Can Do Health & Care - NHS Uncomfortable Truths Report

10 November 2023 CAN DO CAN DO Uncomfortable Truths Part 1: WHY as system leaders we need to address culture to improve outcomes

2 | ICS System Learning: Uncomfortable Truths Ed Garratt OBE, Chief Executive, NHS Suffolk and North East Essex Integrated Care Board Event hosts normally express the hope that people are sitting comfortably, but today I want people to sit uncomfortably. At a recent conference I attended one of the speakers commented that culture is defined as the behaviours that we tolerate as leaders. What are we tolerating in Suffolk and North East Essex, either explicitly, the behaviours that we are aware of, or implicitly, the inequalities and unfairness that we are not paying attention to in our system? “What is the culture that we as health and care leaders in Suffolk and North East Essex are willing to tolerate?” We are a respected system, thanks to all the work that the people in our system do, but the truth is we are unsustainable, we deliver performance that we can’t and shouldn’t tolerate. We should accept there are good things in our system, but there are so many other challenges we need to start exploring. Today is about establishing the ‘why?’ as we talk about outcomes and accountability. Our accompanying data pack has been put together to stimulate your thoughts and provoke your ideas. For example, half of our looked after children locally have a mental health disorder, half have not been able to access an NHS dental appointment, and there is a strong relationship between looked after status and the criminal justice system. I recently visited a young offenders’ institution and saw that many were Black, many had been looked after children, and many had been drawn into county lines, because of their vulnerabilities. We need to think about a left shift in terms of early intervention and prevention. The first 2,000 days of life are vital; being in the education system makes a significant difference to children’s prospects and aspirations. We also need to shift resources, and we have started to do that but we now need a radical shift into community-based integrated care. This means a shift in culture, and today starts this process. Introduction

Part 1: WHY as system leaders we need to address culture to improve outcomes | 3 Susannah Howard, Director, Suffolk and North East Essex Integrated Care Partnership As an Integrated Care System we come together across all sectors, and whilst it looks like a complicated system to us, it is also a very confusing system to the people using our services. At its heart, our system recognises that what people want a health and care system that is genuinely ‘Can Do’ and that ‘Will Do’. Our health and care system needs to be one that is safe, compassionate, inclusive, fair, courageous, collaborative, evidence based and continuously learning, and our regulators want to see that too. Integrated Care Systems have four purposes, bringing partner organisations together to: • improve outcomes in population health and healthcare; • tackle inequalities in outcomes, experience and access; • enhance productivity and value for money; and • help the NHS support broader social and economic development. In 2024 the Care Quality Commission will start its programme of reviewing integrated care systems. Being ‘Well Led’ involves “an inclusive and positive culture of continuous learning and improvement. This is based on meeting the needs of people who use services and wider communities, and all leaders and staff share this. Leaders proactively support staff and collaborate with partners to deliver care that is safe, integrated, person-centred and sustainable, and to reduce inequalities.” The questions we pose today draw on these statements to ask, ‘Are we Well Led?’ We work together as an ICS in different ways. We come together through the Integrated Care Board, the Integrated Care Partnership Committee, Health and Wellbeing Boards, our Alliances, our acute and community NHS collaborative, VCFSE Assembly, our Chairs Group, Integrated Neighbourhood Teams and Primary Care Networks. We want to build an ICS that is genuinely inclusive of every voice, and together we are the system, and to do that we want to cultivate our ‘Can Do’ Integrated Care eco-system. Integrated Care Partnerships are a core part of ICSs, driving their direction and priorities, and are rooted in the needs of people, communities and places. ICPs create a space to develop and oversee population health strategies to improve health outcomes and experiences. ICPs will support integrated approaches and subsidiarity. And ICPs should take an open and inclusive approach to strategy development and leadership, involving communities and partners to utilise local data and insights. (DHSC Guidance). Today is about creating that thriving integrated care eco-system, drawing on those principles. “Our shared vision in the ICS is to support everyone living in Suffolk and North East Essex to live well and provide the care they need to stay well in their local communities.” The data shows these are longstanding systemic issues, and we are not turning the curve on many of the data trends. To achieve our shared vision, we need a ‘left shift’ for the people we serve, and this means bringing together all areas of our ICS strategy, and together focusing on Culture.

4 | ICS System Learning: Uncomfortable Truths 1. Start with Why? we want everyone to live well Focusing on outcomes for people, enabling everyone in Suffolk and North East Essex to Start Well, Be Well, Stay Well, Feel Well, Age Well and Die Well. 2. Work Upstream - protect health and prevent ill health Supporting people to live well for longer by intervening early, preventing disease and slowing progression. Building resilience and focusing on the wider determinants. 3. Subsidiarity and ‘Thinking Differently Together’ Working with communities and the VCFSE sector to move care and resources to more local, community-based solutions. Subsidiarity and focusing on place and neighbourhood working. Building VCFSE sector resilience. 4. Equality and Equity Addressing both health and healthcare inequalities for each population segment including the CORE20PLUS5. Driving equity, and equality and diversity for our workforce. 5. An inclusive ‘Can Do’ Health and Care Culture Building a culture of ‘Can Do’ of truly person-centred care, which is collaborative, built on trust and belonging. Being Collaborative, Compassionate, Cost effective, Courageous Community Focused and Creative. How should we be Today’s conversation is Part 1 of 3, starting with WHY we need to change our culture: 1. How are we doing? 2. What is the story behind the curve? Part 2 will focus on HOW we could achieve meaningful change in our culture: 3. Who are the partners who have a role in turning the curve? 4. What works to turn the curve? Part 3 will focus on WHAT we need to do: 5. What is our plan to turn the curve?

Part 1: WHY as system leaders we need to address culture to improve outcomes | 5 Panel 1: Are our services safe, integrated, equitable and compassionate Chair: Wendy Herber, Independent Chair, Healthwatch Suffolk Panel: Sharon Alexander, Chief Officer, CVS Tendring Nicola Cottington, Chief Operating Officer, West Suffolk NHS Foundation Trust Dean Dorsett, Clinical Lead for Personalised Care NHS Suffolk and North East Essex Integrated Care Board, and Senior Partner and GP Principal, Burlington Primary Care Joyce McIntyre, Community Connector, African Families in the UK Rebecca Pulford, Director of Nursing and Chief Nursing Information Officer, Essex Partnership University NHS Foundation Trust Jeptepkeny Ronoh, Consultant in Public Health Medicine, Suffolk County Council Wendy: This event is unusual, as we don’t usually have open ended and personal conversations. It is also a timely conversation, with marginalised people being subject to abuse, and racism on the rise. We worry about language, using the right words and saying the right things, but today let’s be curious, leave judgement behind and acknowledge we are all trying to do the best we can. Uncomfortable Truth 1: People in our most deprived places in Suffolk and North East Essex have consistently poorer health outcomes than those in more affluent areas. Essex and Suffolk Joint Strategic Needs Assessments

6 | ICS System Learning: Uncomfortable Truths Dean: Reducing inequalities is not about our strategic direction, we already know that. Marmot told us about that 13 years ago and since then inequalities have widened. If we look internationally at the places which spend less than we do on health but have more centenarians and more comfortable, dignified deaths, we know the strategic direction we should take. When I look at the data pack for this event, I ask myself what one thing could change it all. The research repeatedly tells us that it is to get communities involved. “We should shift leftward into the community, the question is how far and how fast? This takes courageous leadership.” The differences people experience in care are not due to the intelligence of the doctors, but whether the doctors engage communities and trust them to tell us whether we are getting it right or not. Listening to that brutal honesty allows us to respond faster. We might waste our learning from the crisis we had in Covid, and the crises now and to come, if we only focus on the strategic direction. We need to move now, and fast. Jeptepkeny: When I started my training in public health 20 years ago, I was involved in a population health needs assessment in Clacton. I remember going to Jaywick with environmental health officers who were working to improve the quality of housing, and they spoke about the lack of trust between local people and public sector organisations. Local GPs told me about high GP turnover. I saw the Surestart centres doing good work, teaching young mothers how to cook, for example. The data then showed issues of poverty, teenage pregnancy, lone parent families, and low educational attainment. At that time the Wanless report had been recently published, which talked about taking a long term view to securing our public health. Wanless highlighted that the UK had fallen below other countries in health outcomes and outlined three scenarios for a vision for the NHS in 20 years’ time, which would be 2022. At one extreme, ‘slow uptake’ is the most expensive scenario where there is no change in public engagement, life expectancy rises only minimally, people’s health is constant or deteriorates, and there is low uptake of technology and low NHS productivity. At the other extreme, ‘fully engaged’ is the least expensive option, with high public engagement where life expectancy increases beyond forecasts, health improves dramatically, people are confident in the health system and want high quality care, the health system is efficient and responsive and uses technology especially in disease prevention. Reflecting on my experiences in Clacton and the Wanless report, if I did the same needs assessment today the data shows there is still a life expectancy gap nationally, and that gap is worse in some areas. In Tendring the gap is just over 10 years for men and almost 8 years for women, and it is increasing.

Part 1: WHY as system leaders we need to address culture to improve outcomes | 7 Sharon: Clacton is a beautiful area, where day trippers enjoy excellent facilities. But it grew in Victorian times and its houses were built for the needs of a different era. Today these houses have been converted into bedsits and houses of multiple occupation with dreadful health outcomes for residents. One story illustrates the challenges. Tammy was married, 44 years old with 2 children, and on the surface all was good. However, she was a victim of domestic violence and fled her home near London overnight with her two sons and only the clothes she wore. She found a bedsit in Clacton, the family living in one room with no cooking facilities. The local area has county lines, high unemployment and mainly seasonal employment. Tammy has a health condition, one son has autism, and Tammy found it hard to control her sons who were walking the streets, extremely vulnerable. We can imagine the risks to them. Nicola: The West of Suffolk doesn’t comparatively have the same number of areas of deprivation. However if you are that family that is living in deprivation it doesn’t matter that those around you are not. We need to direct resources where the greater need is, but that doesn’t mean we leave people behind. “If you are one family in deprivation you feel its impact and in fact it can be more isolating because you don’t tend to have the community groups, the support around.” Uncomfortable Truth 2: Black and Asian women are more than four times more likely than white women to die in pregnancy or childbirth, women of mixed ethnicity two times higher and Asian women almost twice as likely. MBRRACE Joyce: I work with local women who use GP and hospital services and we have to support them with the consequences of their experiences. To prepare for today I shared with our women the data on maternal deaths among Black women, reporting that Black women are least likely to feel they are treated with kindness, care and respect, and being most likely to have postnatal depression and least likely to have access to care and follow up after treatment. They shared their uncomfortable truths about their experiences: • Unconscious bias in health that contributes to disparities in health outcomes. We see in the community some health outcomes that are irreversible. • Failure to recognise medical conditions in Black babies and their mothers.

8 | ICS System Learning: Uncomfortable Truths • Lack of choice and consent around care options. • Ethnic minority women not being listened to by health professionals, their health concerns being dismissed, being ignored and disbelieved. • Racism by caregivers, microaggressions and negative stereotypes about ethnicities, such as Black women being strong and they don’t feel pain as much as their white counterparts. Sometimes medical records are inaccurate, their backgrounds are missed so that affects their healthcare. • Dehumanisation and lack of physical and psychological safety, structural barriers, culture, and lack of support for trauma due to the quality of care that they have received in the past. • Accessibility of services and staff shortages that lead to having to wait for help. Uncomfortable Truth 3: In 2020, approximately 23% of deaths in the UK were considered avoidable. Of these, 69% were preventable and the remaining 31% were considered treatable. Office for National Statistics Nicola: The data is clear, and the responses in our system will be mixed. I felt a range of emotions and wanted to find out more about the reasons behind the data. Some of the deaths are preventable through secondary prevention and immediate care and treatment, and then there are deaths that are part of our structural inequalities, such as the maternal deaths data. I don’t believe that most people in health and care get up in the morning intending to be racist or intending to give worse care than they should. The structural inequalities in the NHS exist because we are an inequitable society, and internationally there is bias too. “The people experiencing inequalities aren’t ‘others’, they are ‘us’, part of our community. Their experiences are linked to the context around them, the bias in how systems are designed and how care is delivered, and societal structural inequalities.” The Marmot report in 2020 highlights that between 2009 and 2020 the expenditure per person in local authorities in the 10% most deprived areas fell by 31% compared with only 16% in the least deprived areas. What drives that is structural inequality. Rebecca: Both listening and acting are really important. Recently, hearing on the news from the mother of a child who died from sepsis and Martha’s Rule on listening to families, the response came that implementing new structures might take longer than the set target date. This made me angry: why should it take me so long to listen?. I watched the Dispatches programme and felt a pressure on my chest. We must not reduce the lives and experiences of people in physical or mental health crisis solely to assessing risk, we need to start to believe and understand their truth. I am on a journey of passion about how we

Part 1: WHY as system leaders we need to address culture to improve outcomes | 9 care and assess individuals holistically and how we look at the whole person as partners with the people who we have the privilege to care for. We have made great strides in some areas of healthcare, but I also believe we have become siloed in our thinking. By opening up our thinking we can help reduce avoidable deaths, but this requires a fundamental cultural shift. Dean: Strategists talk about this story: “If one fish in the aquarium becomes ill, you treat the fish. If most of the fish are sick, you treat the water.” The water is strategy, it is culture. If the water is pressured, or toxic, the fish become sick. If we make things more difficult for clinicians, requiring significantly more effort with some groups to achieve the same result as for others, clinicians tend to become unconsciously biased, non-listening. At some point a strategic financial decision is needed about where we invest. “The uncomfortable truth is that in practice our leaders are making financial decisions that in effect make inequalities worse.” As leaders we need to hold a mirror up to ourselves, as something we are doing is enabling the culture we have now. Do we want to change badly enough? Uncomfortable Truth 4: Not every patient experiences the care they should: recent learning from mental health and maternity. Care Quality Commission, Healthwatch, Channel 4 Dispatches Joyce: Partnering with communities is essential, and there will need to be differences in the way money should be invested in an area. “Communities just want to be listened to, to be heard.” Coming into our communities makes a real difference, we have seen clinicians coming into our safe spaces, listening to our mothers, taking them seriously and making changes by investing in the communities. Sharon: When people experience real stress they don’t want to speak, don’t want advice, they just want to hide in a corner. In CVST our cost of living action group identified issues with poor housing and poor health, one teacher telling us 50% of the children in their primary school were living in temporary accommodation. The action group dropped leaflets in the poor housing inviting families to come for breakfast. Tammy came and as a result the family is registered with a GP, Tammy obtained her medication, registered her child in school, and was found a new house and furniture. The family is now stable because of this very local community partnership.

10 | ICS System Learning: Uncomfortable Truths For many people, our system is still too complex to understand. It takes one thing going wrong in their lives to go from being a stable family to chaos, and because they are in poverty and under stress they are more likely to become ill. Nicola: When staff are under stress it can be harder to actively listen, but that is not an excuse. There are structural inequalities, but personal interactions have an impact too. A friend with fibroids has been offered a hysterectomy but is very reluctant, as Black and brown women are more likely to have fibroids but are also more likely to be recommended hysterectomies very early on. I then found that Black women are twice as likely to be given a hysterectomy as White women for benign gynaecological conditions. “Personal interactions are important to understanding why a person may not trust the information they are being given, and to recognising that the information is in fact biased.” Rebecca: If we truly want to shift left to be partners with the people we serve we need to listen at all levels. We need to think about how we listen, learn and build partnerships together and shift that culture. “We need to develop a shared philosophy and push boundaries, placing a real pressure on ourselves until everyone using our services feels physically and psychologically safe.” If we don’t listen to people and to our workforce we won’t make the progress that we need throughout our system. Dean: We need to treat the perpetrator but also empower the victim. We need to go further than simply mandatory training for our workforce, research is showing that we need to tackle equality, diversity and inclusion by co-producing with communities what we plan, what we do, what we study and how we act. Cultures are very diverse, and we cannot understand every one, so we should show empathy not just sympathy, and show compassion by asking, what am I doing wrong? We should not just say we care, but show how we are spending, and how we are sharing power with people by involving them in our decisions. This should be an iterative process so we can respond rapidly to what people tell us, and continually improve every single day. Joyce: Recently, we found our women were being given advice by health professionals on what to eat, and then coming back to us saying this was not culturally relevant to them. As community ambassadors we respond quickly, finding someone who can come into our community space to give us tips about eating the foods from home in a healthy way that will benefit the baby and mother.

Part 1: WHY as system leaders we need to address culture to improve outcomes | 11 Comments Shane Gordon, Director of Strategy, Research and Innovation, East Suffolk and North Essex NHS Foundation Trust: We are fighting against structural inequity in funding formulas and priorities, for example NHS’s primary focus being on elective care and reactive emergency care, and less on prevention. It is hard for us as an isolated part of a national system to deviate from that narrative. “There are little acts of rebellion that we can muster amongst us. I wonder if we could be more systematic in that rebellion, how could we address inequality in the ways we report our progress, our performance and our achievements, and in how we make our investment decisions?” I chair the capital investment group in ESNEFT, and my little act of rebellion is to require each business case to tell us how it is making a difference to inequalities. Cath Byford, Deputy Chief Executive, Norfolk and Suffolk NHS Foundation Trust: There is a lot of evidence nationally to show people with serious mental illness die 15-20 years sooner than people without serious mental illness, and many of those causes of death are preventable. In O’ level English I learned from George Orwell that all animals are equal, but some are more equal than others. Some people in our population are treated significantly differently by services not being available, accessible and provided equitably. People die sooner in some cases for physiological reasons, but also due to inaccessible services, poor housing, higher risk of drug and alcohol misuse to mask symptoms, the risk of vulnerability associated with exploitation. My uncomfortable truth is that we have all the evidence but we are not taking accountability and responsibility as a whole system across health, social care, voluntary sectors etc. “What are we going to do about all the evidence we have that demonstrates how we are failing members of our population? When is this going to translate into a commitment to take ownership and deal with this?” We won’t fix it immediately, but the problems for our populations are getting worse not better, and mental health is just one example of that. Andy Yacoub, Chief Executive, Healthwatch Suffolk: Inequality is the biggest and the most damaging and enduring illness that we have, for our workforce and amongst our public. “We need to be aware that as a system we are shutting down the voices of people who want to be heard.”

12 | ICS System Learning: Uncomfortable Truths The Suffolk and North East Essex system has a very good reputation from a professional perspective, but this is a comfort blanket. If we look under the blanket we can hear what communities have to say, both workforce and the public. Please let us listen to them collectively and make decisions collectively. From today, I want us to do things differently. “We are very reliant on signposting to the voluntary and charitable sector. In deprived areas this often means families having to travel, they might take time off work to attend a drop-in service, wait all morning and then not be seen.” “Is our culture driven by templates and our targets for ourselves? Covid taught us that we need to ask our communities how they want to be approached and helped, we need to do the same again for the pandemic we face now.” “Could we start with how our formal Boards and committee meetings listen to people and enable their voices to be heard e.g. changing practices re who speaks and when?” “Racism is endemic in our society, but also prejudice, preconceptions and if you have an inability to articulate your feelings or your fears or your problems you are not going to be heard, you are immediately dismissed.”

Part 1: WHY as system leaders we need to address culture to improve outcomes | 13 Panel 2: Is our health and care system a fair and inclusive place to work? Chair: Andrew Kelso, Medical Director, NHS Suffolk and North East Essex Integrated Care Board Panel: Tanvir Alam, North East Essex Alliance and BAPIO Amina Chitembo, Chair, Suffolk and North East Essex Review and Oversight Group, and NHS England East of England Workforce, Training and Education Melanie Craig, Chief Executive, Suffolk Community Foundation Fiona Ellis OBE, Chief Executive, Survivors in Transition Harprit Hockley, Director of Culture and Organisational Development, Norfolk and Suffolk NHS Foundation Trust Belinda White, Regional Manager Integrated Urgent Care, (111, Clinical Assessment Service and Out of Hours) in Suffolk and North East Essex, Practice Plus Group Andrew: Today we are aiming for maximum discomfort, but from discomfort comes better things. The uncomfortable truths we talk about are happening in plain sight. This is important because the standard that you walk past is the standard that you accept. If all of us can’t say we have done everything in our power to change these things, then effectively we have walked past them. This series of events is a call to arms to stop accepting the incredibly uncomfortable things that are happening around us.

14 | ICS System Learning: Uncomfortable Truths Uncomfortable Truth 5: Ethnic minority professionals are disproportionately impacted by fitness to practise referrals and proceedings. Social Work England, Nursing and Midwifery Council, General Medical Council Harprit: The reality for people who look like me is that in work, we are expected to fit in. I have changed my accent, my dress and my hair, and lost my cultural heritage in order to progress in my career and fit into society. We are described as minority communities but we are the global majority. Many people in roles such as mine have had negative experiences, and the reason is unconscious bias, though I would question whether bias is really unconscious or whether we are just not doing our homework to understand the communities we work alongside. There are huge disparities in Fitness to Practice referrals between ethnic minority communities and white communities across all health and care professions. Unconscious bias may be a reason, but we can also argue it is simply bias and racism. When staff say ‘I don’t understand what they are saying’ or ‘I don’t understand their accent’ or ‘their practice in their other country is different’ it suggests people are not living up to the standards of ‘our country’. Rather than doing our homework and working alongside people we push the problem to a professional body to review, so that it is ‘not my problem to fix’. It is an uncomfortable truth that we put sticking plasters on these problems, creating an action plan, holding some events, doing listening exercises, but we don’t get to the crux of the problem. These are not new issues, we just haven’t been willing to look at them. “We need to stop trying to de-bias people, stop sending people on training, stop the sticking plaster interventions, and instead look at our system, our practices and our processes, and ask ourselves what we are doing wrong and what we need to change if we are really going to have inclusive organisations where people belong.” Tanvir: BAPIO has been a sort of shield for physicians of Indian origin and deprived groups for a long time. Its origins are in activism as there was inequity in the visa system for doctors in the early 2000s. A seminal moment was the suicide of Imran Yousuf, a young doctor who couldn’t get a job and a visa, and this galvanised the movement. Now BAPIO is a system partner working very closely with all sectors. BAPIO has intervened in cases in several Trusts where people have been referred to the General Medical Council (GMC) for Fitness to Practice, and 80% of those issues have been resolved. At the last BAPIO conference the GMC admitted they have a problem with differential attainment, which they plan to weed out by 2031. Interestingly we have a national target to be carbon neutral by 2030; if carbon is more important than people we are not in a good conversation space.

Part 1: WHY as system leaders we need to address culture to improve outcomes | 15 A great deal of differential attainment is due to communication, crossed wires and cultural differences. We are all different but embracing those differences is not everyone’s cup of tea. The greatest area of concern in this country is someone saying they have concerns about you. People said that about me early in my career, I was sent on a linguistics course, but my language scores showed I am an expert user of English so there was no need. There are wider systemic issues here. The number one reason for referrals is differences in communication and perception. “Rather than working antagonistically we must work together in synergy to accept each other’s differences.” The overseas workforce will be 50% of the workforce in the next 10 years but representation in management leadership spaces is only 17%, so there is a big gap. In 75 years of the NHS there has always been a glass ceiling. When I came to Clacton and took over a surgery assessed to ‘require improvement’ a leader in the CCG asked me to ‘humble’ myself; if there is a block right from the entry point of your work, how can you progress that conversation further? Being a brown man with a beard, you are profiled as a ‘towel-head’ first, so as well as the colour of your skin you have to overcome that too. First people see you, then they speak to you, and only if they like what they hear will you have an opportunity to get to the next level. “The NHS is standing on the shoulders of its international workforce.” This is uncomfortable but it is the reality for the overseas workforce and has been for a very long time. Harprit: The overseas workforce has, does, and will always make up a large proportion of our workforce. But the NHS gets it wrong. I ask organisations to put themselves in the situation where you go abroad to pull staff from organisations that are also struggling with their own healthcare workforce, you bring them here and separate them from their families and their friends, you have no affordable housing for them, you pay them at the lowest possible scale not taking into account their previous experience, and you put them in a stressful environment with no support, teams who don’t want them and have prejudices and racism against them. That’s what we are doing.

16 | ICS System Learning: Uncomfortable Truths Amina: How many of the people here today, when they walked in, looked for somebody who looked like us? And not just in this room, but in every room we walk into? Imagine somebody who has just come into your organisation and who is expected to leave their true selves outside to be like everybody else. As Black people we have to work twice as hard, and colourism is a further factor, as the lighter your skin the more life chances you will have. Our colleagues, line managers and leaders do not understand our cultures and the ways we express ourselves. We are judged on the way we speak, how we express ourselves using our hands, and when we speak up people see that as a problem. “We look more at how somebody is going to perform, how they look or how they come into the organisation, not so much in terms of understanding them and where they are coming from.” Melanie: To illustrate some of the challenges for the international workforce, I saw at a foodbank in Suffolk that also supplies furniture that most of that furniture is taken by overseas nurses working in the local trust. I was shocked that when the NHS should be supporting its international workforce, that workforce is instead relying on donations. It is not only about finding people who look like me but also people who are feeling like me, who are my feelings important to? During the disciplinaries and fitness to practice, disputes and behaviours, what is also going on for that person? Are we spending enough time thinking about how people are feeling? The world is not a fair and inclusive place to work and the issues we are talking about today are reflected in all parts of society. Look outside the bubble of health and care, and spend time looking at different sectors such as education and business too. Uncomfortable Truth 6: The 9,000 VCFSE sector organisations in Suffolk and North East Essex employ around 16,000 staff. The effects of the pandemic and the cost of living crisis have left smaller charities particularly vulnerable. NCVO, The Charity Commission Melanie: I am a relative novice in this world, but the voluntary sector are small organisations that have developed in response to a crisis, a passion, and issue or a need, and they are very different from each other. In the last few years there has been a perfect storm. “There is significantly increased demand for certain needs due to societal changes… There has been a massive shrinkage in public sector funding both to those services and in the public sector offer so that many of those services are trying to respond to the shrinkage in what has previously been available.”

Part 1: WHY as system leaders we need to address culture to improve outcomes | 17 Around 50% of voluntary sector funds come from public donations, but during the pandemic years people were unable to fundraise so they dug deep into their reserves; now there is not much left and public donations have not recovered since that time. We had an overwhelming flood of money from the public sector in response to Covid and then the cost of living, and organisations became reliant on that to respond to the increased demand, but almost overnight this is now drying up and organisations are worrying about how to pay their staff. The voluntary sector and statutory clinicians see people’s everyday lives, but if you are not a clinician you do not have that privilege. I think now, that if only I knew when I worked in the NHS what I know now, what might I have done differently? It has been very difficult for small organisations, whether they are voluntary sector, whether they are small businesses, to recover after Covid because the way of working has changed enormously. In terms of digitalisation, organisations do not have the kit and an IT team on tap. Now there is a greater maturity in using technology that has left a lot of smaller organisations behind and struggling to operate in this world. Fiona: Funding in the VCFSE is an uncomfortable truth that we have become used to. “The statutory sector is shirking its responsibilities, failing human beings who are being dumped into the voluntary sector without sufficient funding, to deal with more complex issues than we have ever dealt with before.” As an example, pre-Covid on average we offered people 15 therapy sessions, now we offer on average 23 sessions. This is a measure of the complexity arriving on our doorstep. Many are survivors that the statutory sector do not want to deal with as they cannot resolve their problems themselves, and often these people are then forgotten about. Many are expected to have the resilience to self-refer, the statutory sector will not spend even a few minutes filling in the referral form to ensure people get to where they need to be. In the voluntary sector we must never apologise for our passion, as it is what will lead to change. We must work together, and the statutory sector must start to listen in a different way than before. People in the VCFSE are accused of being loud, and it has taken years for me to become more articulate. When I did shout, people put their shutters down, but people shout because they are not being listened to. We do not apply a trauma informed lens, we don’t recognise people are traumatised, and we re-traumatise them by making them repeat their story or sending them to another organisation and not doing the things on their behalf that we could easily do. “The way that we listen has to change.”

18 | ICS System Learning: Uncomfortable Truths Amina: I set up a charity in the past, bridging the gap between mainstream services and local minority communities. The charity sector then changed and became very competitive, we had to compete for the little funding we had against bigger charities, and this became unsustainable. “Smaller organisations that would make really big differences would rarely get funding because the funding would go to the big organisations, or ‘preferred providers’”. Our overseas staff need the right social support, without it there are impacts on their workplace and on patient care. Uncomfortable Truth 7: 98% of NHS staff report they have experienced incivility in the workplace: the NHS is described as having “poor leadership behaviours, discrimination, bullying, blame culture and responsibility avoidance”. NHS England, General Sir Gordon Messenger and Dame Linda Pollard Belinda: Practice Plus Group employs 5,500 people providing some secondary care services, as well as healthcare in prisons where as you can imagine our staff experience a lot of abuse. In Suffolk and North East Essex we operate NHS 111, an out of hours GP service and our Clinical Assessment Service. We need a major piece of work on what we walk past and what becomes normal for our teams. For example, a huge amount of abuse that our staff experience in our call centres is based on their accent. Staff tolerate verbal and sometimes physical abuse because they care about their patients so much. They say they understand why the person is like that, recognising they are uncomfortable, in pain, frustrated. “As leaders we have to say that abuse is not acceptable, and we need to encourage our staff to speak up.” Our Clinical Assessment Service is telephone- and video-based support, dealing with 30,000 patients a month in Suffolk and North East Essex. We are losing dental nurses as they are on the receiving end of verbal abuse every day from frustrated patients who cannot get access to a dental service, in pain and sometimes threatening self-harm or suicide. We never thought we would be training dental nurses in how to deal with abuse and providing wrap-around support. The uncomfortable truth is that patients are in that extreme state, and that staff are leaving as they did not expect this extent of verbal abuse when they entered their careers.

Part 1: WHY as system leaders we need to address culture to improve outcomes | 19 Recruitment is a challenge, but also retention. Answering the phone on 111 is a living wage level job as it is a non-clinical role, many of our staff come into the role with great intentions to make a difference but it is relentless work, and having to listen to patients’ abuse and frustrations makes it very difficult. Tanvir: I am a clinical consultant for out-of-hours in Norfolk and Waveney, working in parallel with the 111 service. The amount of vitriol that the call-handlers face is tremendous. By the time the patient speaks to the doctor they have already been asked their problems twice, and they are at fever pitch in their disappointment with the service, so you have to apologise. The patient then asks which country you are from, and you have to reassure them sufficiently so that you can start to address their medical problem. Dental issues are a significant issue, as the GMC does not allow GPs to prescribe antibiotics for dental matters; in the out-of-hours service we prescribe them and have to explain this is on humanitarian grounds, but the patient feels we are doing them a favour and talking down to them. The call handlers have to follow prescriptive pathways which don’t always lead to the right outcome for the patient. Harprit: Nationally across the NHS, from a workforce of 1.3 million, 15-20% of our staff have experienced physical assault from patients or service users. The rates are higher in the ambulance and mental health services, and staff can experience multiple incidents each year including being punched, broken bones, lost teeth, or chemicals sprayed in their face. There is significant under-reporting as incidents are seen as just part of the job. We place the onus on staff to manage these situations, telling them to be more resilient, or to have more training. “We have to be able to work together, for us to understand the impact we are having on our communities but also the impact our communities are having on us, because if we don’t resolve this we are not going to have a workforce left.” Younger people have very different expectations from their employers and for their work, so we have to get this right for the next generation. Melanie: In the last few years emotions have been up and down across the country. We had clapping and valuing the NHS, a feeling of flexibility and freedom, volunteering for the greater good, and just being there for each other as we didn’t know if we had a future. Now the level of anger and outrage in the UK is at an all-time high, with people not acting for others and community groups losing their army of volunteers. This is important as a fifth of voluntary sector organisations work in the field of social care, many very small organisations dealing with very complex needs, and if they close this will be very concerning. Uncomfortable Truth 8: Nearly a third of female NHS surgeons have been sexually assaulted by a colleague over the past five years. University of Exeter, University of Surrey and the Working Party on Sexual Misconduct in Surgery

20 | ICS System Learning: Uncomfortable Truths Fiona: To prepare for this discussion I spoke to some survivors of sexual assault in the workplace. Firstly, they said, we are not allowed to talk about it, and when we do, nothing is done. Secondly, they said, I don’t feel safe going to work psychologically, physically, sexually. Thirdly, they said it was almost an expectation that it would happen at some point. This is just not good enough. “We are so slow to respond to this issue. Why has it been necessary for the NHS to launch a sexual safety charter, in 2023?” And this charter has only happened on the back of a damning research report. Kneejerk responses have got to stop. When sexual offences happen in the workplace the person who experiences them can seldom move from the environment in which this took place. Lots of people who survive abuse in the home can remove themselves from their abuser, but many survivors of sexual violence in the workplace have to see the person or people who abused them, or the people who didn’t listen to them, or the people who further traumatised them, every single day. We make it very difficult for them not to be in that environment. I do not think we treat sexual violence in the workplace in the context of the law, we process it in the context of HR, or the optics of our organisation’s reputation to the rest of the world. These offences often start as unchallenged infringements of people’s personal space, and quite often they progress into an overt criminal activity which is never addressed through the law. “We have got to start looking at sexual offences in the workplace as infringements of the law.” Tanvir: I am a former surgeon, and that world is unfortunately a male bastion with the women there often seen as trophies. The conversations in the changing room are about cricket and sex. There is a big cultural problem, and so many talented female surgeons have chosen alternative career paths because of this, which is a loss to the system forever. We need a sense of urgency. The Royal Colleges have accepted their culpability in this but we need to see action. Someone, somewhere is probably being abused as we speak, and that is the ultimate tragedy. Comments Ruth Bushaway, Medical Director, Suffolk GP Federation: Our organisation carried out a review to find out how we can be more inclusive. We had some good results, but some staff feel ‘othered’, and staff felt leaders are detached and don’t listen. This means that they don’t speak to me in the way they could, and I don’t hear their truths. I can only change what is in my sphere of influence, but I won’t be stopping.

Part 1: WHY as system leaders we need to address culture to improve outcomes | 21 Tracey Williams-Macklin, Director of Practice Partnerships, University of Essex: We have seen larger numbers of ethnic minority students being referred to fitness to practice, and the majority of those come from practice placements. We also have a widening gap in attainment between white and ethnic minority students. I want to invite the system to think about that early career experience and to think creatively about what experiences we offer students, including non-traditional placements in the community. Daniel Spooner, Deputy Chief Nurse, West Suffolk NHS Foundation Trust: 53% of our nurses at Band 5 are from ethnic minority background, that reduces to 5% at Band 7, and 2% at Band 8 and above. There have been so many programmes in the past about lifting up ethnic minority staff, giving them opportunities to understand where they fit in leadership roles, but the people recruiting them need more education. “The term unconscious bias is used in our vernacular all the time now but white privilege isn’t, and it should be… It’s about understanding the experiences of BAME staff to understand your own biases... Now I have had my eyes opened to that I am seeing it regularly.” Godwin Daudu, Engagement Officer, Community 360: What we are talking about today is change, and change is always uncomfortable. Truth makes us uncomfortable too. When an organisation presents itself, it tells its mindset. “If we have a situation where we have become comfortable with the fact that being black, brown and female isn’t good enough for leadership, that represents the mindset of the organisation, and that needs to change.” This is a huge opportunity for us to be blunt, blunt in the faces of the people that make the changes and make the policies. One of the reasons I joined the voluntary sector was that I was tired of standing on the terraces throwing stones at the players on the field of play. I want to be on the field of play and tussle with the players so that we can bring about the change that we need. We should no longer accept being comfortable. Cath Byford, Deputy Chief Executive, Norfolk and Suffolk NHS Foundation Trust: In mental health we have normalised abuse towards our staff, whether its racist abuse, gender-based, physical and verbal violence. Why would someone report an incident if we don’t act as a result? We ought to consider where we can opportunities for convictions for physical and verbal abuse, so that people have support and feel safe to report, and comfortable that they will be believed and it will be acted upon. “Some of our colleagues in all sectors are talked down to and minimised because they don’t have the right accent or the right academic qualifications. They feel less valued and that what they bring doesn’t have the same level of meaning… We contribute to the perpetuation of that and it’s not fair.”

22 | ICS System Learning: Uncomfortable Truths Moira McGrath, Director of Commissioning Adult Social Care, Essex County Council: We have a high proportion of ethnic minority staff, managers and owners in our social care providers, and understanding their experiences is really important. After one racist incident where our response was not the right one, we have been on a journey and are learning that we need to be actively anti-discriminatory. Andy Yacoub, Chief Executive, Healthwatch Suffolk: We have been talking about how staff do not report incidents as they fear being marked and don’t want to put their heads above the parapet. Don’t hide behind data and don’t be fooled by the data. Jeptepkeny Ronoh, Consultant in Public Health Medicine, Suffolk County Council: A lot of people won’t have the agency to speak out because the stakes are really high, you need to pass your exams, and your visa depends on your job. We need to get comfortable to have these conversations and hear that lived experience more. We need to start early, even in schools with our children, talking about our history. “My father arrived in the UK in 1969, as a qualified doctor; later practiced as a GP. His experiences are those of Tanvir’s - why are they the same, 54 years on?!” “How do we embed co-design and continuous development of both services and workforce practices so they are not just delivering for middle class white people?” “We are very reliant on the well trained overseas workforce. How do we proactively support their inclusion so we all fit together and it’s not about fitting in?” “If we see someone fall over in public, we offer to help. Why do we ignore sexual offences in the workplace? How can we bring about normalisation of a challenge?” “We need to reduce the burden of expectation on professionals from certain groups to take the lead in changing culture and recognise the trauma this can cause.”

Part 1: WHY as system leaders we need to address culture to improve outcomes | 23 Panel 3: Are we continuously learning and improving based on evidence and experience? Chair: S hane Gordon, Director of Strategy, Research and Innovation, East Suffolk and North Essex NHS Foundation Trust Panel: Z oë Billingham CBE, Chair, Norfolk and Suffolk NHS Foundation Trust Godwin Daudu, Community Builder/Engagement Officer, Community360 and Community Ambassador, African Families in the UK Anthony Douglas CBE, Chair, Suffolk Safeguarding Partnership Ian Turner, The Partnership in Care Ltd and Chair, National Care Association Richard Watson, Deputy Chief Executive and Director of Strategy and Transformation, NHS Suffolk and North East Essex Integrated Care Board Shane: This is a challenging conversation and I am conscious I am the third white middle class chair. I am passionate about reducing inequalities, fairness and justice. Uncomfortable Truth 9: The many inequalities in clinical research include who does research, subjects recruited and type of research. British Medical Journal Caroline: The first point to consider is what we mean by research. Using the term in its broadest context, this is not just about clinical research but gathering all the research evidence base across our population, including public health, our voluntary and community sector, and Healthwatch. Our patients are the foundation of research, so we need to be as inclusive as possible to bring diversity into our research. There are barriers to being involved in research for people with different socio-economic backgrounds and different populations. How can we support people to be more involved in the continuum of taking research into innovation and then into practice?