots of areas of deprivation, very low levels of health education in some of those, some of those populations. So you know, you're thinking about universal health, we look after 12% of London's paediatric population. What we know, it doesn't matter, really, where you look, we know that those groups don't access primary care as much. I mean, in fact, if you look at the Universal Healthcare Inquiry, I think the figure is that GP populations the under 25 year group make up about 16% of your average GP population, but they only use about 10% of primary care resources, so that underrepresented in primary care.  

Gill Phillips  17:13
Big difference, yeah. 

Tom Holliday  17:14
It's a huge difference. And if you, if you look at, therefore, where they're going, because they still got needs, they might look a bit different to adult needs, but they're still needs very often tied up with their family's needs. If you look at any sort of local secondary care, A and E, chances are that they're turning up there. Because we know that A and E attendance for those groups is proportionally higher. And in fact, your under fives, wherever you look, are very often, your single largest number of attendances to A and E, and very often the under fives, they're also the group who are one of the most likely groups to leave A and E with a diagnosis of 'nothing abnormal detected', or simple issues that could be seen and sorted in, in Primary Care.  

Tom Holliday  17:58
So the answer, really is, in my book, is working together to provide more robust care in primary care that better meets their needs there. You can look at, sort of, high performing healthcare systems around the world, and almost without fail, there isn't a high performing healthcare system that doesn't in some way work to strengthen or have robust primary health care. It's so essential, and so it's really tied into this idea of universal healthcare provision. So the question really is, how can you meet more need and do more of The Right Care-Right Place-Right Time in, in primary care for, for young people. So the way that we've done that, we use a model called Child Health hubs, you know, it's very, very much not our model. A lot of my people, who I'm very, you know, privileged to be able to call colleagues now, like my colleagues at Imperial - Mando Watson, Bob Klaber - our neighbors in in Hillingdon, to the west of us, we're working on similar models for over 10 years now. So we were relatively late adopters, but we've had some success. And the idea is that there's a there's a whole proportion of of issues that will come to us at the hospital, normally to outpatients that actually could be seen and treated just in primary care with a bit more joined up working between the GPS, the primary care teams and the pediatricians. 

Gill Phillips  17:58
Right. 

Gill Phillips  18:38
Right. 

Tom Holliday  18:43
They've done quite a few audits and studies of this now, where they've sat GPS and pediatricians down to look at referrals that come into secondary care pediatrics, and it's sort of, about 20 to 40% of those could be managed in primary care with a bit of extra support.  

Gill Phillips  19:56
Right. 

Tom Holliday  19:57
So you know, it's about a third of all referrals.

 Gill Phillips  19:59
That's huge. 

Tom Holliday  20:01
Yeah, it's huge, isn't it? It's relatively replicable across across the patch. So the idea is, how can you do that? So what we do is, yeah, we have a system called Child Health hubs, and we run monthly joint clinics, so you have a pediatrician and a GP, and those clinics run at a PCN level. So that place-based initiative and the pediatrician who's allocated to that PCN ...

 Gill Phillips  20:28
- Primary Care Networks, with an acronym alert! 

Tom Holliday  20:32
Primary Care Networks, yes, yeah! Primary Care Networks, of course, yeah - too many TLA's, Gill: Three Letter Acronyms.  

Gill Phillips  20:40
That's the one.  

Tom Holliday  20:41
Yeah, do catch me out. So yeah, the pediatrician who's allocated to that PCN stays as the link pediatrician, so that way they build up the relationship over the patch, and that becomes that patch, that place. So we provide both, here's some integration terminology for you: we provide both vertical integration, which is integration across care levels, so primary, secondary, tertiary care. You know, I still think it's important to think about the words and actually, hierarchy is even implied in that, isn't it? We say primary, secondary, tertiary care. 

Gill Phillips  21:16
Yes, it is, yeah. 

Tom Holliday  21:18
But it's the terminology we've got. So you have vertical integration across care levels provided by a joint clinic. And then we also provide a monthly MDT. 

 Gill Phillips  21:30
So what's an MDT? 

Tom Holliday  21:32
A Multi Disciplinary Meeting.

 Gill Phillips  21:34
There we go! 

Tom Holliday  21:35
Which provides horizontal integration across services. And the joy of doing this at the moment is that these days you can do that as a virtual MDT. So there we will invite in, for example, you know, you'll have your pediatrician, the GP, we'll have people from CAMHS - CAMHS professionals will come- local authority, the school nurses, the therapists will come, our community pediatrics colleagues will come. Very often we have commissioning colleagues there. And of course, GPS, from the primary care network will join as well. And so in, in that way, we can work on actually quite complex issues where, you know, patients, young people, are stuck and very often, as a result of a fragmented system, because their need can't be met by any one of those services working in isolation. 

Gill Phillips  22:24
Exactly. 

 Tom Holliday  22:25
It's really wonderful. You know what, the thing is, it's not rocket science, is it? 

 Gill Phillips  22:28
It's not no! 

Tom Holliday  22:29
Just get all the people in the room. But you can see it working. Yeah, I ran one yesterday. We had our monthly meeting for Sphere PCN in Harrow, I'm the link pediatrician there. We had our monthly meeting yesterday, and you can see it working. Sometimes you get simple clinical aueries that actually, you know, normally, you might put through advice and guidance, you might get reply in a few days: I can, I can answer that. Right up to much more complex stuff, where there's a social services need, a schooling need, you know, a primary secondary care need, a mental health need, but you've got all of those professionals in the room, so you're joining up the system, providing much better access for that young person, and you are hopefully unsticking something for them somewhere in the system, and getting everyone on the same page. 

Gill Phillips  23:15
I think it's brilliant, Tom, I can actually hear the people that I work with, you know, the parents of children with perhaps complex needs, just going, yes, yes, yes! It's just what people are crying out for, really, because, you know, you flip it, and people have got an appointment here and an appointment there, and they're spending half their time telling their story to somebody new and trying to explain what happened last week. 'Does that make it different', or, 'is that more of the same', or just trying to join things up, whereas you're getting the professionals together for the children and families and... listening. 

Tom Holliday  23:55
Well, no, I think that's exactly it, Gill. And you know, I was, I was speaking to some of my colleagues from that meeting yesterday, and we go back to our point about integrated care is about relationships and relationships between professionals and between organizations centered on meeting need. There's the direct benefit of the discussion you have in that multidisciplinary team meeting to that patient being discussed, but there is a much, much wider, more long term benefit that you get for free because of the lasting relationships that have formed over the time we've done that. We've been running that MDT for about two years now. And if I need a school nurse for a patient I see in my clinic, I will just email my friends, the school nurses, in Harrow. If I need CAMHS advice, I can just email the CAMHS team. It's brilliant. If I'm stuck and I need the therapy services, an OT, physio, I can send them a quick message and say, and likewise, they will do the same for me, and that's built in. You get that for free, yeah. Whereas before, you know, if I if I needed a school nurse before, my goodness, I wouldn't have had the faintest idea to start, but it, it joins up care. If I see someone who I'm worried about in my pediatric clinic, I think...oh, let's choose a patient, you know, if I've got, like, a nine year old with asthma that I'm a little bit worried about, I might not see them very often. And in fact, the total time that I might see them across a year, even if I see them, you know, three times, four times a year, probably adds up to about an hour in total actual contact time. If I think, oh, I need someone to check in on them, and actually, in that context, in that place, I can just message the school nurses and say, 'would you mind just like seeing how they are?', and they'll report back to me and we join up care that way. It's a much more, you know, person centered, relational way of doing things. And it feels, it feels much nicer to work in that way as well. You know, you're not an island. You're not there, you know, banging your head against the wall, fighting the system to do your best for the patient. You can, you can do that because you've got the relationships with the people who, who are there to help you. It's, it's nice, feels much better. 

Gill Phillips  26:01
Yeah, I'm sure everyone appreciates that. That's really nice. Like, yeah, you know, I know you said to be on first name terms with people, rather than just, like a phone number or, yeah, it's such a difference. 

Tom Holliday  26:12
Yeah, you are on first name you know, we are on first name terms. I didn't give that names because I didn't want to embarrass any of them in this channel.

Gill Phillips  26:18
No, no, sure, yeah. And then aren't you going a step beyond that as well, or, a different aspect joining up? Oh my goodness, physical health and mental health? Have you got an equivalent kind of joint approach? 

Tom Holliday  26:33
No, we have. We have, I wonder, Gill, actually, if you want to hear some of, because I know we're talking about improving access and strengthening primary care. And I wonder if it might be useful to briefly tell you some of the results of our local evaluation on that. 

Gill Phillips  26:49
Brilliant, yes, please, yeah. 

Tom Holliday  26:51
Because we've got some some data from our evaluation of our pilot, which ran for about 18 months. You know, I think probably one of the important things to say is that one of the unique things about working for the NHS is whenever you try and do a new change initiative anywhere you're asked to evaluate it in place, despite the fact that probably similar things have been evaluated over and over again wherever they're done and show the same thing. And so you always have to do your local version evaluation. So we did ours, we evaluated our three most mature hubs for about an 18 month period. We had one hub in Ealing, one hub in Brent and one hub in Harrow. And what we showed was that by providing monthly joint clinics and then monthly pediatric multidisciplinary meetings, we were essentially meeting the domains of the Quadruple Aim of of Healthcare. Is it worth explaining what the Quadruple Aim of healthcare is? 

Gill Phillips  27:49
It certainly is. Now you've mentioned it. Yes! We want to know. 

Tom Holliday  27:50
Yes, yeah. Originally, originally came from the triple aim, which was developed by the Institute of Healthcare Improvement by Donald Berwick and his team, and they said that any high performing healthcare system should seek to do three things. They should improve the health of their population. They should provide a high quality individual experience of care, and they should do that for reduced overall cost or more efficient resource use, and the, the received wisdom was always that you could do two of those at the expense of the other one. So, for example, you could improve the health of your population, and you could provide them all with a really high quality experience, but that's obviously really expensive. Or you could improve the health of your population, and you could do that for a reduced overall cost, a low cost, but actually your experience of care is going to be really poor. So they they suggested that there was one good way to do all three, and that was to provide integrated care, which will come as no surprise... 

Gill Phillips  27:53
Ta da! 

Tom Holliday  27:54
...given the subject we're talking about. And a few years later, they expanded that to the Quadruple Aim, and they also included staff experience as a really important factor. And then two years ago, they now expanded that to the Quintuple Aim, and the fifth aim is social justice and inclusion. 

Gill Phillips  29:12
Right 

Tom Holliday  29:13
We evaluated our primary care work, integration work, against the Quadruple Aim. And you know, just to give you some figures about how, how you could suggest we are improving access, I think, first of all, any patient who is seen or discussed at a hub, over two thirds of those will avoid a referral into secondary care. 

 Gill Phillips  29:37
Wow.  

Tom Holliday  29:38
So whether it's for a first new outpatients appointment, or for advice and guidance, they'll avoid that referral in and the reason for that is you are meeting need much sooner. It means that they don't have to join a 18 week minimum wait list to be seen in the hospital. And as you know, Gill, as you were talking earlier, you know some of the, some of our waiting lists at the moment are even longer, even longer than that, you know, sometimes over a year, sometimes approaching two years.  

Tom Holliday  30:07
So if you're able to see and treat need much earlier, then obviously that's better for everyone. We had a little look at that actually. And I think one of our most, one of our most important measures is we looked at the time it took from the family's first presentation to primary care with a problem to, to accessing specialist care in a joint clinic supported by primary care. And the median time in that case from first presentation to being seen by a specialist was 30 days, so a month. And when you're comparing that to you know potential to wait 18 weeks, six months, a year, to be seen for secondary care clinic appointment in some cases, then obviously you can see how you've improved access to specialist care, and you've met need at a much sooner time point, in a situation in an environment that is on family's doorsteps in primary care. And you know, as a result, one of the things we wanted to do was, by providing this is that you're promoting trust in primary care, you're strengthening primary care. So we also take qualitative data from the families who come to the clinic. And I think, I think 100, 100% of the families said that they would recommend the service. But we also asked them if the clinic was improving their trust in in primary care, in their local primary care service, and across the board, that was always the case. So patients were much more likely to return to primary care if they had a similar problem in the future. 

Gill Phillips  30:07
Yeah. 

Gill Phillips  31:45
It just sounds brilliant and simple, and I like simply brilliant, and I'm sure that some of the statistics around prevention, early intervention, some of the things that, to me, probably you can't measure in terms of, you know, preventing crises further down the line and just helping people. It's exciting, Tom and, like, not rocket science.  

Tom Holliday  32:10
It's not rocket science, is it? You know, that's the thing. It's funny, isn't it? Because the reality is that actually, it's not a difficult thing to do. You just have to find a time and a place to get the pediatrician and GP to sit in a room and book the patients. So on the face value, it's not, it's not rocket science, but you know, the reality of doing that in a system that's worked a certain way for years and is organized a certain way, is as you know, as you're very aware, very complex, and takes a lot of perseverance, and it's the work of a lot of people to get that up and functioning in a way that actually has worth and is sustainable. Yeah, but it's absolutely worth doing. I think you know it. It speaks to a point I often make. You know, I sometimes, I go to present this work and people say 'it's a really good project, it's a really good pathway'. And I'm always very keen to make the point that it isn't a project, it's not a QI project, it's not an optional extra, it's a, it's a fundamental change to the way that we organize care, and in fact, it's a new technology. It's a new technology for the way that care is delivered that better meets need at an earlier time point, closer to where the families live and work.  

Gill Phillips  33:25
Wow. That's so interesting, Tom, and I think you also had some brilliant examples around the other holy grail, which is joining up physical and mental health by bringing some of those professionals together. What are you up to there?

 Tom Holliday  33:40
Yeah, so that's a really exciting area of work. You know, I'm not going to pretend that this is well-established and has been running, it's really novel, it's very new, and it's something we're just dipping our toes into the water with. But I think it's absolutely essential, you know, to, to my mind, our collective failure as a society to address the mental health needs of some of our young people is scandalous, really. 

Gill Phillips  34:08
Yeah, yeah. 

 Tom Holliday  34:09
I think, I think, it's scandalous. And I think, you know, people there, seems like there's a lot of talk about it in the media. But in another way, I don't always see signs that we're actively addressing it. I know a lot of good work is being done in lots of sectors, and the reality is, I still, every week, I still see young people turning up in crisis and struggling with mental health challenges. So, you know, we were thinking about what, you know, what can we do? You know, I think that this is another area where the system, for very traditional reasons, has remained very fragmented and very siloed. We talk about primary and secondary integration that's all largely physical health, so at least you're in the same book there. But the way the system is organized around physical and mental health, in my experience is just that there is a gaping chasm between those two things. And the funny thing about that is that we have the evidence that that, in real life, that's, that's not the case. It's not the case. Those two things are the same, and they are absolutely related. There is a Venn diagram there. You know, we know that if you have a long term chronic condition, or, in fact, any physical health condition, young people, you know, adults, are much, much more proportionally likely to suffer from poor mental health. And the converse is also true. If you suffer from poor mental health, you are much, much more likely to experience a physical health complaint. So those two things are intricately linked, and yet our system is not intricately linked...

Gill Phillips  34:15
Not at all.

Tom Holliday  34:44
...in away that can appropriately address that, you know, and it goes back to, it goes back to how do you meet need, for me, and examples from my own clinical practice, and I know for a fact the clinical practice of lots of my consultant pediatric colleagues, because they we've spoken about this, is that in your secondary care clinic, we see huge numbers of young people who will come with physical health complaints that are not wholly explainable through a physical health lens. You can do all the investigations, you can send blood tests, you can do imaging, ultrasounds, X rays, everything will come back normal. Doesn't always mean to say that there isn't a physical health problem, it just means that we haven't found it on the, you know, the limited, reasonably limited reasonably limited number of tests we have, and the limited lens that we look through, as you know, as physical health practitioners. However, lots of the time it's abundantly clear that there is a large overlap between mental health, the spectrum of mental health, and, you know, the physical symptoms that that young person has come describing. Very often this plays out as, you know, headaches, tummy aches, aches and pains. Again, it's a spectrum, it's a spectrum. So, you know, the question is, how can I adequately meet that need? There's always a there's always a temptation to say, you know - I know this this does happen - there's always a temptation to say, well, actually, we've done all the tests and there's nothing wrong with you, so I'm going to discharge you. Doesn't really feel very adequate. Most health practitioners in, you know, any discipline, any sector, probably went in to the NHS to help people.  

Gill Phillips  37:32
Yeah.

Tom Holliday  37:32
I think, you know, it's a, it's a, it's the medical school answer, isn't it? 'Why did you want to be a doctor?' And I want to be a doctor to help people. But there's something glorious about that. I think there is something wonderful about that.

Gill Phillips  37:43
Absolutely, yeah, we've got to celebrate that. 

Tom Holliday  37:45
We should, we shouldn't let go of that. So, you know, the question is, how can I help you? You know, I could refer you on to CAMHS, or, you know, one of our voluntary sector primary intervention services, and then they're going to join a waiting list, and actually that I won't see you again, and they'll go over there and they'll say, 'Oh, well, hang on, you've got headaches. That's a physical health problem'. And very often, you see, you know, young people going round and round in the system, yes, and of course, all the time the key issue isn't being addressed, which might be anxiety, you know, stress, something in their home life or their wider environment. So as long as that's not being addressed in an appropriate way, they can they keep coming back. So it's not it's not uncommon to see young people pop up time and time again at different parts of the system, because the system can only deal with the episode and not the core need. So, what we wanted to do is to build a new clinic that could better meet total need, combined physical and mental health need. Because I, you know, I might have part of the answer as a physical health practitioner, but equally, my colleagues in CAMHS will, will probably have, you know, an equally large part of the answer there is a there's a distinct overlap there. So rather than seeing you in separate silos, again, it's not rocket science. We just said, let's just have one space where you can be seen by a pediatrician and by a CAMHS psychiatrist together. And actually we, we want to make sure you've got space to properly explore both of that because if you, you know,  you can't meet need inside a 15 minute appointment, and that way you can much better meet the the overall need of that patient. Everyone works together. And you know, I always say you've got, you've got three experts in the room. You've got the pediatrician, who's, who's the expert in physical health; you've got the CAMHS psychiatrist, who's the expert in mental health; and then you've got the patient, who's the expert in them and their condition and their life and how it affects them. So you necessarily need more time. It's very exciting, been very lucky, and again, it's not the work of one person. This crosses boundaries. So it's, you need a really, you know, you need a relational approach to leading that change. And there isn't just one person who leads that change as well. So very grateful to lots of my colleagues from both the pediatric department, lots of my pediatric management team are fantastic, but also the CAMHS team and the wider sector, particularly, you know, the CAMHS psychiatrist I work with, who've really, you know, really pushed to create that space for the young people, and we've just started having our first prototype clinic. Was actually last week.  

Gill Phillips  40:22
Wow, okay! Yeah, this is very topical.  

Tom Holliday  40:25
It's very topical. It's very topical 

Gill Phillips  40:27
Super topical.  

Tom Holliday  40:30
Yeah, so we had our, we had our first two patients last week. It is, it's funny, because although it's, again, it's a very simple initiative, it's a very new way of doing things for the NHS. It's surprisingly novel 

Gill Phillips  40:46
Yeah,  

Tom Holliday  40:47
And so, of course, we, we want to start small and make sure we, we're building on success in a way that is sustainable for the clinic and for, you know, it has to be sustainable, and we have to show that it actually has, you know, a positive impact on the wellbeing of the young people, and it's providing something that's needed, but it's really exciting to be doing. The feedback from the first clinic was fantastic, and the young people that we saw there, you really got a sense that, at least, in my interpretation, that there, I don't think that there was a space that could have explored their issues in the same way, yes, that would have, you know, unlocked things for them.  

Gill Phillips  41:33
Yeah, I can feel that. 

Tom Holliday  41:34
Yeah, you really needed that joint understanding of both the physical and mental health contribution to the overall picture, to be able to say, well, you know, I to have those conversations in a way that's going to be helpful for them. And so it's a really exciting venture. And again, you know, I think it, it speaks to that idea that, you know, children get less because, you know, mental health provision for children, as is very well documented, is absolutely an area in which children get less. If you look at, you know, some of the some of the data, some of the figures from the NHS, even if you go back as far as the five year full review, which is 2014 now, and there was commitment in the five year full review for all acute hospitals to provide appropriate mental health liaison services for all ages, right? All age appropriate mental health liaison service. And then the system remained committed to that in the long term plan. So 2019, five years later, they recommitted to that goal. And then every year there's a group who does audits of mental health care provision. So I think the most recent figures I had were from, from 2022 and they found that for adult mental health liaison, 100% of acute trusts had some form of access to adult mental health liaison, and the equivalent figure for young people was 26%, so a huge gap between what's provided for both adults and, and young children. And then, you know, we thought, how can we, how can we start to address that? And you know, the beauty of providing an integrated clinic isn't just that you get the clinic. It starts to form a relationship with our local CAMHS professionals, our local CAMHS team 

Gill Phillips  43:16
Of course, yeah.  

Tom Holliday  43:17
So if we want to build on that in the future to look towards providing a much more integrated mental health service, which is, again, what's needed, and the evidence is there. It's very clear: you have an integrated, properly integrated, mental health liaison will improve mental health outcomes for young people who are admitted to secondary care with a primary mental health problem, across the board, and it's more efficient for this. So it's the first step in starting to build someone to build some of those relationships, and, you know, and work towards a much more joined up offer there too. 

Gill Phillips  43:48
Well, Tom, thanks for explaining that so well. I think the fact that you've explained, in the way that just ordinary people can relate to, you know, a child with headaches, perhaps with anxiety. How did you get to the bottom of that: is it an optician issue? Is it... just, what's causing this ongoing problem, and the idea of just being kicked out of one service and into another service, or not, with a waiting list? And so on. Now, I'm super excited about it, because I've mentioned that I'm doing this work around integrating services for children and families with Midlands Partnership Foundation Trust, and my impression is that they are a super innovative, listening, wanting-things-to-progress, service, and it's huge, Staffordshire and the area they serve is huge, and even integrating things and joining them up within their own service is a challenge. But I think perhaps there's an extra element going on here that I've discovered by talking to you that I want to feed back to them? I'm actually meeting with the chief exec to take the who's shoes board game there and show him what we're doing across the trust. 

Tom Holliday  44:54
Oh, fantastic. 

Gill Phillips  44:55
But to have you know extra elements, and that's why I love these conversations. Because you just pick up nuggets here, there, everywhere, and throw them out to somebody else and try and create those ripples, which is obviously what I'm trying to do with Whose Shoes? so...  

Tom Holliday  45:09
Fantastic. 

 Gill Phillips  45:10
And you've even managed, Tom, to throw in a lovely shout out to Bob Klaber, who's been a previous podcast guest in this series. So that's joining things up as well! 

Tom Holliday  45:20
Oh, excellent, yeah. You know, we're all standing on the shoulders of giants, aren't we, Gill. 

Gill Phillips  45:24
Absolutely, yeah, yeah.  

Tom Holliday  45:25
It's worth saying that the mental health clinics as well: we're not the only people doing this. And you know, like I said, for our integrated primary care clinics, the original idea for joining up those clinics, of course, I saw really good practice being done elsewhere. UCH in London are probably, you know, one of the national centers of excellence for integrated physical mental health care and adolescent care, and they have for many years run combined clinics in such a way that's a slightly different setup, again, because it's a different time and different place. But the original idea came from, actually, I went to, it was a talk on integrated physical and mental health care, and I saw some of that team who were running those clinics come to talk about it. And I was just struck by what a needs-based initiative that was, and how that was absolutely what we should be doing in the current climate. 

Gill Phillips  46:16
Right. 

Tom Holliday  46:17
So absolutely, you're talking about ripples. You know, you can just see how, like, you know, if you're there and you pay attention and, you know, you focus on meeting the those ripples of good practice, you know they they do spread. They do spread. They are there. It might not always look the same where it lands. I guess, what I'm always keen to stress is, I guess, we have this thing in the system where we really like to attribute good work to groups or to individuals, and very often, that gets people say, 'oh, well done. You've done this brilliant piece of work'. But, you know, the best work is never done in isolation. There's no such thing as a sudden bright idea that's going to change the world. You know, those things are few and far between. You know, it's all a contribution to an iterative change process, and you're always working on the wide network of good work that's come before and which you've seen in which you take something from which resonates with you and with both, you know, the integrated care, primary/secondary care clinics and the integrated physical mental health clinics, both of those have borrowed heavily and are indebted to really good work done by really dedicated professionals from a wide, wide network of people. And it's, you know, it's just our next local step in trying to, you know, nudge things forward a little bit there. 

Gill Phillips  47:37
It's been brilliant Tom to talk to you in this opening episode of this Universal Healthcare Podcast series. I think it's unusual, isn't it? Tom to start with children, and we're acknowledging children get less, and we're trying to flip that, make sure that children are higher up the agenda. And I think the way that you've described some of the problems and some of the solutions, and the modest, typical Tom way that you've built on the work that others are doing, and relationships and so on and ripples, that's how we're going to go forward, I think. 

Tom Holliday  48:12
absolutely Gill, thank you so much for having me. As always, I'm always really keen to say a big thank you, because loads of people contribute to this work. I often am the one who will end up speaking endlessly about it, because it's my stuff. Like, I really care about it. I'm really passionate about doing it. But if I, you know, if I could end on one note, first of all, it's a thank you for making this the first episode, because so often, you know, I see children, young people, babies put to the back of the agenda. So it's lovely to be first for once. So thank you very much. And then my final thing is just to say a huge thank you to anyone who's involved in this work, anywhere I meet with huge amounts of people every day in my working life, both clinically and involved in my change work and my leadership work, and all of them are delivering to me. 

Gill Phillips  49:01
Well, thank you Tom, and keep up the good work. Thank you so much for talking to me today. 

Tom Holliday  49:06
Thank you, Gill. It's always a pleasure, anytime you know, I always love an excuse to talk to you. So thank you. 

Gill Phillips  49:13

Thank you so much for listening. If you enjoyed this episode, it would be fantastic if you would leave a review and a rating, as well as recommending the Wildcard Whose Shoes? podcast series to anyone who you think might find it interesting, and please subscribe that way you get to hear when new episodes were available. I have lots more wonderful podcast guests in the pipeline, and don't forget to explore and share previous episodes, so many conversations with amazing people who are courageously sharing their stories and experiences across a very wide range of topics. I tweet us whose shoes thank you for being on this journey with me, and let's hope that together we can make a difference. See you next time.