Inside the NHS Race and Health Observatory

In this episode, we take listeners inside the work of the NHS Race and Health Observatory (RHO), with a focus on its role in addressing race inequality across the NHS.  

Dr Guddi Singh is joined by RHO chief executive, Professor Habib Naqvi MBE, and Director of Implementation, Dr Nandi Simpson, for a discussion about how evidence is translated into practical recommendations, the challenges of implementation within complex systems, and how the RHO supports NHS organisations to turn insight into impact.  

The conversation highlights what it takes to move from research to change and the role of system leadership, accountability and collaboration in making workforce equity a reality. 

Transcript

SPEAKER_01 0:00

Hello and welcome to Race and Health Matters, a podcast produced by the NHS Race and Health Observatory. I'm your host, Dr. Goody Singh. In today's episode, we discuss how evidence is translated into practical recommendations, the challenges of implementation within complex systems, and how the Race and Health Observatory supports NHS organizations to turn insight into impact. Well, hello, and uh thank you for joining me on Race and Health Matters. Um, I am joined today by the wonderful Professor Haeb Nakvi, who is the Chief Executive of the NHS Health and uh Race and Health Observatory, and of course Dr. Nandi Simpson, who is the director of the implementation of uh the observatory. Now, today's episode is about the work of what you guys do at the NHS Race and Health Observatory, but it's really about that bigger question of how do we move from evidence on race and health equity to institutional change? Because I think we all share the same experience of the recurring frustration of seeing recommendation after recommendation, report after report, and sometimes even toolkits and standards even being set, but little change on the ground. And what I would love for us to discuss is that process of going from evidence to implementation to change on the ground. And so I wanted to start with um actually just a bit of scene setting for for the listener, and maybe Habib, you could help me with this, which is can you tell us what the NHS Race and Health Observatory is? We know it by name. Help us to understand what it's there for.

SPEAKER_00 1:33

Sure. So the idea of an observatory was around longer than before it was established, but it wasn't until a special edition of the British Medical Journal, the BMJ, uh called Racism in Medicine, which came out, I think, in 2020, uh, that a very concrete idea of an observatory was outlined. An observatory or an organization, a body that would hold up a mirror to the rest of the system with regards to the inequalities that we see play out in terms of race and ethnicity. But not just an observatory, so not an organization that would just observe, but would actually act and implement and support the implementation of very clear recommendations for change, for improving access for patients going into healthcare, their experience and their outcomes, but also looking at the workforce within the NHS as well. So the observatory is here not just to outline the scale of the challenges that we have with regards to inequalities, but to provide solutions to those uh to those challenges.

SPEAKER_01 2:42

And was that the gap that you think that the observatory was trying to fill? Is that what was missing in the system?

SPEAKER_00 2:48

Absolutely. I mean, historically, if you think about it, our collective efforts to tackle inequalities in health have focused largely upon socioeconomic differences between populations. Um and we always say deprivation and socioeconomic differences tells you where the inequality exists geographically, but not why it exists. So trying to get into try to get under the skin of uh exactly why those inequalities exist and the root cause of those inequalities is critically important. Otherwise, we focus on surface-level solutions to deep-seated challenges, and historically that's been the case. So if we want to shift the dial of inequality in a sustainable long-term way, then we need to look at some of those causes of the causes, and that's one one of the reasons why the observatory was set up.

SPEAKER_01 3:48

Yeah, and I think one of the from my perspective as a on-the-ground clinician, but also someone who does public health research, one of my frustrations has been that public health so often seems to be descriptive, and it seems to be that's where it stops. It it almost enjoys the fact that there can be epidemiology paper after epidemiology paper to give you that graph, which shows that there's people who are doing worse on the bottom and people who are doing well on the top, and then that that's it. And that just seems like, well, we know that story now. And Nandi, I want to move on to you and ask you from your perspective, what does it mean then to build implementation in that kind of space where that's the norm?

SPEAKER_04 4:22

Yeah, I mean it's it's a really big challenge, isn't it? And I guess that perhaps part of the reason why we often stop at description is because there are huge barriers to implementation. Um and when we think about what those look like, we can describe those in many ways. One of them, one of the key things that we come up against is um the external environment. So obviously we're living uh in a time now when there's open promotion of racist ideologies. This acts against implementation, you know, but there needs to be some kind of enabling, and this this acts against that. There's resistance to change, you know, this system is overloaded with demands. Diversity work is often seen as a nice to have. Um, although, in fact, you know, we know that uh unoriented variation variation is a is a patient safety issue. We were in an event a couple of weeks ago where Lord Victor was saying if your leadership isn't producing equitable outcomes for the people you serve and employ, then you're not leading. So, you know, it's like there's a there's a there's a kind of disconnect between embedding anti-racism in the way that everything is done and seeing it as something that can be separate. So uh these are the kind of challenges, you know, that the the systemic nature of uh racism means that there are those kind of barriers to implementation that exist. So that's um uh essentially what we're here to overcome. We work as an in a kind of uh we work as a knowledge mobilisation organisation. So we say we collate and take evidence and we ensure that that's taken to the places where it can have the most impact. And that's uh I mean, I think the uh to me when I joined the the observatory, one of the things that was really exciting was this real focus on okay, uh identifying and using the levers of change. So that's something that is done not only in the policy sphere, but also in practice, and then also thinking about the wider um system around the NHS, so thinking about regulators, thinking about um educators, thinking about um um learned bodies and so on, you know, actually looking at all of the levers that sit around the system and that's and understanding how we actually um action those levers to Yeah, and I think what you're speaking to is the fact that we have to take a systems approach to this, right?

SPEAKER_01 6:34

There is no single body or organization, definitely no single human being who's gonna you know sort this problem out. And what you've very like cleverly done with the way the way that you work is you mentioned that beautiful word, no knowledge mobilization, that it requires a vehicle, right, for this evidence to be translated into action on the ground. One of the things that strikes me, even in hearing you talk, is that it's it's almost as though like there's never been a shortage of concern about this issue. I think feel like people have espoused concern about inequality in some shape or form, and especially around the pandemic, for a while. But what is clear is that concern on its own is insufficient, right? You can't just be worried about this. There has to be that extra step. So, would it be fair to say that maybe part of what the observatory is here to do is just to make it harder for us to ignore the problem? Is that kind of why you exist?

SPEAKER_00 7:25

I would say so, absolutely. Um the the knowledge we gather, the uh the evidence we produce, and the way we translate that then into the resources for the system. Those resources are resources, whether they're infographics or is it it's um it's um a you know a table with data or a bar chart. But those those those resources are also excuse removers. So you know once uh once the evidence is clear uh and where once the solutions are known, what rem what the the question that remains isn't if we want to act, it's but it's if we choose to act. And and that's the that's some of the underlying challenge that we that we have. Um but I I guess historically the data hasn't always been clear. Um and I gave the example of socioeconomic differences as being kind of the the prime focus historically, and of course that's right, and that's important as well. But we do really need to understand why those inequalities exist in the first place. So you mentioned the pandemic. The pandemic is a classic example, I believe, of that. Um throughout the pandemic, we saw very clearly and very vividly how it was having an uh uh disproportionate impact upon ethnic minority communities and staff working in the NHS, and we were given a uh a list of uh reasons for why that was the case. More likely to work on the front line, um more likely to live in uh high-rise uh flats, uh less likely to live in open space, green areas, etc. etc. And the list goes on. But we were not told why that's the case in the first place. Why is it that ethnic minorities are less likely to live in open space, green space areas? Yes. Why is it that they're more likely to work on the front line, less likely to be seen within the boardroom, for example? So it's it's about understanding those root causes. And again, I I think you made a very important point uh earlier on. The NHS has a role to play in terms of equity, but it cannot be the only enabler for equity. And when it comes to tackling inequalities, when it comes to those inequalities themselves, racial inequalities and bias, they're systemic, uh, they're system-wide, and they require a systemic and system-wide response. And that includes the other agencies and other bodies that we have, uh, not just within healthcare, but beyond healthcare.

SPEAKER_01 9:56

Totally. I'm struck again, but when we think about the system, of course, we also mean everyday citizens, right? And the conversation you mentioned is Nandi. Like, we're in a climate right now where it seems to be okay to be hurling racial abuse at people in a way that, like, even just 10-15 years ago would have been unheard of in this country, right? The pandemic was an interesting time for me personally. So I helped to co-write and present a television programme with David Harewood at the time, which is about why is it COVID killing people of colour. And that was the first time on the BBC we were literally calling out racism in this country in a very kind of like to millions of people kind of way. And I think the pandemic opened that up, but it kind of feels like to me that that opportunity has kind of almost closed. We had this opportunity to talk about this quite openly, and now it's kind of like back not to business as usual, but back to how the empire kind of runs, which you know, there's a whole other conversation around that. But one of the deep things about um the work that you do is this idea for me, which is that evidence does not implement itself, right? So we needed the enabling conditions, whether it's what people are thinking out on the street or whether it's what's happening in the boardroom and at the highest levels of government. And so my question to you now, Nandi, actually is why do you you think that some recommendations and some evidence fail to translate into action? Like, what is it? Maybe you can help pinpoint like what where are the places where this is failing to make that uh bridge?

SPEAKER_04 11:18

Yeah, um, so I suppose, and and the point you've been making, Goodyear, about you know, it being a system is um is is really critical here. So, you know, racism is a system and it's operating in a complex system, which is RNHS. So what we really need to do to understand why, you know, why recommendations might fail to land or why they might fail to make an impact is to understand the contextual factors that enable change to happen. And this can be on a you know on a micro level in a service, it can be on a on a bigger level, it can be on a you know on a meso level in a kind of an organization or even in a macro level at a regional level or something like that. So what one of the things that we're really interested in in the in the observatory, and one of the things that I think we do really quite well is to interrogate those contextual factors by bringing in an approach or by using an approach through our work which involves not only experts by education but also experts by experience, be those patients or service users or members of the workforce, particularly from minoritised groups. So this kind of understanding of the contextual environment and you know, flushing out through that a deeper understanding of barriers and facilitators to the implementation of change is really critical and it's central to everything that we do.

SPEAKER_01 12:37

I'm glad that you brought that up because I think still, actually, so often in the NHS, we confuse certain kinds of knowledge as the truth. So obviously, quantitative evidence in general still gets privileged. And even within that, the randomized control trial is seen to be the gold standard for all kinds of evidence. And of course, I have yet to see the randomized control trial on racism, right? So there is like, you know, we're missing, if we're gonna go with that as our like gold standard of evidence, there's obviously gonna be a problem. And I wondered if, from your perspective, Habib, working in this space, public health, now thinking about implementation, do you find that that's one of the places where things stall? Is there still a kind of a block in terms of the way that we think about knowledge? Um, or is it is it more complicated than that? Is it more further down the line? And it's not just what we think of, it's like what counts as knowledge.

SPEAKER_00 13:22

I think it is more complicated than that, but but but but you're right at the same time, in the NHS, what we know is what you know, what gets measured gets done. Um, and there is that culture within the NHS with regards to looking at data, looking at uh uh quantitative um data and analyses. But of course, behind every number is a person uh and understanding trends by speaking with people and the qualitative evidence is even more rich in terms of providing us with ideas for solutions. But it can't just be people sat in a room that um listened back to uh uh qualitative um uh discourse or look at data. Those solutions need to be co-produced and co-designed, and I guess historically that's been one of the challenges that the NHS has had in that they have the the NHS hasn't really focused in a sustainable way and in a meaningful way around co-production.

SPEAKER_01 14:26

I mean again, I it kind of comes you you're right to kind of um pull me up a little bit on that, which is right. I think I think the evidence is not that it's weak as such. It's not that there's I think people are looking at all the evidence and of different types, but I think there is a sense in which it feels like maybe the way that we respond to certain types of evidence is different. And I think I think there's still a reluctance to to take some of that what you are actually treating as rich, valid data in that noise.

SPEAKER_00 14:51

I think there's something else as well. I think um very often when we go and we speak with uh people in in the NHS and leaders within the NHS, they often do say, we know there's an issue, we know there's a challenge, we know there are inequalities, but we don't know what to do.

SPEAKER_03 15:06

Okay.

SPEAKER_00 15:06

Uh and and therefore providing the NHS with evidence-based interventions and solutions is critically important. But those solutions and those interventions need to be based upon uh the data that looks at the causes of the causes of those inequalities, as opposed because otherwise we go back into this kind of uh the cycle of having surface-level solutions for deep-seated challenges.

SPEAKER_01 15:40

So let's stick with that idea then of like what are we going to do about it? Because that's ultimately what this is all about, right? And um, Nandi, um, when people hear the word implementation, certainly, as I say, an ordinary clinician like me, what I think of is like dashboards and I think of like a delivery plan and some kind of thing, like you know, the those trackers that people in boards must look at when it's like red or green or whatever. Um, but what does implementation actually involve um when we're thinking about a complex system like the NHS?

SPEAKER_04 16:06

I mean, there and you know, there are formal definitions of implementation. There is a science of implementation, implementation science, but actually, you know, all of us every day are implementing things all the time, aren't we? It's you know, finding appropriate ways to do things. And I think that one of the things that we've done in the observatory is we've developed an implementation toolkit, and this is specifically to support organisations that we commission to do research to develop recommendations that are implementable, so to develop recommendations in a way that makes them more likely to be put into practice. And there are, you know, we've based this toolkit on implementation science principles, so you know, the evidence is really important, and I think, you know, to come back to your point, so I I understand, I understand what Habib is saying, I understand what you're both saying, obviously. But um, but actually, I think there's a really important point there about evidence and and the high the hierarchy of evidence. I mean, it's like, you know, we people, for example, hide behind the data, is the data aren't good enough, but we have lots of qualitative evidence and that's not so often foregrounded. So I mean it's like you know, you can think about you know, multiple reports where people talk about their experiences, but but are still yet still ask for more information about their experiences. So I guess there's that evidence kind of as the as the baseline. Then um something about identifying the context, so thinking about what type of what type of intervention is required and also what level it's going to sit out. I mean, thinking about how to actually leverage something, you know, an approach that you might take in a in a service might be different from an approach you take at organizational system level, but also thinking about, and this is important for us as an organization that kind of has a bit of oversight of, you know, a bit of a bird's eye view of some of the things that are going on. What we're also able to do is identify common issues and think about how those are escalated. So I'm thinking about, for example, we've done some work with maternity and neonatal services, and some of the barriers, some of the const consistent barriers that organizations have found, you need a common solution. So what we've been in a great position to do is the observatory is to commission research and to commission work that actually addresses those issues, as well as escalating into policy-making spaces, so that we're actually being in some ways a conduit between the frontline and the policy-making and decision-making spaces, so that we can we can um pass that information in both directions too.

SPEAKER_01 18:34

I mean, yeah, I think you've beautifully described how you genuinely are an observatory, right? That you are able to observe uh almost from like this elevated eagle's view of what's going on. But more than that, not just see it, then respond to it and try and connect up where people need to be connected. Um, but just to stay on what you were talking there about, you know, this idea of like trying to provide uh toolkits um for implementation, what have you learned in this work about what actually needs to be in place for recommendations to become action? Have you got any kind of principles or values or conditions that you can say, actually, this is the this is kind of what needs to be there if we're gonna make any change happen?

SPEAKER_04 19:13

Yeah, so I think this comes back to our RHO anti-racism principles. So, in was it November of 24, we published seven um principles of anti-racism. Could you just go through them? So there are seven of them. What I'm gonna do is I'm gonna outline in particular the first one, okay, because this is like really, really kind of everything else hinges on this. So the first principle is demonstrate accountability and leadership by naming racism.

SPEAKER_01 19:37

Yes.

SPEAKER_04 19:38

And when we say naming racism, you know, obviously we can it's actually not as easy as you think. When you're in a when you're in a pressured work environment, if you've if you are a minoritised person or if you feel that you're in a minority and wanting to exp wanting to actually name racism, it's not always easy. So that's really critical. Anyone who's heard me speak before knows that I'm a massive fangirl of Professor Kamara Jones.

SPEAKER_03 20:00

Yes.

SPEAKER_04 20:00

Um and so Kamara Jones has got an incredible way that she describes naming racism, which I think is really helpful in this context. So she describes it as three distinct actions. So the first of these is acknowledge racism exists. And that's important actually, because in many spaces there might be an acknowledgement that racism exists, but not an acknowledgement that it has any influence on what's happening in a clinical space. Second one is commit to um understanding how uh racism is operating here, and this comes back to subsequent anti-racism principles, for example, data, community insights, bringing those things in to break to bear on really understanding how the racism is in operation. And then the third point is um organise and strategize to address it. And I guess what this reflects here as well is what we've been doing in the observatory is underneath each of these anti-racism principles, we've been developing tools and resources to support organisations, to support individuals, to do that organizing and strategizing around addressing racism.

SPEAKER_01 20:59

Brilliant, that was a fantastic answer. And you're right to bring up actually Kamara Jones because um there's something that I take from her work, which is this idea that um institutions can actually produce these patterned inequalities without even being explicitly racist, right? And that's something that we obviously understand, right? There's so many people who are genuinely good people and yet somehow still manage to reproduce these inequalities, and and it obviously comes out through systems. And it feels like what you're doing as an observatory is actually just to make that um make that visible, make what is systematic actually visible, so that we actually see it as this thing, that pattern that recurs across the whole um NHS. And Habib, I wanted to ask you, you know, we just had that beautiful description of um some of the things that need to be in place really for us to take any action at all. But apart from the reports, which are obviously excellent that the observatory produced, can you tell us a little bit more about how you might support an organization with that implementation process? What else can we look to the observatory for?

SPEAKER_00 21:56

Sure, yeah. So if I give you an example, in fact, of the very first. Of work we did, which kind of really exemplifies um and describes what Nandy has been talking about. So during the pandemic, so the observatory was established just before the pandemic. It was almost like building a plane in flight. So we were building the observatory. And I still remember this. It was at the BMA House where we launched the British Medical Journal Special Edition. And two weeks later we went into the pandemic. And that highlighted for us really the foresight, I guess, that Lord Stevens had in establishing a body that would be semi-independent and would be able to hold up a mirror to the rest of the system. And that's what we began to do during the early stages of the pandemic, not just in relation to the vaccine and vaccine hesitancy and everything else that came along with that, but also to highlight some other key issues that we thought were really important to flag up to the system. And that included the very first piece of work we did, which was to look at racial bias and pulse axymetry. So the little devices you put on the end of your fingers to test the level of oxygen in your body, which obviously was important during a pandemic that was affecting the level of oxygen that people had in their bodies. But the the evidence, particularly from the US, was striking that the darker the colour of your skin, the less likely the infrared light is to penetrate your skin. And we thought it was a very important point in time, but also a very critical issue during a pandemic to highlight this racial bias. So we did what we've been doing since then over the last five years. We brought together the evidence base. We turned that evidence into policy recommendations for change. And those recommendations weren't a very long list. In fact, I think there were only four or five clear recommendations pinpointing the organizations that we wanted to make the changes. And then thirdly, the implementation bit, we supported those organizations to make those changes and to implement those changes on the ground. Whether it was the NIHR, which is a research body, putting out further calls for evidence, particularly from the UK on this particular issue, or it was NHS England updating the guidance around pulse axymetry on the NHS Choices website. And in fact, our work led to the Secretary of State for Health and Social Care of the time, Sajijavid, announcing and initiating an independent review of medical devices and racial bias in medical devices more generally. So it goes back to the first principle of anti-racism that Nandi highlighted, which is about acknowledging that racism exists. Because if we want to change anything in life, to change it, we need to acknowledge that there's something to change. And in fact, that piece of work and our initial work at the observatory did make the front pages of the newspapers, not because we were doing this work, because you know these kinds of rapid reviews have happened before, and I'm sure there will be more in the future. But for the first time, uh we were beginning to associate the term racism and racial bias alongside our beloved NHS. Yes, yes. And looking at, and in fact, racial bias impulsive exemetery is just one example of probably a very long list of uh biases that do exist, whether it's in uh clinical assessments, whether it's in medical devices, like I've highlighted, or it's in medications themselves. And in fact, we've looked at all three areas uh in terms of the work that we've been doing over the last five years.

SPEAKER_01 26:06

I also do um an interdisciplinary um PhD in philosophy, and so I'm really interested in philosophy. And there's a philosopher called Joan Tronto who's a care ethics philosopher, but she talks about responsibility and this question of who is seeing, who is responding, and who is staying with the work once the initial momentum fades. And it's a question I feel for us in the NHS, right? Because sometimes it is a bit trendy, isn't it? Something comes out, there's a report, there's some kind of fanfare over something, and it's really easy to jump on that bandwagon and then for everyone to fade into the background because you need to see, respond, and stay with that work. And I guess my question to you guys is um, how do you see the role of the observatory in helping that process of seeing, stay, um, what is it again? Yeah, seeing, responding and staying with the work.

SPEAKER_04 26:51

Yeah, that's a really great question. And um, I guess if I can just use the example of the um learning in action network that we um we established with the Institute for Healthcare Improvement, um, and that's was focused on um maternal and neonatal health. And one of the things that we did through that programme was we uh co-developed with um with 10 teams across eight integrated care systems in four regions in this country um a quality improvement methodology that integrates our anti-racism principles.

SPEAKER_01 27:21

Interesting.

SPEAKER_04 27:22

And the purpose of this was not only to test in uh test approaches and interventions um to improve health outcomes for for um women and families and babies from black, Asian and ethnic minority backgrounds, but also to establish a methodology um that does exactly that, that enables, you know, quality improvement is an established methodology. The idea of it is that um local tests of change can lead to sustained changes within within um services and systems. And so by integrating those anti-racism principles, what we did was we provided a tool which enables organisations to do this. And the the you know, the the MFA MFI AR, we call them model for improvement anti-racism, is um you know, it's service agnostic. We we we tested it in perinatal services, actually, it's applicable more widely. And by integrating those principles, what we've done is we've provided a mechanism whereby there can be a retention of that focus on anti-racism through a methodology that people use anyway.

SPEAKER_01 28:27

Yeah, and I think again it kind of comes back to philosophy, right? You've woven it into the architecture of that work so that it becomes hopefully business as usual, and it is just hopefully for the next generation of clinicians and um managers, this is just how they do the work, and it's not something that you have to kind of parachute in, which is so often what happens that it's something that feels like it's an add-on as opposed to part and parcel of the work.

SPEAKER_00 28:50

But there's something else as well. I think um so we've you know we have the interventions and um we have the evidence um based um resources, but it's about how do we hardwire that then within the system. Yes. And going back to your point, it is around philosophy, but it's also the it's also the moral um impetus to do something. Yes. So during the pandemic, we had lots of commitments and pledges that actually we're seeing inequalities in health by race, and we're we're now as a healthcare system and almost as a country, as a society, acknowledging that racism exists at that time. Um but now we're out of the pandemic. Yes. It's about how do we hold those people, those leaders, uh, those organizations to account to actually you committed, you pledged to tackle racism and racial bias in healthcare, to improve access to experience and outcomes. Where are we now? So this it cannot be a flavor of the month. It needs to be sustained because you know it's not um, it's not numbers, it's you know, it's not a game. This is about people's lives. 100%. And it's about how do we improve uh uh people's lives, um, not just for the here and the now, but for future generations.

SPEAKER_01 30:08

I mean, that's a brilliant point and a really important point because you're talking about there holding those in power to account. And if to to the extent that you're able to answer this question, what role can the observatory play in in doing that? Not that you necessarily need to be the one holding people to account, but maybe you could help support those who want to do that.

SPEAKER_00 30:26

Well, it I mean, that it makes me think of a point that um Lord Stevens mentioned to me as we were establishing the observatory. Uh, he said, um, do not get caught up in wokism.

SPEAKER_01 30:37

Yes, okay, yes.

SPEAKER_00 30:38

Uh focus on what the evidence tells us. And that's what we've been doing right from the outset. Uh we're not saying, oh, this is a nice thing to do because it will make things better, but actually, here's the data. This is what the evidence is telling us, this is what we can do. And it won't just benefit certain communities or people, it will benefit everyone. Um, so our role is to hold up that mirror, is to present the evidence, the objective evidence, uh, and then the evidence-based solutions to those challenges.

SPEAKER_01 31:08

So let's imagine that somewhere in the NHS, somebody's actually doing this really well. Um, what are the signs for you guys that implementation is actually going well? That something has landed and a trust or a system has responded and is doing more than just kind of, you know, the rhetorical lip service. What would good look like to you, Nandy? Yeah.

SPEAKER_04 31:31

That's that's actually a giant question. But um, I'm just thinking about a conversation that I've come from this morning um through a program that we are delivering for NHS England. Um, so this is a perinatal equity and anti-discrimination program. And we had a meeting with it it will be in all of the um prinatal services in in England, and we had a uh a meeting with um one of the teams involved, and they're they're really advanced in their race equity work. And what it looks like is messy. Oh, yeah. Because they're actively testing things, they're challenging themselves. They've achieved some really good things, they've got some fantastic data that demonstrate that they've made progress, but they're still challenging themselves. And so the kind of conversations that we had this morning were about how do we do more, how do we do better. And in the case of this organization in particular, one of the main things they were thinking about was integrating, um, not just integrating community insights, but integrating communities into into accountability spaces. So, how are how are organizations held to account by community partners? So that was one of the things that they were thinking about. And I think this is a really exciting idea in relation to, you know, as the as the health services goes, service goes through these transitions that we're going through right now. This is really critical because it's only through the engagement and the input of communities that we're actually going to make the changes that we need to make.

SPEAKER_01 33:04

I love what you described there about it being messy, because I think we all intuitively know, whether you're um high up in the system or if you're down on the ground, that real life and health is messy. Um, but it does require a bit of humility, doesn't it? And that that organization to be able to say it's going to feel uncomfortable. This is going to feel terrible, probably, if you're in the middle of it and you're trying to manage it. If you're a brave, courageous leader, then you're able to say that, like, actually, this is what change requires. And almost, it almost sounded like what you were saying. They were almost willing to redesign themselves, like redesign the service itself, what they do, what their roles are, which I think is a very challenging thing, because it's confronting history, power, privilege, all of those things, right?

SPEAKER_04 33:45

Absolutely. And it's and it's so necessary. In the observatory, we show this slide which was developed, I don't know, five years ago, which shows ethnic inequalities in health across a huge range of conditions. And what that slide actually says is that we are systematically providing unsafe care for some populations. Right. And we're not necessarily doing that because of malintent by individuals, but we're doing that because the systems and the processes that are in place are actually racist.

SPEAKER_03 34:16

Yes.

SPEAKER_04 34:16

Um, and they're racist, you know, by omission because they don't take into account the diversity of the populations that they're serving and so on. And so it's really necessary that we do that interrogation and the organizations do that kind of reflection on the processes, on the systems, on their policies. You know, that's how does how does racism become embedded? How does structural racism become embedded in organisations? It's through policies, it's through decision-making processes and so on. And so it's really critical that organizations do actually do that reflection.

SPEAKER_01 34:48

I mean, it's that whole thing, isn't it? Um, I don't know if it was Demings, but that system thinking about you know, every system is designed to get the results that it gets. I mean, yeah, you're right, we're kind of trapped, aren't we? And unless you're willing to do that, unpicking, let's start again almost, yeah, you're you're always just going to repeat um history.

SPEAKER_00 35:03

So that's I and in fact, though those are some of the things that we are beginning to do within the observatories to work with organizations um such as those organizations that um that produce clinical guidelines, for example, um, and not just to de-bias current clinical guidelines, uh, whether it's for maternal health, sickle cell uh disease, or it's for uh cardiovascular disease or diabetes, etc. But also to work with that organization, which is a national body, to build in processes so that the development of any new guidelines going forward do not have those biases built in. Brilliant. And it goes back to Nandy's point, which is that actually these clinical guidelines, whether it was 20 years ago, 30 years ago, I mean the APGAR score as a clinical guidelines is one classical example that came out in 1952. Yeah, judging the health of a baby partly based upon the colour of his skin wasn't right um in 1952 and certainly not right today in 2026. But things have moved on since 1952, and so we need to work with those organizations, those uh those uh oversight bodies to make sure that this doesn't happen going forward and that we look at the the present um as well, but also with regards to research, so looking at representation in clinical research, in medical research, so that the development of medications or clinical guidelines um or medical devices such as the app um such as the pulseymetry uh, for example, you know, we have that representation so that the devices and the outputs are fit for purpose and you know help meet the needs of all of our communities and not just some of our uh communities. So it's really important that we go further upstream to tackle and to kind of de-bias some of those uh long-standing challenges.

SPEAKER_01 36:52

Yeah, right from the ground up, exactly. We talked about the kinds of signs of when implementation might be going well, but we obviously know that in reality there's going to be lots of barriers to implementation. And I wanted to talk about that and this and maybe from your experience because you're in that observatory positioning where you can see things from high up. What have you seen are some of the common barriers or obstacles for for trusts or organizations to implementation? I'm asking both of you, Habib, maybe you could start.

SPEAKER_00 37:19

Well, I think you used the word in your question, trust. I think it's but not in the sense of an organized NHS uh trust, but trust and confidence that uh the patients and communities have um with regards to uh the NHS and with regards to healthcare services and interventions. And this is historical. Um, we saw it play out so vividly during the pandemic with regards to uh the vaccine. Um, but it's not just in relation to the vaccine, it's in relation to any kind of uh medical intervention. Uh but building levels of trust and confidence is critically important. I'm hoping the work we're doing around debiasing clinical guidelines and medical devices and medications will help to build levels of trust and confidence. But that trust will also come with the co-production and co-design of services so that actually those services and those interventions are fit for purpose, and we will know that they are fit for purpose because they will be co-designed for the people that we're here to serve. Um, and we define trust as truth told consistently over time, so it's a bit like an algorithm. So if there's a breakdown in any part of that algorithm, the truth, the consistency in time, and there's a breakdown in levels of trust. So it's about, you know, it goes back to my point around the pledges and commitments we heard during the pandemic. Those need to be followed through. Yeah. Otherwise, there'd be a breakdown in levels of trust and confidence.

SPEAKER_01 38:48

That's a profound thing that you brought up, brought up there, right? The trust in institutions, which I think in the UK and probably around the world right now is at an all-time low. I don't think there is a single institution on the planet that actually has maintained the trust that it used to have. Um, but of course, people still love the NHS. Um, and so Nandi, I'm turning to you with a similar question about you know obstacles, barriers, but actually a slightly different spin, which is actually what forms of resistance are you seeing as the most common when you're trying to get this work underway? Where are you seeing resistance? And what what does it look like?

SPEAKER_04 39:23

I think one of the key things that we see is that you know, you're talking about a kind of creaking system, right? And everybody, you know, everyone's under strain and pressure. There's not really quite enough resource for anything. And so, you know, in some instances diversity inclusion work is seen as nice to have, not as integral to what's happening. So there's a so there's um resistance around resource allocation for this work.

SPEAKER_01 39:57

Yes, as if it's a luxury.

SPEAKER_04 39:58

For example, as if it's a luxury. But of course we know that you know outcomes are improved for everybody when you address the issues that affect the people who are the who the worst um who have who've got the worst health outcomes. So I think that that that point about resource and resource allocation, and I mean one of the pieces of work that we're doing in the observatory is we have a programme of work around the cost of racism, and this is really to provide some tools to support advocacy, to support an understanding of you know how actually it is economically advantageous or can be economically advantageous to address these inequal inequities and inequalities.

SPEAKER_01 40:37

Yeah. Do you have a cost of racism worked out? So we don't have it yet.

SPEAKER_04 40:41

I mean, one of one of the pieces of work um our fantastic uh lead for um policy and strategies leading on a uh development of a piece of work which is will produce the aim is to produce a kind of headline figure, exactly that you know, you know, you know, you know the kind of figures that we have. Yeah, yeah. That are actually really powerful um levers for for change in policy and decision making and so on. Underneath that, we're also doing some more work to develop um frameworks that you know services, systems can use to actually do calculations on a on a local level to understand. That sounds perfectly cost-like.

SPEAKER_01 41:14

That's powerful because often you have people maybe at a lower level in systems who want to make the case for some of this stuff and they don't have those stats, obviously, or those figures to hand. But we've seen it in other realms, right? Whether it's uh you know in the uh humanitarian or development world where Oxfam is able to tell you, like, you know, this is how many millionaires are they able to uh you know has more money than this many countries or whatever. That's like a really powerful statistic, um, which just helps to move kind of action in the right way.

SPEAKER_00 41:41

I think it's uh I think it's a really important point as well, because the cost of inaction goes into its billions for the NHS. Yes. Um, but the point around the different cases for this, I mean, you've obviously got the moral case, it's the right thing to do. You've got the legal case, we've got the Equality Act and the health inequalities duties, then you've got the the patient case as well, patient safety, etc., which is critically important, is probably right at the top. Um, but the financial case, because some people, if you think about a boardroom in the NHS, um this so I always say this uh subject matter is important for everyone, not just your nominated uh non-executive director who has uh a role to play with regards to uh equity. Um not just the chair or the chief exec, and leadership is so important in this, of course, but also the chief nurse for the obvious reasons, the the medical director and the finance director as well, because the challenges that the NHS has today, whether it's waiting times, whether it's um shortage of staff, uh etc., those challenges are not distinct to this subject matter. You get this subject matter right, it will have a profound positive impact on those challenges. So sometimes people see those as being separate, but they're not actually, they're intertwined.

SPEAKER_01 43:09

It feels like the same kinds of difficulties that I guess anyone who's doing any kind of public health work struggles with, which is that, you know, you you beautifully described the different cases for taking action. And yet it feels like so often with public health arguments, because it's not immediate often, the the benefits, it's it's hard sometimes to kind of get into people's psyches and to get them to be motivated for it. But I think there is something about being systematic in your approach to tackling it, doing it in a very kind of organized way, and providing the providing tools for anyone to be able to take take that up themselves. So there's not just it's not your in fact, it's not the observatory's job to make the case on its own, right? You don't see that as your your solely your job, right?

SPEAKER_00 43:48

No, but I mean your point is absolutely right as well, because it uh uh these changes that we want to see will not happen overnight. And sometimes organizations and people want these changes to happen overnight. The government may want these things to happen overnight because of their electoral cycle. Right. Um, but I always I always say uh think Mofara, not Usain Bolt on this agenda because it is a marathon and not a sprint. There are some things that you can get right and you can put into place, particularly around workforce uh inequalities. You can have you know one extra person from an ethnic minority background on your board that will shift the representation of the leadership within the organization. But to change how it feels to work in an organization uh from a staff perspective, workforce perspective, that takes time. You cannot shift culture overnight.

SPEAKER_01 44:40

Yeah, I'm really aware that you you know you've been producing excellent tools, and we've also obviously had like um race equity kind of statistics for a while as well, actually now, uh, and those metrics. But I guess my fear is that sometimes you produce all this beautiful work, but kind of the tools are not used, or they kind of like fall by the wayside. And and I guess my question to you would be is what what could we be doing? Or what you know, what what do you see as the way of making sure that organizations use these tools, like they actually use day in, day out? And what could we be doing on the ground maybe to encourage that upwards?

SPEAKER_04 45:12

Yeah. Well, in developing the tools, one of the things that we're one of the things that we're doing is we're working with a wide range of individuals to um to get their input so that they, you know, they feel valid to a wide range of users and end users. Um the other thing that we're doing is we're not we're trying where we can not to invent new tools but to adapt tools that exist. So we're not like saying, okay, now here's a completely new way, we've got to work. It's more about, okay, here's here's a here's an approach that you use normally, here's how we've tweaked it, and this is going to support you. Um I think importantly, and we are we've got a fantastic head of implementation, and she's leading on a development of anti-racism evaluation framework. And I think this speaks also to the point about you know the the time frame that is required to see outcomes, um, and really something about understanding progress. People are motivated by making progress, aren't they? Yes. So understanding progress along the way, but not only understanding progress, but really understanding what, again, coming back to those contextual factors, what are the enablers? How is it that change is made? How is it that we embed anti and implement anti-racism? And so providing that kind of feedback as an adjunct to the tools and resources so that people can actually, you know, have the motivation from seeing progress, which may be incremental in some ways, but actually having an approach that means that they can see that that progress is being made.

SPEAKER_00 46:38

And just on that, um we obviously want organisations and people to focus on these interventions because they want to and not because they have to. Yes. Um, but there is an important role for regulators, the oversight bodies, whether it's the Care Quality Commission or some of the other regulatory bodies. And one thing that we've done over the last um few months is to bring together all of the health and social care regulatory bodies, and they've signed up to our principles of anti-racism, which was in fact announced just this week. If there's one thing that keeps a chief exec of a hospital trust awake at night, is their uh regulatory grating. Um, and so if we can build this in in a way to achieve the balance between supporting and encouraging, educating people and organizations to do this for the right reasons, but also regulating that actually does happen. Because if you if you regulate for, for example, in in a healthcare setting, you regulate for hand washing, uh, which obviously has an impact upon safety, etc. Then why wouldn't you do that for tackling racism? Yes, which impacts people, which leads to adverse outcomes and in some cases death. Yes. So it's really important that we kind of begin to understand the importance of this agenda and look at the various policy levers that we have in place that we can focus on in order to begin to get that movement going. And of course, regulation and accountability is is an important one.

SPEAKER_01 48:13

So we're gonna have to wrap up now, but um the thought that I want us to kind of finish on is this one that Sir Michael Marmot and many, many others have been making for many, many years, which is that inequalities are not natural. And so they are indeed socially produced by the systems that we ourselves are complicit in. And so you have the ear now, let's imagine, of every important NHS leader listening to you right now. For both of you, what would you be telling them so that they can understand that they actually have a role to play in this? That inequalities are in fact not natural and they can help changing in in changing that reality for people. What would you be telling them that they could do tomorrow that might be different uh from implementing their stuff?

SPEAKER_00 48:56

Yeah, these inequalities are uh immoral, unjust, and they're wrong. They're wrong because they're avoidable. Um but what's avoidable is not inevitable. So it's about encouraging organizations and leaders to think about their role uh in this. Um I think to a line in one of the Lord of the Rings books, uh, which is um uh all we have to do is decide, sorry, all we have to decide is what to do with the time given to us. Um, and those organizations, those leaders that we have in place, if they use their time well by tackling these inequalities, they will not just be uh improving lives, they'll be saving lives uh for this generation and future generations. So investment in this agenda and in organizations that do hold up a mirror to the rest of the system uh is it really is an investment um in humanity.

SPEAKER_01 49:55

That's so inspiring. Have you got a Frodo Baggins type line to be telling people that? How can I possibly think of that?

SPEAKER_04 50:00

I should I should have jumped in straight away, shouldn't I? Um the only thing I would say is um, in addition to that, is that we live in a really data-rich time.

SPEAKER_01 50:11

Yes.

SPEAKER_04 50:11

We've got lots of, you know, we have so much data. There are arguments about, you know, the quality of ethnicity data and so on, but there there are no excuses for not knowing what's going on. Because as you said at the top of this podcast, you know, quantitative data are one thing, but if you don't have the quantitative data, people exist, you can talk to them, yeah, and you can find out what people, you know, people will share their insights and you can get the qualitative information. So where there are data gaps, talk to people, find out what the issue is. And then, you know, as Habib has said, we have a responsibility to act once we know what the issues are.

SPEAKER_01 50:50

Yeah, yeah, it comes back to listening and to being willing to have the courage to make those changes. And can I just thank you both for the incredible work that your observatory is doing and for providing these tools to people to use? And thank you for your wonderful chat today. It's been really, really great. Thank you so much. Thank you. Thank you.