Chamber’s ‘Delivering Integrated Healthcare’ Midlands Seminar held in collaboration with IQVIA UK focused on improving population health, addressing health inequalities and specific therapeutic areas.
This fireside chat was chaired by Angela McFarlane (Vice President, Strategic Planning, Northern Europe, IQVIA). Sir Bruce Keogh (Chair, Birmingham Women and Children’s NHS Foundation Trust), Naomi Eisenstadt (Chair, Northamptonshire ICB) and Professor Mike Bewick (Former Deputy Medical Director, NHS England) discussed their perspectives on how Integrated Care Systems are collaborating to improve patient outcomes.
#politics #government #uk #healthcare #health #seminar #iqvia #data #research #inequality #inequalities
So um going to move on now to uh our panel um so um I’m going to invite um s Bruce and Professor uh Buick up to the up to the seats here and Naomi unfortunately wasn’t able to join us in person but you can see her on the screen
And uh hopefully Naomi you can hear us now so um I’m going to invite uh all of our panelists to introduce themselves of course you’ve all had their biographies but I think there’s nothing like hearing um from uh the panelists themselves so Naomi would you like to lead off who are
You and where are you from and what are you passionate about I’m Nomi eisenstat I’m chair of n hamptonshire integrated care board I am passionate about health inequalities and I’m particularly passionate about poverty itself and child poverty thanks Naomi Mike Buick I’m a GP by background I was formerly his sidekick at NHS
England some time ago um and I now really passionate about training in the new Workforce and that’s probably where I’d like to stop at a moment my name is Bruce Kio I’m chair of the Birmingham Women’s and Children’s uh trust in this city uh prior to that I was a cardiac surgeon I
Was a professor cardiac surgery at UCL and medical director of the health service for about 10 years my I guess two areas I’m interested in are the measurement of clinical outcomes and I worry about the retreat of the focus Fus on quality in the NHS thank you so I’m going to invite
Naomi uh to lead off first so each of our panelists is going to just give a little overview for five minutes on their area of passion and concern um and then we’re going to take questions from the floor uh and let’s make this a conversation yeah so uh we a number of
You have pre-submitted questions and I’ll I’ll call those people out so hopefully you can actually remember the question that you put in two months ago uh if you can’t don’t worry I’ve got it here um but I’m going to invite Naomi so Naomi um could you share with us um for
Five minutes uh your thoughts in respect of integration and ensuring that the people who need the services the most um have Equitable access to them and also your views on where the closer collaboration uh between systems is actually going to begin to address the issues of poverty so over to you Naomi floor’s
Yours all right thank thanks very much I’m really sorry I can’t be with you and boy could I speak longer than five minutes on that question so I’m going to divide my five minutes into three areas first of all I think that we use the language of integration and C
Collaboration too Loosely and each of us has a different think bubble about what it means and for me the most important thing about integration and collaboration is the way that Frontline workers work together um in the in the interface with the end user patient pupil child whatever but I do think that
The way in which we try to restructure to deliver integration and collaboration takes us into a whole area of very complex arrangements and fundamentally the most important part of collaboration is how well professionals on the ground working with people respect each other’s contribution believe that they each have
A valuable contribution to make and don’t think gee if only there were more of me everything would be all right I think in terms of reaching the people that need it most it always makes me smile because I think basically we want people to want what we
Think they need and the reason that we don’t reach people that that we think need it the most is because we’re not actually trying to figure out what they think they need and doing an open negotiation with them on what they think their issues are as opposed to what we
Think their issues are it doesn’t mean that this should be a knowledge free zone it doesn’t mean that you don’t share it it doesn’t mean that you do everything that the end user wants it does do mean that you have to understand the context in which they’re living to
Understand why sometimes people are resistant to our services or Our advice sometimes it just doesn’t suit with with what what they think is important to make their their lives better and the third bit I want to talk about is that final bit about working together with integrated Care Systems one of the
Things that really surprised me when I took on the role of chair of an integrated care board is that I thought the main job was about bringing together health and local government social care and I didn’t realize how much of the job was about bringing together the internal
Bits of the NHS itself now my own view is that the real important working together is between local government between place and the NHS and that ICS is should be working together where there are um tertiary care needs on I systems on those things where a much bigger footprint really counts in terms
Of efficiency and also better services but I am also I think that it shouldn’t be I don’t think that systems should be working together at the cost of the way in which an individual ICB Works locally in terms of in terms of local government and we are very lucky in Northampton
Shire we only have two local authorities we have two places which makes that working together much much more intimate much closer we meet weekly both Chief executives are on my board so I think there’s always a tension between what we’re trying to do two things at once both of which are vital
But being clear about which one is suitable for which aim is really important in the extent to which ics’s work internally with local government and the NHS and where different integrated Care Systems work across on a larger geographical foot print Naomi there’s a load of food for thought there
And um thank you for the pace with which you delivered that it was it was almost quite difficult to um to take it all in at once um so it yeah should we go um thank you Naomi and I know you’re going to get lots of questions so um I’d
Like now to move on to Bruce so Bruce um you’ve been at this game a long time sorry I’m not making any observations there um could you share with us um your thoughts on what integration actually should mean yeah and perhaps some of your thoughts on the domains that could
Make integrated care really move forward as a coalition of the willing I spent some time working in the department of health and they were interminable meetings on integration and slide decks produced by McKenzie which were half an inch high and then one day I was meeting with some
Mothers of children who had varing degrees of disadvantage and the meeting went on for the best part of 55 minutes me getting towards the hour and they kept on saying you need to focus on integration Integra so I I said actually what do you what do you guys actually mean by
Integration and there was a pause and then one of them said not having to repeat ourselves and I found that quite a quite an insightful observation because we run a pretty fragmented Health Care Service where everywhere you go you’re having to not just give your name but tons of other details and
Things Fall between the cracks so I think integration starts with making the journey for those people that we trying to help more convenient easier simpler and um with less fractures where things can fall between the cracks and the second definition which I think is kind of helpful to start this
Conversation off is what do we mean by inequalities and people write thesis on these um and we need some kind of simple understanding of it so in my head an inequality is an avoidable unfair difference in outcomes at a systemic level for different people in society
And I then find myself work trying to think how can we use integration to try and address those issues perhaps we’ll draw that out a little bit more in the conversation but one of the more challenging things uh I got asked um many years ago by Andrew lansley was um
Develop an outcomes framework for the Health Service was beyond my comprehension but fortunately Ely Mike and I also worked with a very smart guy called John Stewart who came back one day and said he said I’ve got it he said there are five things that a Health Care
System should do and do well now I’m going to argue that there should be a sixth and the first is that the Health Care System should stop you dying from things that it can now you’ve already heard Andy Street implying that a lot of the major determinants of mortality like
Lie outside the jurisdiction of the NHS we probably affect somewhere between 10 and 20% of that so things like stroke heart attack cancer we can influence the second thing is that the Health Service should help you live well with the long-term condition whether that’s dementia rheumatoid arthritis asthma something that’s not currently
Curable the third thing it should do is look after you well when you have a short episode of of illness whether that’s a broken leg cataract operation um measles whatever the fourth thing that it should do is that it should treat you decently and I have to
Say we’re absolutely rubbish at that we we don’t offer the kind of customer service that everybody in this room expects from every other industry and then finally uh uh the system should treat you safely and by safely what I mean is that when you’re talking to a patient um they
Understand the risk of their disease they understand that their uh treatment might carry some risks and they make a value judgment you know do I want to have surgery or not for example what they should never have to take into account is that the way that we organize
And design our services or the way we fail in the integration of services will adversely affect that equation and then finally I I would just add in safety that inequalities in a way kind of they cross all of those domains but they also play into the safety domain
Because if people aren’t getting access to care if they don’t know where to go their outcomes their outcomes will be different uh and that’s as a consequence of the way that we we organize our our service so I think i’ prob oh the sixth thank you um the sixth thing thing is
And I raised this with Andrew lansley I said we I said one day someone’s going to stand up in Parliament and say oh the NHS just costs us money you know it doesn’t really do much good we need to spend the money somewhere else and I
Said we should have a six domain which um is economic benefit of the NHS to the economy because we’re a tax funded system um so we’re utterly dependent on how well the economy does the economy does well the Health Service does well if the economy doesn’t the Health Service
Doesn’t and there are a number of voices um around the country who argue that the NHS just costs a shedload of money and makes no real contribution and I think I think that’s a kind of superficial argument because the Health Service employs you know well over a million people all of those
People pay taxes it then buys kit all sorts of expensive kit from companies who pay corporate tax tax who employ people who pay personal tax and those people spend money in the economy um and there is there is an argument that investing in health is actually investing in the economy as well
Particularly in a tax funded system so I think that that also plays into if you like the inequalities agenda because if you if you look at people at the higher end of the social econom IC scale they’re less dependent in some ways on the Health Service because if
The Health Service doesn’t work they go somewhere else but for people who are are not in that position they often come from backgrounds where there may only be one person earning in the family they have transport difficulties they have all sorts of other problems and we owe
It to help them because if we don’t help them their whole family suffers economically and if they suffer economically equally our local economies suffer economically so I think I’ll I’ll stop there and hope that I’ve said enough stuff to provoke a conversation no I think your Point’s really well made
And I I particularly that one on transport really resonated with me we did um a piece of real world work for uh greater Manchester about four years ago now and the medical director there had said I’ve got a hunch that the doctors in Stockport Barry and Burnley are
Hanging on to their women with breast cancer for too long and not for sending them forward for um Christi care can you prove it and so we used multiple data set so we used hairs we used our own prescription data but we also used Google Maps and we found out that his
Hunch was absolutely right these women were being diagnosed later they were not getting access to nice approved drugs at the right stage of their their treatment but it wasn’t that their doctors were hanging on to them in inverted commas it was when you look at Google Maps it’s 20
Minutes to the Christie from Barry Bolton um and uh Stockport um as the crow flies but these women aren’t crows and they don’t fly and that was why their doctors knew they wouldn’t travel they wouldn’t be able to travel they wouldn’t be able to make it across the
City so they re-engineered it and took christic care to Berry Bolton and Stockport but that kind of you know that economic piece is is is a really important play and you know I said at the beginning about how much investment we attracted in to the UK and it’s not
To be underestimated and people who are in clinical trials have better outcomes than those who are not yeah and much of our inequalities really are driven by by access yeah yeah and I really liked uh Naomi’s point there because I thought that really played in well um when she
Was talking about um you know us as not really checking about what what really properly checking what people need as opposed to assuming that we know what they need need uh and I think that that that plays in really nicely Mike I want to come to you now um last but by no
Means least um would you share with the audience uh your thoughts on the opportunities and challenges facing uh integrated care uh systems and kind of three themes I know you want to call out Workforce culture and delivering on P public health and I’m really glad that
You put culture into it okay uh but I couldn’t go through any talk without maning culture at the moment from I’ve been doing late um firstly just say it’s not an uable position to to be running an integrating care service at the moment it it really isn’t you you’ve
Come at the back end of a pandemic you’ve come when there’s a Workforce crisis you come when there are strikes uh within that Workforce and there’s a great disenchantment nationally with with some of the services that we provide yet we provide Universal Services from Cradle to gr that hasn’t
Gone away but we’ve we’ve got something missing at the moment in how we’re delivering it and people want us to think differently about how we deliver it there’s a commitment now from both parties I think cross government now cross party that we need to increase the workforce that it’s fallen behind the
Numbers that can produce and go back to your point a safe service requires access requires train people to deliver healthare fundamentally the inequalities will not get better unless we set the scene there um and the workforce that I’m looking at at the moment because I’m trying to set my medical skill at the
Moment is one where we’re trying to attract people into what it superficially looks like an unattractive career at the moment now it’s interesting we did some market research with students who are currently studying across the UK in different medical skills and actually if you talk to them they’re very optimistic about their
Futures but they wanted to change that train that training to change they want to be more involved in how the structure of the Health Service Works they want to know about how to get into leadership positions within the Health Service and they want that research that Angela
Strives to bring to this country for to partake in it as early as possible and to see their education as a longitudinal thing not one that ends at the end of a training program and their speciality and talking to them was quite refreshing because it made me think that maybe some
Of the design that we’ve got around placements for for example that could actually be helped if across an integrated system because we tend to send students to a surgical w a medical w a pediatric unit why don’t we send them on a patient Journey that looks Ross the system so that they would
Understand what it was like to be a patient and you’re quite right people hit these gaps and you have to duplicate everything now to do that we need a better digital system and yesterday I was at a company with with B we were given short seminar EST on how to
Integrate some of those digital systems now those those students they they integrate everything digitally everything is on their phone everything is on their computer they don’t study like I used to study in a library with index medicat they sit there and have the world at their fingertips what they
Want are the relationships with professionals about how they learn their crims and it they’re very instructive it’s a bit like asking patients to co-design with you their care plan or their care as their care plan works a lot better but the other thing that they they did identify and having interviewed
A lot of Junior doctors in the past year and very senior doctors some very local to hear is that sometimes I just not felt that they’re listened to by the management structures that are imposing and implementing new policies and if they did as during covid they did and
They’re all passionate that during covid it released them from some of the governance issues that that were inhibiting them for Change and they all say that’s down to the culture of the organization and when the culture is wrong the culture is it it becomes uh almost an aesthetic force it it it
Causes the dissolving of confli confidence in in a team and people leave they either leave or they get into trouble and they get into trouble sometimes because they’ve be taken their eye off the ball they do something wrong and they end up going to a regulator and
That is very very difficult for them we lose a person from the system often for up to two years my record has just been beaten for somebody who’s been off now for six years while under investigation and things like this happen all the time and people lose confidence in in the
System and yet all these people are dedicated every day going in and trying to make a difference but they are looking over their shoulders and worried that this culture is not going to improve and we’ve heard both from reports coming from the BMA from the GMC we’ve heard reports coming uh locally
About bullying cultures which have been really quite difficult to deal with and people have responded um by either leaving or whistleblowing and those whistleblowers have not been looked after and interesting the students will say we see things on the Ws that we’re very unhappy about we think that that’s
Unsafe now the GMC of course wants those people to report having confidence at the age of 1920 to come forward to do that we need to make it a permissive environment for people to report and then to make sure that they can be heard and my last point is that the inequality
Side of this is we describe inequalities and I I take the definitions are difficult sometimes we we describe them but we don’t put things into place they’re actually going to make a big difference at an integrated level so your child that goes to the GP three or
Four times uh and and there’s a problem with the home life there’s not much connection anymore with that with the social environment that they’re in that that changed some time ago I think probably changed after uh Ken Clark’s um initial um legislation but there’s got to be a joined of version of Public
Health that makes it happen now I think you know we’ve got loads of Public Health policies coming out and recognizing where the challenges are but we’re just not very good yet at at how we actually Implement those policies in a uniform and systemic way otherwise as Bruce says that systemic failure uh
Comes back to haunt us in the data that comes out and shows those differential outcomes and I think I’ll stop there thank you Bruce I know you wanted to make another comment on Workforce before we go to questions from the floor yeah I just wanted to be a bit
Provocative on Workforce if I may um when I hear people around the NHS talking about Workforce it basically boils down to recruitment retention and return and somehow the idea that if we just carry on doing what we’re doing now we’ll get enough stuff I don’t accept that um if you look
At data coming out of the World Health Organization or the oecd um there is a clear indication that worldwide in terms of healthc care Workforce we going to be somewhere between 16 and 30 million people short by 2030 now that’s only a few years away
We are not going to be exempt from that so continuing just to think that if we try harder in this Workforce space that we’re going to solve the problem is to delude ourselves and that’s going to mean some cultural changes it’s going to mean some technological changes and it’s going to
Mean some changes in the way that we think creatively and I think that partly came to mind I was visiting Korea and I was on an intensive care unit there and um they had a nurse staffing ratio in one intensive care unit of one nurse to two patients and in another intensive
Care unit one nurse to four patients and I said to them we’d never get away with that in the UK because we’ve got a whole bunch of um kind of ingrained standards which can’t be breached and they said well we we had the same problem but we
Just didn’t have the people so we either didn’t look after people or we changed and I think we’re going to have to do the same and I think technology offers a root into that it’s not the solution the complete solution but it offers a root and I was speaking to someone from uh
The cabinet office re yesterday actually and um they had been doing some work for the Council on science and technology and interviewing people about technology and someone had said NHS shouldn’t be spending money on technology it should be spending it on patient care and I I just thought
Really you know because the two can funnily enough go hand inand with the very people who look at look off after their health on their iPhones or whatever 100% and that brings me rather beautifully very good segue actually um to one of the first questions from the
Floor um is Callum Coburn here today Callum hi can you remember what your question was because I’ve got it well let’s um let’s get a mic over to you because I’m going to give you the first few lines and then you see if you can finish them how about that so um can
We have the roving mic over to Callum if you put your hand up and uh Callum is a project engineer with synoptics limited I believe correct uh roving Mike where’s it gone so Callum the first few uh words were how do we ensure that new software and systems products meet
The requirements yeah there we go so yeah H how do we actually deliver on the requirements of people on the front line how do we communicate those requirements back up how do we incorporate the requirements of everyone involved in that whole patient Journey so pre interaction with a Health Service post interaction during
And then all the kind of management requirements as well how do we pull it all together and and deliver something that actually works rather than kind of a bodge solution that is a compromise on too many fronts yes I quite liked your finish it was and doesn’t simply add the
Technical overhead of the NHS techn ology estate so how do we ensure that new software and systems meet the requirements of Frontline clinicians who wants to take that I’ll start but he can finish um yesterday we were with a A company that produces both software and hardware for integrated Services um
Their their way of doing it and I think you is the one I suppose is reasonable which is you know your customer and you ask them what they want know and and what what is what’s their requirement often people come to me with great new
Bits of tech and say how can the Health Service use this as opposed to Let’s develop the tech to to help the Health Service and you need someone who helps you negotiate through the the the vast array of regulations and procurement requirements I’m sorry but it’s never
Going to be easy and as they as those change periodically with with with with with new regulatory standards Etc you need someone who can keep you up to date with that and the third thing is I think you just need people who are uh to be less risk averse and to take it
On with you so that actually you can do those those initial um experience work and then report back in in a reasonable time so that you you as a company or as an organization can make investment decisions about whether you’re going to continue to serve the NHS and and and
And at some point you need to have a discussion about is this really adding value or is it just a nice other clever thing that we can do it’s a it’s a complicated question and I as I thought about change in the NHS I came to the conclusion
That you can affect change if you can accomplish two things if you can demonstrate that whatever you’re offering will improve the quality of care that’ll get you somewhere if you can demonstrate that it’ll make the lives of people people delivering the service easier that’ll get you somewhere
If you can do both of those you’ve got something that’s potentially Unstoppable so I think that that also applies to the question that you asked actually the one the one thing that people really worry about change they don’t worry so much about the change they worry about what they’re going to
Lose so if you can if you can demonstrate with your software that it does those two things that it improves the quality of care that’s on offer um through a variety of different lenses and that you can prove that it makes people’s job easier rather than as you say adding to the tech
Overhead then I think you’re onto a winner but then you’re you run into the the roadblocks around procurement and that’s a whole separate issue I don’t think we want to go into procurement but no that’s let let’s no let’s not Naomi has been very patiently sitting with her
Beautiful yellow hand up well I have a very very quick answer to that I mean in terms of how unbelievably difficult it is because for 15 years we’ve been trying to get uh the Department of Health and the department for education to agree that there should be one NHS
Number not a unique pupil identifier and a different NHS number and unless you get agreement on systems to collect data in the same way you’ll never get the benefits of data and data integration second point I want to make and this is again rather contentious my experience
With running sh start is that the most difficult people to get data out of was the NHS and they wouldn’t tell us where the new babies were born so we couldn’t do the visits and I think the real problem is that if you really are interested in lowincome families to get
Their benefits they have to tell everybody everything about them the data protection stuff I think is chattering classes I think that it works against um equity in Health Access um you you possibly can’t see it Naomi but I tell you what the head nods that were going on there for that forthright uh
Forthright answer thanks so much I’ve got a lot of questions on Workforce not surprisingly is Emma here Emma Perry yes Emma would you put your hand up can you remember your question no okay um it starts with what ideas or areas of integrated healthc care practice can be shared
Support mental mental health it’ll be about supporting mental health Workforce yeah yeah so uh ideas of good integrated Healthcare practice and and to your points uh with regard to Recruitment and Retention challenges for impatient and Community Health uh Services questions and Emma I believe you’re the divisional director at the nursing adult mental
Health um is that black country yeah yeah and it it was kind of thinking about um some of the work that I’ve done in a cument with NHS England around International Nurse Recruitment and the 50k Target so it’s kind of what I learned was there’s really amazing best practice going on in
Silo and actually terms of thinking about integration how do we kind of share some of that best practice around Workforce and mental health um and around the impatients and Community not just one one setting and even third sector and social care so Emma can I I’m
Not going to take three answers on that can I direct that question who would you like to answer that question probably I was actually really fascinated in Mike what you were saying really about some of the placements thank you for that um and also well now
I can’t just pick but also Bruce it’s kind of that bit about we’re not we are going to have a gap and we’re going to have to accept this is Gap so what do we do differently um and what could we do differently in terms of the placements and the skill
And the opportunities for Recruitment and Retention well without wanting to go into a long lecture about how we could reorganize undergraduate training for just about everybody coming into go less than five minutes um but I think the there isn’t an a a answer to your question that the but if you have good
Practice we’ve been really bad at sharing good practice and often when we do people say well actually yeah but it wouldn’t work around ear would it you know and and it’s it’s a common throw and and in fact if it’s that good and it shows that you can retain staff then
Other people should be using I I I go back to the covid experience again when when we had webinars during that people were coming with best practice and people were repeating it you know but why should we just do that under really real adversity when actually we’ve got a
A slow burn sort of adverse situation at present so I think you know the you know these these willing people coming together to collaborate there’s no reason why they can’t collaborate at a regional level and then at a national level and I I think that’s actually for
You know the leadership of the NHS to actually you know make sure it happens you know and and you know not just have a conference where you go along and say this is what we’ve done and whatever but actually you will go out there and you
Will go and teach other people how to do it that’s how I do um I’m getting signals from the back about um room moves that we’re going to be doing uh in about four minutes I’m going to just uh bring this session to a
Close if I may um Mike um Bruce are you going to be staying around or are you should shooting off depends on the questions okay well what I’m going to say to is it’ be great because I know there’s quite a few people that have got
Lots of questions for you both um so Bruce um what would Bon do with Health and Social care were he around today I think I’ll shoot off no um so in 1948 the average life expectancy of a male and forgive me for just picking on
A mail but the numbers were easy um was 65 which is retirement age 50% of people dead by retirement age fast forward to now where it’s 80ish maybe just a little bit over 80 so suddenly there’s a a 15E increase and where that brings with it a whole bunch of comorbidity problems and
The Frailty problems and what have you that you all know about now the jurisdiction for the prevention of disease largely sits with local authorities as Andy Street was pointing out how housing transport recreation employment so on and so for when that kind of and vaccinations and when that doesn’t work and people become
Ill the NHS picks it up and then people go into hospital or into care of their GP but then they get past back into the local Authority for social services and what have you and I think that if Bon came now he wouldn’t be arguing we’ll have an NHS which will make everybody
Better which was sort of the argument at the time he would say we need a health and social care system and I think that that well I don’t think actually that is the underlying philosophy and the policy intent of the integrated Care Systems the idea was to bring the local authorities and the
Um and the Health Service closer together now now that’s worked better in some places than it has in others um so I think that’s what he do now but thank you so going from bevon to Aristotle Mike and I’m gonna give I’m bringing Naomi in last she had the first
Word and she’s going to have the last word which is of course um woman’s prerogative every time um Aristotle allegedly said give me a child until he’s seven and I will show you the man how does this apply to Public Health strategy Pian so I wish my wife was here no you prob
Probably know this but my wife used to work alongside you delivering shoer start so I got to know a lot about developing sh start at that time and the travails of trying to involve my colleagues in general practice into the spilling the beans on on on the data so
It was a very real problem but what she she taught me and I I I knew from from other areas and I’m not a pediatrician by background at all and actually it’s about the best St in life is always going to decide your outcome in in probably mainly in your health if your
Genetics are okay and but many other things I as a a GP I once read a letter which described a um a seven-year-old boy who’ been hospitalized and a very brilliant pediatrician called John willly Platt had sat down with him and realized this boy had really good
Computational skills and in his view was was absolutely outstanding intellect I read that letter uh 20 20 years later as a GP um and this is not not in any way to say an electrician isn’t a great job but he never went to University he never achieved his potential and that must
Happen so often and it does describe what what to me is a passion really that is if you can wake up in a child that does educational stimuli then it that that that I think bodess well for our for our country well I i’ then like to
Link that question uh very well to uh Naomi if I may and Naomi I’m going to take kind of second half of a question that I wanted uh you to answer is how do we strike that balance between investing in early prevention and supporting education for the poorest
Children actually I want to ask a I want to answer a slightly different question I’m going to take the prerogative because surprisingly I think the really important message is never too early but never too late and I really worry I I think it’s enormously important to concentrate from from prenatal right
Through um pregnancy period right through the very earliest years to get a good start but it is not inoculation stuff happens so we need to have a very good early year system we need to have a very good Primary Care System I’m sorry Primary School System but we also need employment support that
Keeps people healthy we also need much better prevention of Falls to make sure that people don’t at every stage in life you can prevent downturn in the next period to prolong healthy life so I think that an early intervention approach is a life cycle approach it’s not just an early years approach in
Terms of the poorest or lowincome it’s really about understanding what people need understanding the context in which they live their lives and I’ll just do my my my best line on it is if you want me to take a parenting program have it in a Freel LA duret because if I can do
My washing at the same time I’ll be very happy to learn how to be a good mother you know I have to give her that [Applause] One