Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Good evening everyone and welcome to this learn with nurses in conversation session. I'm Joanne Ha, I'm the clinical director of Learn with nurses and I'm joined this evening by the wonderful doctor Farzana Hussein. And we're going to be having a chat about health inequalities. Now, you can probably see my dog just jumping down off the chair behind me. I'm at home as, as probably you are too. So apologies in advance for any noises or anything that are coming in in the background. But here we are in our real lives. Um You found your way on to med all. Ok. So that's, that's good news. You may have used this before. I know we often see lots of people coming back again. So if you're new, welcome. And if you're a returning visitor, then it's lovely to have you with us again. You will find three icons on the side of your screen. There's a chat box there. Hopefully you found that if you're a verified member now of med or if you're a healthcare professional, which probably most of you are, um you should be able to join in the chat. So do let us know um where you're coming from this evening, what you do? It's always lovely to know who's with us. Everyone can see the chat. So anything that you put in for and I will be able to see as well. Um Friends and colleagues who are on the webinar as well. You will get a certificate of attendance generated for attending this webinar. It will also be available on demand through our website. So if you enjoy the chat and want to tell your mates, then do it will be there forevermore for people to have a look at um no slides this evening because it is an in conversation session, but do join in with your questions. So, um Zanna, you may well know already, I've known fos for a number of years now. She is a practicing GP in East London. She's done so much amazing work um in all of her years and I, you know, you only look about 25. So obviously, there's no way you've been 20 years in your job as a GP. But I first met Faan many years ago. We were both doing some work for the National Association of Primary Care. And Fasano is one of those people that the first time you meet her, you just think she's one of the nicest people I've ever met and we instantly hit it off and have been friends ever since you may have seen her up in lights at Piccadilly Circus. Um, she has been the GP of the year, the General Practice Awards in 2019. She's also been voted an outstanding BB A, em E leader. And you were one of the ranking NHS stars, weren't you for ana when they did the photography bit. And, er, yeah, so she actually had a, had a face and a name up in PC for a while. So incredible woman, incredible role model and incredible friend. Um So we're going to talk about health inequalities this evening. Now we come from very, very different areas. I'm up in North Norfolk by the coast, which probably couldn't be more different from where Zanna is in East London. So we have had a chat previously about of the different types of inequalities that exist. I was having a little bit of a read up earlier for Zanna and I saw that um just in England alone, there is a 19 year difference in the life expectancy between people that live in the poorest areas in compared to the more affluent areas. And that's just in our little country and I know that this is a global issue. So, um you know, the first thing I want to ask you about health inequalities is um kind of what are they, how big a problem is this for most of us, wherever we live and how do we know what kind of health inequalities exist in our area? Hm. Well, thank you first. Of all. Thank you for having me, Jo and thank you to everybody for joining us this evening after a, a busy day. I'm sure. And what a great introduction and I want to be on this is your life. You know, my, here's my book, but what a, what a great question you raise about, what is health inequalities. So I think with COVID, it's become a term that many, many people are now aware of. Everybody's hearing about health inequalities. But of course, health inequalities was a problem before COVID as well. And many of us will have heard of Michael Marmot and Michael Marmot is um you know, a guru on health inequalities and he just back in 2020 did a um what was it? 2020 did a 10 year on report. And as you say, not only is there a massive difference between um the affluent areas and the poorer areas and that 19 year difference. So I always say I'm in East London in Stratford. If you sit on the tube and you go along with the tube line from east to west London, within an hour, you're losing years of your life. You know, if you're going west to east, if you like or if I'm going to west and you're gaining a year of your life every few stops, if you think about it like that. But what Marmot found, which was a particularly distressing for me is that if you're a woman. Um You are more likely now than before. So more likely now to die 10 years younger. So we're in 2022. But if you're a woman living in a poorer area, you are more likely to die 10 years earlier than you might have done previously. So you know what is happening? The answer to the question, what is health inequalities is one that I find quite hard. So we often think about areas like mine in Newham where we have 74% B AM we have a lot of poverty. So we often associate um health inequalities and poorer health inequalities with areas where people have more B AM people. And certainly that was found during COVID. So sadly Newham had um in the very first wave, sadly, had one of the highest death rate in the country COVID. Um But then jo areas like yours where um you know, I'm looking at your garden and I was just saying earlier, you know, your background looks picture perfect, but it's real, that's not a black background. I'm looking at it is beautiful and it's green. But then there's um we have often inequalities and health inequalities, but we might have a population that don't have the same transport to their health services. So maybe some of our elderly may be quite affluent areas are still suffering from health inequalities because they're not managing to access the health, maybe just because the transport isn't here I can jump on the tube every five minutes here. If I want to, then we can think about our coastal communities and they're generally not the AM E but actually, um still very, very poor. And then we've got also of our, our traveling community. So it's a bit larger than what we, we often think of is we think of um areas of high areas of BM and poverty or health inequalities. It's even a wider definition than that really. And I think one to look out for because otherwise we might ignore the people who are living in perhaps affluent areas. And we think, well, poverty doesn't seem to be one of the factors but they still can't get to their appointments, they still can't get to their hospital because the travel isn't, the travel facilities aren't there. That's certainly something that we see up here a lot. And, um, you know, where I live, for example, I'm kind of in the middle of two district general hospitals. Each one is about 25 miles away. Um, if you go to the closest coastal town to me, which is 10 minutes away, it's actually the, got the longest sort of response times, ambulance response times and things like that because just getting there is a nightmare and you can imagine what it's like in the summer time when everybody is up here on their holidays and nobody can get anywhere, people living in rural areas as well. Um, access to healthy foods, believe it or not can be an issue in areas even where we are surrounded by farmland, orchards, everything like that. You know, sometimes people are limited to their village shop if they're lucky enough to have one. Um, because it's just too difficult to get anywhere. So, you're right. There are so many things to consider beyond what we would normally associate with health inequalities. And I guess they're the kind of the big hitters, aren't they that we talk about with um, poverty, ethnicity being the sort of ones that we would naturally think about. So I think the second part of my question there was, um we can kind of think, well, I haven't got any inequalities where I am because it's a really nice area or I'm living somewhere where I think, well, it's poor here. So naturally that's the biggest problem is, is there any way that we can kind of find out what our sort of issues are, what our health inequalities might be within the populations that we're serving? Well, this is something that's really pertinent. I was talking to a GP who works in um Oxfordshire and I said, oh, how lovely Oxford. How lovely. And she said, yes, you would think that wouldn't you? But she's working in, in an area of Oxford that actually it is very deprived. And she was saying how difficult it is for her and her primary care network colleagues. The primary care networks are sort of a number of practices that have come together to work together. And that's part of the NHS plan since 2019 and working with communities. But she finds it very difficult to advocate for. I can't see you, Joe. I hope people see me. I can't see you. I hope you. Oh, where have I gone? I'm back, I'm back. I hope you. I was going to say, can you hear me? Ok? I'm still here. I'm so sorry about that. I went back for a moment and, um, and she was saying that because it's almost hidden poverty because if you look at her overall borough, it looks like it's very affluent, so very different to a Newham and north east London where we know that there's a lot of poverty. So actually, it, it's almost like hidden poverty because it's a small area. So she finds it much harder to get the funding and advocate for her patients. And I think one of the good things that has happened with primary care networks is we now have a lot more data that we certainly as GP practices and, and you know, public health working together bit more are looking at. So I'm standing in an apartment in Stratford and it's very nice and just about less than a mile away from me. I've got the Olympic village where Olympics took place in 2012 and that little pocket of Stratford is absolutely beautiful. It's really nice. And you know, my apartment is a lovely apartment, but that's not um at all connected to, if I just go a mile away to where I work in, it's a very different story. So I think it kind of works both ways. And I think one of the reasons this is important is that we don't miss the pockets of poverty in areas that are banded to be thought of is richer. But it's also when we think about how we're going to deliver our services in areas of health inequality. So a really good example, I think is when new was delivering COVID vaccine, we again with 74% B me, we could see that our, particularly our Bangladeshis and Pakistanis, not so much the Indians, but the Bangladeshis and the Pakistanis and the Africans and Africa had a much COVID vaccine rate. So we went to different places like leisure centers and um faith places and shopping centers. But even within those places, we first went to Westfield Shop center which is a beautiful and you and I are going there very soon yet to date. And that's really lovely. And then we found that people were not going there because actually most people that shop in Westfield are people who are um quite well off and they can afford their designer brand. They're quite good at looking after their health. But actually the old little shopping center in Stratford, only a mile away where I go to get my oa and my Indian vegetables. That's where all the people that needed the vaccines were. So we had a little, our public health director and set up a little makeshift clinic there. So even within the borough, the Oxford example of that hidden poverty and similarly my example of a Borah that's known to be poor, but a really hidden pocket of affluence and that their needs are actually quite different to the people who might be struggling more with their healthy and their health beliefs. Absolutely. And um you know, it's interesting talking about the things that you did during COVID trying to reach out to people. And you know, a lot of the work that I do and I know you do sort of coaching with people as well. We're looking at sort of different things that we can do different initiatives for population health improvement, you know, introducing new services. But I do worry sometimes that with the best of intentions that are we sometimes introducing more health inequalities by sort of doing some of these things are there. You know, like you say you kind of went initially into the posh shopping center thinking this is great. We've got, we're out in the community doing this thing, but obviously, there was a large cohort of your population that weren't gonna access that service there. Do you think we run the risk sometimes of introducing more health inequalities? I think so. And I think I have a solution for that and it sounds so obvious, but the solution for that is to listen to our communities community. So, as, as a GP, I've been working a GP for 22 years and it's always another service. So I was on a, a primary care network board meeting today. Um And they were talking, we, we're going to introduce another service because we don't think our Children and young people are getting enough care. And that's absolutely true, you know, with COVID and the mental health service has arrived and we weren't sure whether there was a need for that service or whether there was already an existing service because actually our p my particular primary care network was doing a lot of work with young people. And I think that we are very um I can cheekily get away with saying that because I work for the NHS, but we're very good in the NHS of introducing a new service without actually listening to the people that we want to serve and think about what they might do. Um And I think sometimes we waste a bit of money doing that. So I think we certainly introduce our inequalities, but also we spend a lot of time. So a really good examples when including me and we were all patting ourselves on the back there. We've done COVID vaccines in Moss the East London Mosque. Very big mo down the road. But what we forgot is that women like me don't need to go to mosque. It's not compulsory for women to go to mosque. And actually a lot of people just don't go to mosque all the time. Not, not all Christians go to it. Very interesting how we were very happy with ourselves, but we wonder how many people did we still miss. Yeah. And this is all, as I say, with the best of intentions, isn't it of reaching people? And I guess you're never going to get all of the people all of the time. Um But I think variety and, and that what you said about listening to your population and getting out there and talking to people is so important, isn't it to try and understand why people are or aren't accessing and engaging with services? Because, you know, you often hear that that and I was trying not to get on my soapbox for this one, but that awful term that we hear all the time of hard to reach groups and that's a real bug bear of mine that hard to reach because I'm not sure anyone is really hard to reach. I think we are just not always reaching in the right way or our services are sometimes hard to engage with rather than, you know, the actual, it kind of that hard to reach, puts the blame on patients and the population doesn't it, rather than even suggesting that maybe we could do things in a different way. So, so yeah, so hard to reach is something that really gets to me. But, and this might sound like a ridiculous thing to ask because to talk to people, we are with them and we open our mouths. But if we, if we're in a practice, a hospital, um, whatever setting we are in and we're thinking about setting up services, how can we ask the people that really matter our population for their input and ideas? What sort of ways have you done that in your area? Well, I think that's where I think Jo I'm really lucky to be in primary care and I don't just mean as a GP or fabulous nurses or fabulous pharmacist because actually we get to see those people every day. So I get 30 of them just in a day that my clinic and I am still privileged that even though the NHS is working very differently to how it used to that we still have. I'm glad to say I've got a 20 year relationship with some of my patients. I've been at the. So actually it's quite easy to listen if we want to. I think one of the difficulties is that we're so busy trying to solve a problem and won't know that we have the solution that we don't always stop to think that someone can actually help us with it. So, really example, this, um, this young person's initiative that we're doing. So today we had a talk and it's going to be, you know, an integrated front door. But three years ago, um, I, um, sadly I had a 15 year old who was actually my patient, I've known him all his life and he is just six months, not even six months, about four months younger than my own daughter. And he was stabbed to death at the age of 15 in the middle of the, just five minutes from where I live. And, um, I've known him all his life. That was my practice nurse. She'd given the childhood immunizations. I used to, you know, is your, is yours talking back now that he's 70 year, mine is talking back. Does yours not answer the mobile when you call off school and he's 12. Now mine doesn't. And to suddenly hear that he had been stabbed to death and it occurred to me that most young people don't come to the GP surgery. They certainly don't see middleaged women like me. So we sort of have this initiative, um which actually Professor James King and who we know from the MA PC runs called Complete Care Communities. And we're looking at health inequalities and I'm just one of the 66 sites, the 66 sites across the country. And we, we teamed up with West Ham United Foundation who are a football club and their charity on the football. And guess what teams love football. And we've got a link worker that actually works, which she's a properly trained youth worker. And we use some of our primary care network funding because primary care networks get some funding for different in our link workers. So we use her and she doesn't see them in, they can come to practice if they want to do. But actually most like to go to West Ham because I'm sure and you know, some like to be at school and see. And so I think part of the solutions, that's just an example of some of the solutions that actually can come if we listen because I would spend ages trying to, you know, see if those Children are all right and reach them. But actually, it saved me a lot of time because the EP practice in the practice is not the right space for them really. And I'm hoping that by doing this, we will hopefully in the future, stop more stuff being and stop more gangs and help with mental health earlier. So yeah, I think not listening, but getting some of the answers from the community and just be willing to do a few bit weird things. Like don't always consult in your consulting room for think about consulting as long as it's private, you know, outside as well. Well, it's probably quite nice for you to go to the football ground or somewhere, isn't it? And go and do somewhere somewhere else. I mean, I'm not a football fan at all but having been roundly told off by my son who's a diehard fan, I needed to sort up on a few players names quickly. So that's, er, I got tested but, and it's wonderful. I mean, one of them just said, um, he's a 16 year old and my link worker said, um, do you want to try some tennis lessons? And they will look on his face the week after he never played tennis. Didn't need antidepressants, didn't need referrals to community adolescent mental health team. He just the look on him. He'd never tried anything like that. Yeah, absolutely lovely. So these are not like they're not rocket science expensive solutions either. Just like really listening to our young people. Yeah, absolutely. And of course, we all know that exercise is the cheapest and best antidepressant that any of us can have if we get around that. You just remind me by saying about football. Um, and you did the sensible thing in reading up about it before you went. I remember doing some sort of stroke awareness work several years ago now in Norwich and, um, one of the Norwich City play, I don't do anything. No football at all. One of the Norwich City players who were premier league at the time came along to have his BP taken on our stand for a bit of publicity and I made a major faux par in that I asked him what he did for a proper job because um to me, he played football and I thought, you know, just do that the weekend. I didn't actually think about it being a proper job. So I felt a little bit silly after that. But anyway, that is me doing silly things. But yeah, guys out there that are watching, if you have any questions at all, then please do drop them into the chat. Otherwise I will just keep talking and asking lots of questions. So, so feel free to join in. Now, I must also mention that if you are watching this on demand, you won't be able to see the chat that's there. So if anything does come in, I'll make sure that I read it out. So, otherwise you think what on earth are you talking about? Because I can't actually see the question. Um So I want to ask you as well. You know, you've given some great examples of some of the stuff that you've done kind of outreach things in your practice. But, but I know that you also do some amazing stuff at your practice as well. And I, you know, I see pictures on Twitter of a room in your practice in the winter with it when it's cold with, you know, boxes and boxes of cup of soups and warm drinks and things for people to have and, and I know about your, your, your garden as well. So, so tell us about some of the stuff that you're doing actually at your practice to try and help your population. Thank you. The, the winter sort of warm hub. I mean, go how sad that there's been a requirement for that after 22. But what we were finding too is that, um, people, you know, last year, you know, many, many mums, not just one or two were actually saying that, that they're skipping meals because there isn't enough food. I feel so emotional saying that as a mum, you know, because you'll do anything to make sure your Children were normal, right? But they were class to be able to feed their child and they were, and then, um, we were obviously very concerned about a cold winter. Thank God. The winter wasn't as cold as we thought, but we actually started it on October half term because in Newham, we're quite lucky that all primary school Children and get a free school meal or there's great there. But of course, over the holidays they don't have that. And so I just looked and I thought, you know, it wasn't like you say it wasn't a three meal course or something. It was really the, wasn't the healthiest food. It was just literally cocker soup and some bread because we thought, well, actually they'll be to just make it themselves as well because one of the things we wanted to make sure that people didn't feel embarrassed because a lot of people say that they still feel very embarrassed going to food banks and these are people working. I mean, I've got patients who are nurses who are going to food banks who are really, really upset that they're working, that they worked on COVID wards and they can't feed their Children, they're going to food. We wanted to make sure that we didn't have sort of the staff have too much involvement. So we put the kettle in there. You just want to make sure health and safety was all right. We put the kettle in there, put the soup in there and put the bread in there. And some people prefer just to take it away as well to, but it was a warm space every day from 12 to 3 to stay. It was interesting that not many people chose to stay. Most people chose to take the food. Maybe that's also because a lot of our liver had opened as warm hubs, right? Ok. Yeah. But the fact that we need to, and one of the reasons I wanted to do it in the practice is because of course, it's one of the places that you can still go to confidentially. So let's say I'm popping out a doctor's appointment because I think I feel very strongly that we underestimate the amount of shame that goes with poverty even though it's nobody's well. And actually Michael Marmo says this. He says that if you're poor and you're constantly thinking about that, it's very difficult to make any other judgments because that's always on your mind. So it's not that you're not right, but it takes time to fill in benefits forms and things. You just don't have the headspace for that. So that it was nice and it really didn't cost me much because I own the practice. I run the practice. It was literally 50 lbs a month that was coming out of my pocket. It wasn't a lot of money. So we were able to do it. I mean, I hope we don't have to do it, but we know we can and we know we can. The garden is a, is a lovely thing because it actually again just came from, um, we've got, we are sort of a corner house. We look like a house, but we've got a little um sort of paved um area and we just put some sort of like wooden. I'm not a gardens. I don't know what you call them, but sort of wooden boxes with soil in them and planter and some of our patients are so amazing that they come. And again, we said you can have a gardening group, but many of our mental health patients didn't feel confident to come in the group and they said, can we come whenever you can come whenever? So we decided that because it's in the garden and we just left a few tools in the port and we didn't and they haven't been stolen. We worried about them being sto they haven't been stolen. We've had, we've had chilies and I think we had like a couple of courgettes that were grown and now the patients love it. Like they, they'll come and do a bit and then they'll say, can we take a few things? They've become a fun thing. The nicest thing about it. It was actually one of my patients who said that when our little kiddies come from injections, you know, any, any primary care nurse will know this, that those three year olds, they're always in tears, aren't they? After their injection? Yeah, that horrible nurse, poor thing. And now the nurse can say, um, do you want to go and water the garden? And it was actually a patient who said, can I buy this? And she bought a little mini watering can. And I mean, I'm not that fond of watering anything but these kids absolutely love it. They see it as a reward and I thought what a nice benefit because they won't always associate coming to the doctor and the nurse with an injection. So that's been one of the secondary sort of benefits. I've never, but they go with their little watering hand and they absolutely love it. So patients made us do a sunflower competition. So all the staff had to have a sunflower. Mine was called Samina Sunflower. But she wasn't growing as high as the other. So I didn't win. But it was really nice. I mean, the staff got involved, the patients got involved and it was just, it's just a nice place and some of my patients said they like that mindful activity just doing it on their own and just coming, they don't necessarily want to group, they just want to come on their own and do it for a bit, which I would never have thought about. I would always have thought of groups and gardening groups, but he wants to do that. So I really need to do anything. I just occasionally buy it, give them a bit of money for a bit of soil or a few seeds and then he does his own. He's brightened up our garden. Really lovely. Oh, that's amazing. And I think, um, you know, for some people it might, then just, pardon the pond, plant a little seed for them. You know, because people might think, well, I haven't got a garden but seeing a small amount of space and getting some planters, people might think, well, maybe I could have a little planter on my balcony or a window box or even, you know, maybe just some herbs on the kitchen windowsill or just something. It might give people the confidence to think why I do a little bit of this myself as well as obviously the social element of you have it. And I love the tale of the kiddies being able to, you know, for some of them that might be the only opportunity they get to come and water a little garden and they won't, you know, when you're a child, you don't forget things like that, do you? And hopefully, as you say, that will stand out more than, more than the needles. Well, we've got a question coming here. Um, I know you'll be able to read it for Donna, but I'm going to read it out um for the benefit of, of anyone that's watching later on on demand. Um And Zoe's asking what one thing could we say or do in our daily interactions with our patients and people that might help reduce health inequalities. This is such a good question because I've talked about almost sort of, you know, big initiative like trying to solve knife crime and, you know, even a garden, it doesn't have to be anything as big as that. I think that health inequality is, it sounds a bit cliche, but I think it's part of everybody's work every day and the main thing is again to look out for it and to listen and to look out for it. So, you know, Joe, even in your area, you know, you can see that there are health inequalities and they can be big and they can be small. So this is a very small but very significant example. So um I was talking to a lady who doesn't speak English as her first language. She speaks bingo be and I can communicate in some beli and, um, she was in her forties so only a couple of years was younger than me and she, um, was having heavy periods and she was able to communicate with me in bingo. And I just gave her some, um, very easy to some tranexamic acid tablets. Really easy consultation out the door in five minutes. She rang again the week after and being a typical overstressed, overworked monie, I just spoke to her last week. What does she want now? And she rang and she said, I just wanted to tell you that I have been suffering with heavy periods for 33 years of my life. And, oh my goodness. I, these tablets, you changed my life because I didn't really want to tell my husband and he does most of my translating and I'm still a bit embarrassed to tell him and I've never wanted to tell a translator and I thought that's health inequalities is right there because we have free translation. But actually, do we always understand that? Not all women want to talk about that? And that was such an easy thing to do. So, the learning I got from there is, should I actually be saying, do you know what if you have heavy periods and you know, you've had a scan and there's nothing, you know, there's these things called these tablets you can take them because it was such an easy thing for me. But it was life changing for her. Yeah. 23 years. And I think there are lots and lots of examples like that that every practitioner will have, whether it's, um, you know, your lady who actually finds it hard to come for her dressing because the bus doesn't come enough for her because she's a ral area. There's so many inequalities that and most of it we'll hear about if we listen. Yeah, of course. And that's always the main thing, isn't it that we have to listen to be able to hear. And, um, that's often the challenge, isn't it? Particularly when people have got so many boxes that they need to take and stuff that they've got to do. And, you know, it's interesting you say about, um, translators because, you know, often people will use family for translators. But, you know, if it is perhaps, you know, it might be a son or a daughter or whatever that's doing the translating, it might be stuff that you think don't really want to. And the same, you know, people have got parents think it's not something I really want to talk about in front of um, a family member. So I think that's something that's really important to remember as well with family members doing um, translations and it, it does sometimes worry it's really helpful, but sometimes it does worry me that if there's, you know, something that, that doesn't get across because it's, yeah, just not working and not appropriate. And um a colleague of mine, um who does amazing training around motivational interviewing. One of the things that, that she was saying when um I was doing a session with her is that what she often says to people or asks people is um what you're doing to look after yourself. And it, it's a really simple question to ask somebody. But, um, it's amazing how much you can get out of an answer to that question, be it. I don't have time to do anything for myself or, you know, you know, people's response, you can, you can really tell a lot, can't you? And also from start it, like your, your lady with the heavy periods example of starting the sentence. Although some people find that and kind of depersonalizing the issue and just kind of raising it as a general, I think can be helpful as well in people opening up, can't it? It's um, yeah, really interesting. What, what difference communication? Um, absolutely makes to us. Um So I don't know if anyone else, um, has anything else that they would like to ask. We've, we've only got a couple of minutes left and that's absolutely flown by Zana as it always does, um, when I'm talking to you. So, so what, what are you, what are you on the case of at the minute. What's your sort of biggest health inequalities that you're looking to do now or next or anything that's emerging at the moment? I think at the moment, Jo, I'm trying to think about really our young people and I, I don't know that this is a health inequality, particularly for new and I think it's a health inequality for our younger generation. I do think that COVID because it's been a larger proportion of their life. I think particularly our teens or probably, I don't know enough about how much our younger Children are affected, but our teens, I've never seen such a mental health tsunami in our young people. Certainly, when I was practicing 10 years ago, I had never seen the young ladies as young as 13, suicidal and I'm seeing that now, I didn't see that 10 years ago. I didn't see 13 year old girls that sick. So, um, so this is probably would I call it, I probably would, I would call it health inequalities with our younger generation because of course, a lot of our planning and our focus because money in the NHS goes towards the hospital and towards our elderly because we know that the last 12 months of life, obviously, people need a lot more care and that's quite as well. But I do wonder whether we need to have a think about what we do with our younger people and prevention. They're the adults of tomorrow. So that's something I'm um you know, thinking about this, this Reducing Life Crime Project has made me think about what we're doing with our young people. And again, it's back to listening and it seems so easy, but I do it so badly because as you say, there's always things to take and we're doing another service without listening to whether you want that we're doing another service. We're doing access. Now, the NHS and primary care are doing access. We're not sure what we're doing access to. Did we do it right the first time. Is that why you didn't, you wouldn't necessarily need three appointments if we gave you what was required the first time. So, yeah, there's, I think there's a lot going on for me to think about. Are we designing correctly? And my B bear with the NHS. I don't think we are. Yeah. Yeah, absolutely. I couldn't agree more with you. Um ok. Well, there's some lovely comments coming in um from people. So thank you for that. Um I was going to try and pop the feedback um form into the chat for you, but that doesn't. Oh, there we go. Now, it's working. Look now, una from um learn with nurses is on the call. So I've just shown my incompetence with the system. So, um sorry, you know, I should have done that properly. Um Pressed the wrong button. Uh We are at our time. So thank you so much for doing this. Zanna, I've been dying to get you on learn with nurses for so long and I hope we can tempt you back another time to come and talk about. Well, anything really because it's always a pleasure to talk to you. And you know, I'm used to seeing you on a screen because you're always on the news or something talking about. Something very clever. So, thank you so much for your time. It's been wonderful and thank you to everybody that's joined us this evening and to everyone that's watching later on demand. And I really hope that this gives you some food for thought, thinking about your own populations and what's going on in your area. Um 19 years, life expectancy difference in England today, a civilized country between people that's based on how wealthy you are and where you live. And that can't be right. Can it can't be right that, that's the thing that I would leave on. And if you're a woman in a, in an area of poverty, if you live in Rockingham ago and five miles away from me, you will live 10 years shorter of life than you would before. We don't want to head back into the Victorian Times. This is not acceptable because this is avoidable, health inequalities are avoidable. And I think each one of us can do something about it and what better message to end on. So let's do it. Let's all do what we can thank you so much and I will see you very soon. Take care. Everyone. Have a lovely rest of your evening. Bye, Zanna. Bye bye.