Health on the Line

[Primary care at scale: does bigger mean better?]

Adam Brimelow

Hello and welcome to Health on the Line. This is the podcast for policymakers and NHS leaders. I'm Adam Brimelow, former health correspondent, director of communications and now with the NHS Alliance media team.

There's a strong consensus about the need to shift care from hospitals into community settings, much less so about how it should be done, how to fund it and how fast to move.

Speaking on Health on the Line a few weeks ago was clear that NHS England's chief executive, Sir Jim Mackie, wants to step up the pace of progress towards neighbourhood care. Since then, NHS England has launched a consultation on single and multiple provider neighbourhood contracts to help this transformation take place. But the Royal College of GPS has warned against moving too fast, citing a lack of evidence for the move towards bigger GP partnerships and at scale primary care organisations.

In a moment, we'll hear about an approach in Derbyshire involving a consortium of practices that's already bringing the vision of neighbourhood care to life.

And what about social care? Could it be the defining project of Andy Burnham? Time in office or yet another political promise that runs out of steam? We will discuss drawing on experience from across the UK and around the world.

But first, the move to neighbourhood health and that key conversation about how the shift of focus from hospitals through to neighbourhoods can be delivered. Can it be done? The answer we know is yes, because it's already happening in some places, including in Derbyshire, thanks to a long-standing partnership between an at-scale GP provider and community trust working in close, complementary harmony.

So, let's welcome Dr Duncan Gooch, a GP, GP trainer and clinical director of Erewash Health Partnership, which is a consortium of practices that serves more than 100,000 people in Derbyshire. Duncan is also chair of the NHS Alliance's Primary Care Advisory Board.

And also welcome Jim Austin, chief executive of Derby Community Services NHS Foundation Trust. With a strong interest and record of involvement in tech developments as well.

So both of you are from Derbyshire. You've worked together to create Team Up Derbyshire, which has been held up as a great example for taking forward integrated care.

Duncan, perhaps we could start with you could just tell us what the scheme is, why you set it up, and how you worked with local partners, including Jim's trust, to get it going.

 

Duncan Gooch

Thanks a lot. First off, I can't claim credit for this. I think it's really important to recognise this isn't one person. This is lots and lots of different people's contribution over many years as well. So, I think it's really important to recognise that a lot of these schemes certainly in Derbyshire, this is a contribution of lots and lots of different people.

In essence, this started many years ago when we heard from our patients that accessing care was really complicated for them, and they were often finding that they were going through one door and then finding it wasn't the right door and having to come out and then go into another route to try and access care. So that was really, really apparent. And that's what our patients were telling us.

And then the clinicians, the doctors, the nurses, the community nursing team were also getting frustrated that when they were trying to access help for the patients to try and support them, and particularly housebound patients and patients in care homes, that they were struggling to get what they needed and that it was exceptionally time consuming, which prevented them from being able to do what they wanted to do.

And so, the programme of work of Team Up was dreamt up probably more as a verb than a noun in the reason it's called what it is because this is very descriptive in that this is the teaming up of the people that sit to try and help and support people that are housebound, perhaps frail, and perhaps living in a care home.

And so, the whole programme of work covers lots of different services. It covers an acute visiting service for supporting GPs, enhanced care and care homes, urgent community response, falls, navigation hubs, with the intention of trying to improve the care and support that we provide for this cohort of people.

And the particular involvement that I had is very much in that primary care space. So, looking at some of the proactive care around long-term condition management, looking at proactive care in care homes, as well as the acute visiting type services that we that we've seen build up.

Adam Brimelow

So, you're looking to improve care and support. And I know just developing that a bit, Jim, I think one of the stated aims of the programme is to prevent people needing to go into hospital by providing both preventative care and reactive or urgent care, as and when required.

So how much of a problem was this for your trust and what benefits has this scheme brought to you so far for your services and your patients? I'm interested just to get a sense of how well this has worked.

Jim Austin

So, I think it's worked very well indeed. And it's been in existence, as Duncan's indicated, for over eight or nine years. So this predates quite a lot of the currently published excitement around how we should be integrating. So this pre-dates a lot of that work.

And while the ambition was around helping people to stay safely at home and to look after them in their home setting, the benefits for that will be much more widely felt, not necessarily within my trust, where we run a number of community support beds in community hospitals, but also the ambulance service, acute hospitals and even social care, there are real impacts around if we can look after people safely at home and without that need to exacerbate them into an acute setting, so much the better.

We all seem to argue in the NHS around the number of acute beds in a system, there are x thousand acute beds, and there are 1.1 million beds in Derby and Derbyshire. They happen to be in people's homes and we're much more interested in trying to look after them safely and appropriately in those beds and get them into hospital when they need to go to hospital. So, it's really worked very well.

The benefit for my trust is a little bit around that, but it's also around the integrated working that Duncan mentioned as well. So, you know, my community nurses, district nurses, therapists, the ability to interact much more closely with social care, with general practice, with other providers, voluntary sector. And Team Up is a collection of people who wear different employment badges often, that have got the same aim which is around helping people stay at home safely.

That coordination and that integration means that we actually get higher staff satisfaction as well. And with staff satisfaction, if you look after your people, my people, they look after the patients better.

Adam Brimelow

Well, there's a lot of discussion, isn't there at the moment about the sort of contractual basis for this type of partnership working and integration and so on.

Duncan, I think the contract is held by your primary care network. Is it fair to say that this sort of programme wouldn't have been possible had it not been for this sort of at-scale primary care model?

Duncan Gooch

So, I think that the scope and the longevity of the programme wouldn't have been possible were it not for the evolvement of the primary care network and the entities that predated that.

I think we can always, in the short term, deliver an additional layered on service. But if we're looking for longer-term transformation and integration of services, then we have to involve all of the partners in doing that.

And when we think about change, then particularly change in the healthcare, it's not always the easiest thing. And if you're involved in change with clinicians particularly, they are a group of highly autonomous individuals, and we want them to be highly autonomous because that's what we need them to do, is they work to look after people's health, trying to have some sort of top-down imposition of change on them isn't going to be effective.

So the idea of local ownership, of contracting at the unit of delivery, becomes really, really valuable to being able to get that local ownership, that local buy in.

And there are and some may argue that this could be done at individual practice level. And some of it, I'm sure could be. What that misses out is the important role of coordination. And it involves that oversight and that ability to work with Jim and the staff that work within his trust.

So, this isn't a change just on the part of general practice to be able to work at scale, to coordinate across the geography. And Jim and within his trust has reorganised his trust to align into this as well, so that the footprints of his community nursing teams then align with the same teams that are delivering these urgent and acute visiting to support that longer-term integration.

And so if we didn't have that sort of by-in that local ownership, then this I think would just be a short-term bit of transformation, not something that's been in existence for as many years as it's got. And it's a real value to that partnership, working to see compromise from both sides and to see change from both sides to be able to deliver it.

Adam Brimelow

And it sounds from what you're saying that this buy-in from both sides, this has been happening over quite a long period of time. As, as you know, the Royal College of GPs has recently raised concerns that we may be moving a bit faster than the evidence base on neighbourhood health contracts. Duncan, you think that's a fair criticism, or do you think it's more of a case the NHS can't afford to wait?

Duncan Gooch

I don't think it's a fair criticism when I see people waiting in corridors for a bed for 24 hours in my local hospital, and I don't think it's fair when I consider the people sat outside A&E departments, sat in ambulances waiting or ready to be discharged and not coming out of hospital.

There is clear evidence of the harm that we are causing to our population and to our patients. And so there is really compelling evidence that we have to do something different, and we have to change.

And the use of no evidence actually is really common. So, particularly amongst doctors, but perhaps wider clinicians as well. It's something I hear quite commonly. Some of that comes out of our medical training and which a basis of evidence or a gold standard of a randomised controlled trial to be the standard of evidence by which we recommend a drug or recommend a vaccination as an intervention to improve health is a pretty high standard, and it's a standard that we as clinicians come to expect of interventions that we do.

But we're not talking about individual therapeutics in the context of highly controlled variables. We're talking about exceptionally complex organisational and system change in a rapidly evolving and highly volatile situation. And so it's not realistic or reasonable to expect a randomised controlled trials depth of evidence base to be built up before we make change.

And so I think particularly not acknowledging the evidence of harm that our current system is causing, and then also not recognising evidence where we are showing really significant benefits – and not just benefits in in one small area, if you look across the country and one of the great things about the network at the NHS Alliance is being able to hear all of this evidence. It's really, really consistent that when you put in some additional services that are well integrated with primary care, it makes a really significant improvement in outcomes for the cohorts that you intervening with. And those are real, real improvements. This is people, not satin corridors, not waiting in ambulances, not sat on a bed waiting for somewhere to go.

And so perhaps it's not a randomised controlled trial, but that's definitely not the same as there being no evidence. And so we have a lot of evidence of what we can do to improve things for, for patients. And we also have a lot of evidence of the risk of doing nothing and allowing us to maintain a status quo as well.

Adam Brimelow

Yeah. So a strong, clear message that we need to we need to crack on with this.

So I'd just like to get into a little bit more about what it what really drives success. We've heard concerns haven't we, that there's an assumption that if we get contracts and organisational structures right, improved outcomes will follow. And neighbourhood health clearly depends on having strong relationships evidenced, I think by the work you're doing. Is that what really underpins this, the relationships involved, Jim?

Jim Austin

I would say absolutely, it's about relationships.

I think if you start from structure and contracts, you're almost bound to end up – you cannot impose integration, I think went into to that a bit earlier. And although there are an important factor to it, you know, some people would use an argument that says, you know, a contract pretty much like a prenuptial agreement for a marriage made in heaven. The prenup is not going to make the marriage work. There's a whole lot of other stuff that sits underneath that makes the marriage work. But when things go a bit wrong, it's useful to have a contract there to help, to understand how to unlock the difficulties.

So, you know, like I was saying, you know, this the Team Up process, at primary care scale – we've been working with the Erewash team where Duncan's from for seven or eight, nine years on this. And we were part of the Vanguard programme together, which really want you to think differently about how should we attend to the needs of the population? And neighbourhoods are not made up, by contracts, they’re made up by relationships, by people. And there is a leadership responsibility and leadership coordination piece that sits across the top.

Now, the challenge here, of course, is the NHS often comes back to money. Who gets the money for doing what? If you start from what are the outcomes we're trying to achieve generally around how do we help people to live healthier lives and healthier lives that are longer?

You start to start measuring things in a very different way, and I think that is a real challenge we have to be careful of within the NHS right now, where we are very good at counting the things that we do, not the things that matter.

Adam Brimelow

Yeah, and I suppose, you know, clearly you've had a very successful partnership which many people will have benefited from.

But Duncan, I guess it's not all been totally plain sailing. What barriers did you encounter with this model which others embarking on neighbourhood health models in primary care could face to it?

Duncan Gooch

I completely agree with Jim's point around relationships and the passage of time with that as well. So, the consistency of purpose that that sits around it. And that actually is the thing that probably helps most navigate the numerous obstacles and barriers that that you face.

And if we accept Jim's point, which I do, that relationships are important, then people are probably one of the biggest challenges we have to overcome. I spoke about some of those challenges of highly autonomous clinicians that we want to take a really important leading role. Bringing them on a journey around common purpose takes time, and that's where the consistency over time becomes really, really important.

There are some real practical problems in trying to integrate care. So differential pay scales amongst primary care and trusts is a real challenge because you'll have people working in the same integrated team that might be on slightly different pay scales with slightly different pay awards. And then you bring into that social care. It is a challenge.

There are real challenges around estates. So where are these people? We want them to sit together, so where are they going to sit and who in whose room. And it's very easy to find a solution to this that says, right, we're going to have a more employed by a single organisation, and then we won't have to bother doing any integration at all because we're just a single organisation.

But that completely misses the point in how we're going to achieve a solution to some of these problems. It's not going to be solved by a single organisation taking over everything. This is only going to be solved by our health organisations and our social care organisations and our voluntary sector working together really effectively. And if the effort is on organisational forms that can confer the most power to a certain organisation so they can build their empire, then we are somewhat doomed to failure.

And so, finding a way through that and understanding where people's perspectives are and recognising that we are in this together and we have to find the solution together, is the way that you can get through that. It takes time, and it takes a huge amount of consistency in messaging and in purpose and in leadership.

And I must say, I think that's where Jim has done an incredible job in that consistency. So, where there's been challenge, where there's been difficult difficulties, having a really great and experienced chief executive help guide through that is invaluable to me as a leader within primary care as well.

Jim Austin

Yeah. And just to build on Duncan's very flattering words there. Goodness me. Lovely. He's never said that to me before. But what I would say is so, you know, within my trust, 4,500 people in my trust, and we've actually got 400 social workers and carers that we've moved in from local authorities to help with the delivery care. And they're all on different terms, conditions, and it's a real challenge. That doesn't fix it. What we need to understand is that my trust, and it's not a huge trust, but, you know, we have a whole lot of governance and we're like an oil tankard moving around, the agility that general practice can move at, the clinical accountability and governance that general practice can do that, t decision-making that's there at scale allows us to complement the gaps that each of us have.

So where I am on agile, general practice can be agile, where I can hold quite big risk and contracts, general practice will struggle to in the same way. So, it's around partners coming together and complementing each other, understanding the gaps and being honest about that, and knowing where to stand back and let others lead and when to lead because others will benefit from that leadership.

Adam Brimelow

Yeah, we're clearly an important and in many ways an exciting role in terms of the development of neighbourhood health.

 Jim, if we were to reconvene in, say, five years’ time, what do you think we should be setting out to convince sceptics and critics that the shift towards neighbourhood health has genuinely been a success for patients, managing NHS demand and easing pressure on NHS finances? What sort of metrics and do you think we need to be pointing to say, yeah, that was a good way to go.

Jim Austin

Well, I'm sure it's not the metrics we're probably measuring ourselves on today. I think I'd be asking the residents, because not all residents of patients, many of them are there, will be missed, nearly all of them registered.

But I'd be asking the residents about how happy and satisfied they are with their access to services and the responses they're getting from them. And I'd be asking the staff who are delivering those services, which isn't just general practice staff or my staff, it's the voluntary sector, it's the wider social care sector and asking them how satisfied they are with the delivery.

And then I'd actually be looking at higher level metrics around employment, education, integration of societies and neighbourhoods. And then you kind of measure that within a financial envelope. And if we've managed to keep pace with the finances and we're delivering a happier population, that's where I'd be going.

There are lots of little widget measures we can put underneath that, but actually we kind of forget the purpose that we're here for, which is to help people live healthy lives and longer lives.

Adam Brimelow

And how about you, Duncan?

Duncan Gooch

I think to some extent I can answer this because we're more than five years on from some of the change. And I can think of my colleagues, my GP colleagues who, as we started developing this, were relatively resistant and thought that this might not be the right thing to do, who now would be the biggest advocate for the change that we've made. And the biggest advocate, not only because it's better for them, but is also better for the patients that are registered.

And the other take that I have, which is not really a number thing, I just find it utterly unacceptable, the care that we're providing to some people. I mentioned the idea of looking after someone in a corridor. It's just inconceivable to me that that could ever be an acceptable way to look after someone. And so surely the only measure that we would have is that the standards of care that we give are acceptable, at the very least.

And so tolerating something that's unacceptable, we just can't, we can't be allowing ourselves to do that. So reconvening and success in five years’ time has to be us eliminating what is just an unacceptable position for us to find ourselves in now.

Adam Brimelow

Okay, well we'll have to bring that to a close now. Dr Duncan Gooch and Jim Austin, many thanks for joining us on Health on the Line.

On now to social care and the Prime Minister's big commitment to fixing what he called a broken system.

Well, we've been here before of course. Yvette Cooper says there have been 22 attempts at reform over the last 30 years. So, what's different this time? Well, there's certainly the lived experience of a Prime Minister with a father in care. There seems to have provided added urgency with the review, accelerated a better deal in prospect for care workers and the start of cross-party talks.

Much, though, remains unclear and the pressure is on to deliver real change ahead of the next general election. Can he do it? Well, let's talk now to Natasha Currie, deputy director of policy at the Nuffield Trust, who leads the trust work on social care and has extensive knowledge of approaches taken by other countries identifying lessons to be learned for England.

And Shane Devlin, now chief executive at NHS Bristol, North Somerset and South Gloucestershire ICB and previously at the Southern Health and Social Care Trust in Northern Ireland, where health and social care have been organised within a single system for more than 50 years.

Natasha, it was an announcement, in some ways, of commitment and intent, more than real specifics on how and who pays. But in your eyes, what do you think were the key components of the Prime Minister's announcement on social care?

Natasha Currie

So, in Andy Burnham’s speech, he announced three things. He said he was announcing three things. So, the first one was speeding up the Casey commission by a year. So, we can expect her to report possibly next summer. Unclear, but that would take us a year earlier.

He talked about an immediate focus on the workforce, and then he talked about cross-party talks. So, there were three sort of components, but I think it was more important, less about what he announced – there was no sort of shiny big new thing – but more about how he said it. And, you know, the fact that he was making social care such a big commitment in the first week or ten days of his of his leadership, I think that was the key takeaway.

And he didn't immediately sort of get into who pays funding, those sorts of things. He was setting out the sort of intent and political commitment to reform.

Adam Brimelow

That tone is important, isn't it? Because we've had successive governments making similar promises to fix social care. How convinced to you that it will actually lead to real change this time, especially when you know time is tight? There's probably just under three years until the next general election and such an ambitious reform.

Natasha Currie

Yeah. So, we've got just under three years now until the next election. So, the time is ticking, and we're doing this on the back of 30 years of successive failures. I mean, Yvette Cooper in her intro talked about 22 attempts. I mean, I've seen different estimates, but around that, you know, we've tried this many, many times and it's failed.

I think it does feel different this time, I think because the Prime Minister is making this a clear commitment. It feels very personal to him. And he started the debate in a different place to where we've started before. We've always started the debate with how much will it cost and who pays? And that's immediately taken us into really tricky political territory.

He started in a different place. He started creating a narrative and a vision to get the public on board. And I think that's really important because we have very low public awareness of what social care is, how it's paid for, you know, how broken the system is. So, in previous attempts at reform, it's been really difficult because the public, I think, have assumed it's free at the point of use as part of the NHS. So, this politician is going to make me pay for something that's free at the moment. And then unfortunately, in our adversarial political system, we've seen that sort of taken advantage of and to make political points.

So, I think we've still got a lot of challenge ahead of us to get the public up to where they need to be. But I think the tone feels different this time. And we are kicking off with the Casey commission's national conversation, which hopefully will take us into those questions. What do we want, what do we need as a society? And then we once we've defined that, we get into the questions of, ok, who pays and how do we sort of make split the balance between individuals in the state?

Adam Brimelow

Yeah. So there's a need for a better understanding of what social care is and what society expects. But sometimes it seems to me that the motivations behind reform can get a bit tangled as well. So, what do you think is driving this one? Is it improving people's lives? Supporting unpaid carers? Relieving pressure on hospitals? You know, where do you think that the impetus is coming from on this?

Natasha Currie

Well, I mean, I think the impetus has to come from all of those things that you've just said. I think Andy Burnham, when he started talking, on the first day he took power and he did a Panorama interview and he made the he started out with, we need to fix social care in order to fix the NHS.

And that was his sort of line. And that made me feel a little concerned, because I don't think it's a very helpful narrative, public narrative. We're going to fix one system by fixing another system. It doesn't really speak to people. But then by the time he did his speech where he set out his three announcements, he had shifted that a bit.

And he started with, this is about our lives. And he talked about his father, who has Alzheimer's. It's a very personal sort of story. So, he talked about, he framed it as, you know, this is about all of us. It's about living meaningful lives independently as possible. And that's the impetus. I think the impact on the NHS is a happy impact or consequence of getting social care right.

But I think it's only one part of it. I think there's a moral and there's an economic case as well to supporting unpaid carers and people, disabled adults, for example, to take part in communities, to go out to, etc. So, there's a moral, social, economic imperative. The NHS imperative is it's in there. But I don't think it should be the lead.

Adam Brimelow

So very strong imperative for reform. But let's just get back to basics, in some ways in terms of how the NHS and social care services work together, how does how do they work together? How do they function in your ICB? Shane.

Shane Devlin

Yeah, thanks. And actually just to come back on Natasha's point as well, I think it's one of the extraordinary misunderstandings of social care, which is social care as a tool for discharge. It's what I discovered when I came to England four and a half years ago. And actually, social care as a tool for independence is a tool for actually enabling the true shift left, the true prevention.

So, I think it's an interesting angle to come back on your point, Natasha, that when the Prime Minister talked about, you know, the NHS will fail if we don't fix social care, I think the tone is changing, which is it's not about that.

I think actually society struggles if we don't fix social care rather than the NHS will fail, because the real value certainly in my experience, I used to run social care and health care services, is actually it's about the tool for independence, about giving people life rather than necessarily a tool for discharge.

In terms of the question, Adam, in terms of how it works within my ICB, we have from the very beginning, I've been about four and a half years now, a really clear view that our system is both health and social care as a system.

And I don't know whether that's the case in all ICBs because you've seen one ICB, you've seen one ICB. They're all very, very different.

But from the very beginning we set out to say that every single part of health and social care are partners and therefore our team that runs our system are both people from provider and NHS as well as all our three local authorities, BNSSG and now we've expanded into Gloucestershire as well, which basically means that decisions are taken as a system with social care as an equal partner to healthcare around our table. That doesn't mean we always get it right. And the money flows in different ways, obviously. But actually, to have a conversation about either without the other part in the room just doesn't work.

So for us, we've been really clear that the chief executive of our three local authorities are equal on our table as the chief executive are provider, executive or community provider or GP federation, because they're all part of one journey. And as we start to move a lot more into the three shifts, social care is even more important.

So for us, we've always had that view. As I say, I don't know whether it's the same in all ICB, but for us we've always had that view and that's hard sometimes because as we know, social care is funded and a very different way. And you know, and local authorities are themselves funded in a way that they've got to break even every year. And it's really hard.

So it's a different business model. And also NHS is free at the point of care. Social care isn't. So there's differences in the models. But if we don't, if we're not all around the table running it, then we are in deep, deep trouble.

Adam Brimelow

Yeah. So, one system. But you mentioned they're different business models. Sounds like you've got a very close and effective partnership.

Is closer integration a good idea? Is it desirable and is it practicable from your perspective?

Shane Devlin

Yeah. So as you know, I spent 25 years in provider land in Northern Ireland and in the last four and a half years as a commissioner in England. And NHS in Northern Ireland isn't called NHS, it's called HSC, Health and Social Care, and has been integrated, I think, since 1974. I can't exact date, but in and around that time. And therefore absolute natural bedfellows in terms of health and social care. It is not the only answer can't be structured integration, okay. It's an enabler because actually the other things that enable it to work is political will, is the right flow of money, staff and skills. There's so much more to make this work, but having come from a system that was integrated, it really helps to have everyone around the table.

So as a chief executive in Northern Ireland, I had my director of social care, and I also had my director of hospital services, my director of mental health services, my director of community services, to have all the people in the room with one shared budget, because again, in Northern Ireland, it's not funded by local authority, it's funded through the Department of Health, is a good thing.

It is not the answer to everything. It's not the panacea. But it certainly makes it easier to say, right, where do we spend our money if you have ownership of the complete pathway and you can make choices that you just can't make if you're in a political system of a local authority. Now, so, I say it's not it's not the panacea, but I think it could be a really important step forward, given my experience of where I've come from.

Adam Brimelow

Yeah, yeah. And Natasha, I'm interested in your take on how far this integration could go. For example, the Prime Minister spoke about better alignment in roles across both services, such as on pay, as well as about social care workers potentially having a career pathway into the NHS. Is there anything else and what some of the barriers be to creating a more integrated service?

Natasha Currie

Yeah, well, I think the two systems are, as Shane says, need to work together. We can't have people falling through the gaps. But just to say social care needs to integrate with other services as well. You know, housing benefits, employment, it spans all of those things. So it needs to work around them. But having social care and health around the same table is really important.

It was interesting to hear Andy Burnham talking about the workforce. And I think, absolutely, we need to get more people into the social care workforce. I was slightly concerned about the idea of social care as a stepping stone into health. I think we need to think about creating social care careers as, you know, value valuable careers in their own right, not just I'm going to do this for a bit in order to get into the NHS.

So we need to be able to build careers and a workplace where people feel valued and fairly paid. And we already know that the Fair Pay Agreement is in train at the moment. It's going to be, you know, that's the Fair Pay Agreement for social care workers – it's a policy that's meant to be implemented in 2028, I think, which is looking at pay in terms and conditions for social care.

So I think it's important to think about it that way and not just think about health taking the staff once they're trained up in the social care.

I think everything that Shane just talked about in terms of how we integrate services better, I think it's partly about, you know, the incentives and the money being able to flow in the right way. But it's also about having the, the will, the vision, shared purpose in your area. What is it that you're trying to achieve and thinking about people's whole pathway and not just at the point at which they leave hospital, but trying to keep them out of hospital, doing the prevention, the investment in keeping people well and avoiding those admissions to hospital.

But, you know, this isn't new. We've had, what, 20 odd years of trying to integrate services. We know it's not easy. There are many barriers, but we need to be thinking about, you know, all of the different layers from the structure to the relationships to the culture and creating the right appetite and incentives for people to do this.

Adam Brimelow

Yeah. So, I suppose there's a temptation here, isn't there, to look for a pretty simple solution. So, I'm kind of suspecting you might want to shoot me down on this, but one possible idea, Natasha, bringing social care just straight under NHS control?

Natasha Currie

I'm not sure that is the answer. You won't be surprised to hear me say. I mean, I've just been talking about social care, it’s about enabling people to live their lives. The NHS is about cure and treatment. It's a different model. And I think fundamentally those two, I think it's right that perhaps they take different shapes. I think we have seen some examples of NHS trusts trying to take over some social care provision, and it's been quite difficult. And as I said before, you know, social care needs to integrate with all sorts of other services. It's not just the NHS. So I'd be a little bit worried about taking social care into a medical model.

Adam Brimelow

Okay. And Shane, many people hear of a ‘national care service’ and assume that social care will become the NHS equivalent. And I think we've heard a lot about equivalence in this conversation. But is that desirable, realistic or even the right ambition for both sets of organisations?

Shane Devlin

Yeah, I think first of all, if I could just come back on Natasha's point. I think it is really interesting. Social care is not the same as healthcare, okay. It just isn't. We have a model where we are trying to prevent illness, but the vast majority is still a sickness service and I totally agree. But it would be interesting because actually a lots being saying that social care becomes part of the NHS, it could become the NHS and social care becomes something new.

And at that point that's a different angle. It's not about social care being consumed into the NHS, but actually could we create a health and social care service? And I think that's something that's not even been put on the table. It's been around – it's about one being merged into the other. And therefore that gets back to your point Adam, my concern would be if we have a care, a National Care Service, then we're not integrating anything. We've got a national care service, we got an NHS service and they haven't actually come together.

And I suppose my concern would be that if you had something national, then the importance of neighbourhood and place really gets sidelined, because actually it's a national. And we all know, I mean, in my own patch of Bristol, North Somerset, South Gloucestershire and Gloucestershire, the makeup of our population is so different from inner city Gloucestershire to Western-super-Mare to the urban part of Bristol, and therefore a national service of anything trying to meet what are really different needs, I would have concerns – concerns is too strong a word – I can't work out how it would come together just yet.

But I would like to think that if we're going to do stuff together, then actually as a health and care service, not a health service and a care service, and that may is a step too far. But if we have the two, then unfortunately I think they will continue to compete, and one will see the other as their solution or their problem.

And that's often the case. I think in social care. NHS often see social care as the potential solution, but it's all their problem. And if we end up with two national services, would that just magnify? And I just I fear it might.

Adam Brimelow

Yeah. So thinking about a way forward Shane, you touched on your career in Northern Ireland, where for several decades, health and care services have been far more structurally integrated than here in England.

Yet some of the same challenges are there and evidenced, aren't they, about hospital pressures, funding constraints and so on. What did you think are the key lessons that England can learn from Northern Ireland and the way things are set up there?

Shane Devlin

Yeah. So, I think for quite a while the Northern Ireland system worked quite well. It is not working quite well at the moment. Okay. I think that's it's really important to state that. And therefore the key lessons are the integration itself – so we had integrated local teams which were social workers, district nurses, occupational therapists, physiotherapists all working as one team around the local person. That's great and that really can work. You can make the right decision for the patient there and then and actually in many cases before they become a patient because you work on the base of the population.

But I think actually the biggest learning is that simply putting two services together doesn't guarantee success. And actually what's equally important is the understanding the cultural journey, understanding what is the right funding model and the right levels of funding, understanding how work gets done, systems and processes. For me, the learning from Northern Ireland was when I was there at the local place level, having social care and health interwoven really worked for the patient.

I don't think when you get to the macro level, the point Natasha made, health and social care are not the only partners you know. Absolutely. It is about housing. It is about education. It is about, you know, the children's level and the adult level and the older person level, many, many other partners.

So, I don't think the answer, my  learning from Northern Ireland, the answer isn't simply health and social care integration is going to be wonderful and it's going to work. It's got to be done in a way that you learn from it, and there are values and benefits. But if you take Northern Ireland at the moment, you know the financial situation is not great, the politics aren't great. And therefore you could then say, well, integration doesn't work. And I think one thing which was great, it is still probably great around integration, was actually looking at career pathways because if the point that was made, you know, you could you could have a career path where you start in social care and then end up in the NHS. No, no, you need to look at health and social care pathways and that bringing them together allowed for us to explore joint roles and not just at the, you know, the band. Three Northern Ireland, for example, all social care workers are on Agenda for Change, therefore, you could look and understand how things relate across both health and social care.

There's some value in that as well, but it's not the panacea and it's simply putting two organisations together won't create brilliance, but it certainly helps to have everyone around the table.

Adam Brimelow

And Natasha does that ring true with you? You and the Nuffield Trust have been looking at approaches taken further afield, haven't you, in Japan and Germany.

What lessons do you think could be brought into focus here?

Natasha Currie

I think there's an awful lot to learn from other countries. I mean, we're 30 years behind in terms of social care reform of most countries, which means we have the luxury of learning from their mistakes and their successes.

And I think there's a lot to learn in terms of the process of reform and bringing the public on board about creating the impetus, the purpose, the vision and building that support.

And then in terms of creating a system that works, there's no perfect system. There's no system we can drag and drop and copy. But I think there are certain principles that have worked in other places that we could think about.

So, I think the first step in a lot of places was defining what it is. What is it that we want that works for us, that that addresses the problems that we as a society are facing? And then create a plan of how you want to get there. Don't tinker around the edges.

So, one of the mistakes I think we've made in England over the last 20, 30 years is to try and take one problem in the social care and fix it without thinking about the whole system and how that one fix impacts on the rest.

The cap on costs is an example of that. You know, the Dilnot proposal was a great fix for catastrophic costs, but alongside that, we didn't reform the revenue raising. We didn't reform how money flows. We didn't think about the impact on local authority capacity, etc. So we need a comprehensive plan.

And then other countries have put in place systems where there is a sort of consistency and a certainty. So as a member of the public, doesn't matter where you live, you know what you're going to be entitled to and access to, to an amount of care is guaranteed. And there's a clarity about what you might expect and then what your costs might be in the future so people can plan. And then they've managed to put in place a stability of provision.

So at the moment in England we have a very unstable provider market with care homes, home care providers going out of business and not leaving the market quite regularly.

Other countries have put in place stable provider markets, and they're working on creating a stable workforce alongside that. And based on the principles of fairness in each of the countries. So, I mean, any social care system that we create has to be rooted in social and cultural values of fairness.

And then the last thing I will say is just the balance between that having that national certainty but local delivery. I think the point Shane was making about the importance of tailoring services to local need, but I don't think that is in contradiction with having national sort of needs eligibility and a certainty of what you get because at the moment there's a real uncertain it's a real postcode lottery in this space. You don't know what you're going to be eligible for.

So I think there's an awful lot, a lot to learn from elsewhere.

Adam Brimelow

Well, thank you both for some really fascinating insights and perspectives from different places in terms of trying to tackle this really knotty and really huge problem. Be very interesting to follow developments. Really appreciate your time today on Health on the Line, Natasha Currie, Shane Devlin thank you.

That's it for this time. If you enjoyed the podcast, please subscribe and do share it with colleagues across the NHS. Also, if you have a great programme of work you'd like to tell us about, please get in touch, we may cover it in a future episode. Just email us at HealthCommsPlus@thenhsalliance.org

Health on the Line is produced by Health Comms Plus and brought to you by the NHS Alliance, which represents and supports the health and care system across England, Wales and Northern Ireland.

So until next time, goodbye.

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[Is summer the new winter?]

Adam Brimelow

Hello and welcome to Health on the Line. This is the podcast for policymakers and NHS leaders brought to you by the NHS Alliance. I'm Adam Brimelow, a former health correspondent, director of communications and now with the NHS Alliance media team. And you, Prime Minister Andy Burnham has hit the ground running on health and care, installing Yvette Cooper as the new secretary of state and signalling his determination to move at pace to strengthen devolution, reform social care.

As you might expect from a former health secretary with a long record of engagement in these issues as mayor of Greater Manchester, Andy Burnham looks like a man with a plan, or at least a very strong agenda. So, what is that agenda and what do you like to work with? We'll be hearing from someone who work closely with him in his Manchester mayoral days, to hear how his approach could take shape on the national stage.

And we're all familiar with NHS winter pressures, but now we're having to get used to summer stories of health services struggling with heatwaves. We'll find out how the NHS is coping and what more needs to be done.

But first, Andy Burnham is making a real impact as prime minister. Nowhere more than in health and care. I'm delighted to be joined by Mark Fisher, who until recently was chief executive of Greater Manchester ICB, a post he held for four years, working closely with one Mr. Burnham.

And welcome to Jane Merrick, policy editor at the i paper. Jane's been writing about politics since 2001 and was previously political editor at the Independent on Sunday.

It's good to have you both on Health on the Line.

Jane, could I. Can I start with you? How different do you think Andy Burnham's outlook on the NHS compared to what we saw under Keir Starmer? And what do you think are the big challenges looming?

Jane Merrick

Yeah, I think Andy Burnham will approach health in the same way he's approaching all policy across government, actually. He wants to be much more interventionist. He's obviously got experience as a former health secretary. He was health secretary under Gordon Brown's government, obviously. I think he's experienced two pandemics actually, on his watch, you could say.

I mean, he had the swine flu pandemic in 2009, which he learned a lot of lessons from. He’s spoken about how he wanted to sort of tackle public health and be more responsible in tackling public health. And then obviously, during the Covid pandemic, he was mayor of Greater Manchester. And really we saw that sort of that really interventionist on a local level approach.

And I think he's learned from those two pandemics. And even though the sort of they're not really on the agenda at the moment, I think he's taking that approach and using it in health. So obviously he's very big on devolution. He wants to see more devolution across the board, but particularly as we've seen in Greater Manchester on health.

I think it's really interesting that he didn't choose to keep James Murray as health secretary, even though it was a very sort of short-term period for James Murray. He solved the resident doctors’ strike. He was sort of seen as a safe pair of hands, I guess, in government. But he's taken a really, I think, intentional decision to appoint Yvette Cooper.

They know each other from the Brown era. She's a very safe pair of hands as well. She's very big on public services. As you say, she's sort of wants to tackle her two big priorities - are maternity and social care, which I think are two sort of, you know, they haven't had enough attention, I think, from politics over the last decade.

So, I think that's really interesting approach. So, part from the devolution agenda, I think putting Yvette Cooper in place sends a real message that this is sort of it's a real break from the Starmer government.

But then I think actually there will be similarities as well. I think the sort of the three strategic shifts that Wes Streeting introduced in the 10 Year Health Plan of from sickness to prevention, from hospital to community and from analogue to digital, these sit really well with the kind of the agenda that we saw in Greater Manchester under Andy Burnham, like the Live Well agenda.

So, I think there will be similarities, but I think it will be faster and more intentional, I think from Burnham and Cooper.

Adam Brimelow

Well, Mark, you worked closely with Andy Burnham when he was mayor of Greater Manchester. You were chief executive of the ICB, and I have to, before we get into some of the details of that experience, I have to ask you first of all, what was he like to work with?

Mark Fisher

Thanks, Adam. So, obviously I didn't report directly to the mayor because under the NHS governance, I reported into my chair, Sir Richard Lees, and then ultimately into NHS England. But we had very close and good relationships with Andy and his team, and I had many a one-to-one with him. I found him engaged, I found him involved and I found him profoundly supportive of everything we were trying to do, actually.

And I think that's the main thing I want to leave colleagues with. He was a very personable, supportive leader. And indeed, one of the great bits about Greater Manchester was the culture. And, you know, unlike maybe the Argentinian football team, there was a culture of playing the ball, not the man, and really focusing on issues of politics. And after that came from Andy himself, actually.

He was very serious but supportive leader of Greater Manchester system. And you could see that in the way people reacted and responded to him, actually. So, I think that's the main thing I want to leave with colleagues - main thought is a profoundly supportive person to have as Prime Minister and as Jane has rightly said, somebody also who deeply understands the nature of the health system and the challenges it faces and has a really coherent and sort of holistic view of what to do about it.

Adam Brimelow

Well, that's really interesting to hear, positive feedback and certainly we’ll all hope that all goes well for the future.

The region, of course, has often been seen as the test bed for NHS devolution. Its Live Well scheme, which has been described as one of the most ambitious prevention programmes in the country.

Could you just tell us a little bit about what has been coined as 'Manchesterism' and how it worked?

Mark Fisher

We've heard quite a lot about Manchesterism, haven't we? We've heard particularly how it works in terms of economic growth. And that is a profoundly important part of what people have coined as ‘Manchesterism’. I think we've actually heard less about what it means by way of public service reform, and less about what that actually means for the NHS, in fact.

So, I think the best thing I can do, and we've heard we don't yet know the priority, actually, at the end of the day, the government will give to public service reform over waiting lists and the day-to-day pressures of life in the NHS.

So, I thought that the best thing I can do is probably just colour in what it felt like to be part of the Manchester system and delivering Manchesterism on the ground, and that that will hopefully give some clues as to how that might play out across the country.

Adam Brimelow

Absolutely.

Mark Fisher

First thing to say was, you know, above all other things, we had, like every other part of the system, to focus on performance and money, you know, waiting lists, GP access, money. And actually we were, in the end of the day, quite successful in sorting out the money and bringing down the waiting lists. And that that will always be, I think, for every part of every part of the NHS system, probably at the top of the list in terms of what you actually have to get on and do.

But beyond that, there was a real focus on an integration of the NHS with other parts of the public service. For example, if you look at what neighbourhood health means in Greater Manchester, it didn't just mean putting health services into the community, it meant integrating those services with other parts of the public service in a very deliberate way.

It meant a real focus on prevention, using our integrated data set, our care record to enable us to really do some really great things upstream in terms of what happens in primary care and so on. And also this programme, which is called Live Well and Live Well. I was you know, I was really pleased that the NHS was a really important part of.

And that was basically saying at the end of the day: we need communities, we need public service to be integrated because actually people are citizens, they're not patients. Twenty per cent of people going to a general practice of Greater Manchester had no health need, you know. So you have to focus on things like social prescribing.

You also have to focus on everything you can do to enable healthy lifestyles and healthy communities. So that was the programme of enabling citizens to be more active. It was lots of practical things, like training every taxi driver to spot the signs of suicide. It was working with local community groups to enable them to play a full and active part in health. Small community groups, for example, some Muslin women in Oldham who persuaded imams that the right answer was to get people vaccinated.

You know, those sorts of things not unique to Greater Manchester but what was unique is seeing that as an entire philosophy and as important to the NHS as, you know, cancer care and all the other things.

Because actually that was the route to enabling people to live longer, healthier lives. And in one of the good things about GM was you could see that in the numbers, you know, Greater Manchester, and you could see that the numbers in terms of living longer, healthier lives had improved. And that was because part, I'm sure, I was always convinced that was part because we had this focus on the community.

So, we have this thing called the Live Well programme. And we have a real focus on prevention, and we have a real focus on integrated data. And I think those things will resonate and be seen more of across the NHS, depending ultimately on priorities and on the views the Secretary of State. But I'm convinced they will be part of the package.

I'm also sure that you will see a governance change, particularly in places like us where we have, obviously, a mayor and there are other mayors and other systems. And at the end of the day, you know, I think we will get further into joint reporting. So we'll end up reporting both to mayors and into NHS England.

I never had any difficulty with that. I always thought, to coin a phrase, you know, if you can't ride two horses at once, you probably shouldn't be in the circus. Actually, you need to know how to report upwards into two different systems, if you like. And it was a real, I always thought it was a real source of power to have local politicians firmly embedded on your side, actually, as you come to take those hard decisions.

I never saw there was a problem with that. I always thought that was something to be sort of worked on and to benefit from.

Adam Brimelow

And Mark, you talked about the success in helping people to live longer and healthy lives. I suppose one manifestation of that is demand for NHS services. Did you see a tangible impact on demand for NHS services during this period?

Mark Fisher

I saw that we brought waiting lists down, and I think that was partly the sort of supply of people needing treatment, but it was also lots of immense, enormous hard work by people in the trusts to get and doctors on the front line, other health colleagues on the front line to get those results. So, I think it was always difficult to see actual demand for people going into hospital reducing because, you know, particularly when you're dealing with a population with a whole layer of inequality, as in Greater Manchester, you know, there's always going to be demand for services, whatever you do.

But what I did see is really powerful specific programmes that you could see reduced demand. For example, we had a really great programme called BeCCor, Beyond Core, which was actually because of our integrated data, we could get general practice to real focus on potential citizens, patients, who are at risk having strokes. And we intervened early with the extra... And you could see the numbers, the numbers of people being referred to hospital with strokes fell.

So you can see particular areas we were having success. Whether you could sort of say demand for the NHS services in the round actually reduced less, less clear because there's so many other effects.

Adam Brimelow

Yeah. So, one of Andy Burnham criticisms, as you know, has often been that national government tries to control too much from the centre.

Jane, I’m interested in your sense of how far you think NHS decision-making can realistically be devolved? Who might lose power as a result? I guess there are risks associated with that type of approach.

Jane Merrick

Yes. I mean, we've just had some great examples of what happens when you do devolve health on the front line and sort of the effect on communities. But I think there are some things that can't be devolved or they or they work less well if they are devolved, like workforce planning, obviously you can do that on a local level, but nationally you need to sort of run a recruitment programme and that's obviously the workforce plan. You know, we're still awaiting an update on that. And that's a huge issue for staff and for unions.

I think central IT systems, which again, is one of the big sort of goals of this government. And it's in the NHS modernisation bill of a single patient data record of modernising the NHS digital platforms. It's really, really crucial. And I think that kind of thing has to be done on a central basis. You can't really have fragmentation.

And I think it will be interesting to see actually what Burnham and Cooper do with the NHS bill, because I think one of the measures in that is allowing the secretary of state to actually intervene with NHS organisations will, you know, Cooper, for me, you know, I was reporting on the Brown government back in the noughties and she was quite interventionist as a sort of instinctively interventionist as a secretary of state. Will she have that those instincts now under Burnham? Will Burnham and want to change the NHS bill and make it sort of take away those powers? So, sort of, I think that will be a tension.

And I think obviously in terms of losers, you know, there will be less control. We are going to see this sort of this devolution. There'll be less control from Whitehall, but ministers will still want to kind of own the good stories of the NHS. I mean, Andy Burnham, for all his talk about being sort of the devolution king, he's actually very interventionist. He's in a way centralising because he wants to own this agenda. And so when the next election comes around, how much of this agenda is he going to want to sort of, you know, to put his stamp on?

And I think there's a risk there, a political risk there, for politicians of when they can claim the good news or can they disown the sort of, you know, when you've got sort of waiting list going up in Newcastle, for example, but coming down in Manchester because of the work that's already happened there, who will pay the price for those good news and bad news stories?

Adam Brimelow

And Mark, you've described some of the benefits of devolution as you experienced it and you were involved with it. But do you recognise there are risks associated with this and there might be some areas where it just doesn't work so well?

Mark Fisher

Adam. Yes. Worth saying I mean, I worked for Yvette Cooper when she was welfare secretary. I was like market director just immediately after the 2008 banking crash. So, she was definitely interventionist, but hugely sensible and hugely, you know, engaged.

And so, yes, I recognise exactly what Jane has said about the way she will be with the with the NHS.

Now as to that the tension between top down and local has to play out doesn't it? And I think there'll be more to say and do about that. All I would say is from a from a local leadership point of view, you have to be able to ride two horses. You've got to be able to work with NHS England and ultimately with the secretary of state and respond to pressures and legitimate challenge upwards - money, performance, quality, all those really important dimensions, and you've got to be able to work as part of a system.

And that actually applies whether you've got a mayor or where you don't have a mayor. You know, there's always - you have to work in, you know, engage with local government, you have to work with community groups, and you'll have to work with the mayors. And I think that's always part of that. And Greater Manchester was a sort of just an extreme example of that. There are other examples too right across the system, and that's going to be - I do believe whatever happens that's going to be more feature of life. And the NHS has got to get better at doing just that.

The other point I would just touch you that I don't quite agree with Jane, if I may, is the central database point because, probably worth a longer conversation. But Greater Manchester has always had its own integrated care record. In fact, when Mark Britnell came into our system experience, he worked systems across the world. He thinks we've got the best data set he's ever seen across the entire world, healthcare world, which I think is quite something. And we built that ourselves. And because it already includes primary care and social care, it has more functionality than the Palantir FTP currently has.

So, I think we will carry on using that database ourselves. And it already covers 2.8 million people, and probably that bit of every other geometry, if you like, will be part of the will be part of the future. So, I think there are further debate and discussion to be had I think about how the federated data platform is rolled out, or whether that becomes maybe more of a use it to sort of explain you’ve got something better than a you must use it debate, if you like.

Adam Brimelow

Can I steer us on to social care? Because Andy Burnham, speaking with great conviction and urgency about the need to reform adult social care. So, drawing on a Manchesterist model Mark, how do you think that might work?

Mark Fisher

So, in Greater Manchester City, since devolution, we already had a pretty good integrated system.

The integrated care board looked after the social care system for Greater Manchester. The local authority chief executives, who obviously had that direct accountability, were my place lead. So they all - it was like a very integrated system and we had done a number of things. We integrated the data into social care, we had some joint roles, and we were very much experimenting with a whole range of ways of integrating the system.

But there's no doubt that it needs that push, that the Prime Minister and the Secretary of State will now be giving it. It absolutely does, in terms of status, pay, all capacity, capability, because there's no doubt whatever you can do by way of sort of integrating the data, improving the flows and so on, there are still far too many cases where, you know, it is weaknesses in social care are basically upstream and hospitals.

So, I think ministers are entirely right to focus on that. And also entirely right, I've heard shades of this, to focus on bits of the system, like the Continuing Healthcare bit of the system, which never really gets talked about or thoughts about enough, you know, that's £8/9 billion pounds of NHS money going into that. And I think that genuinely really needs grit and focus at a national policy level.

So, I really welcome that focus on social care, and I think that will be beneficial. As I say, we've already done what we can as a system to make things better. But that national focus, I think is going to be fundamental.

Adam Brimelow

Yeah. And you mentioned that Continuing Healthcare element there. Jane, do you see a point in the future where we see the proper structural integration of health and social care, the full integration, or are the barriers just too big?

Jane Merrick

I think it's really exciting, actually, that Andy Burnham is getting a grip of this. And I know that sort of you know, obviously we've been covering health for sort of, you know, decades between us. And he mentioned yesterday there have been 22-odd reviews. He obviously wants to have this, this sort of this fresh impetus. And there is a real energy.

You know, Wes Streeting, after he resigned, talked about how he wanted these cases review to go much faster. But Keir Starmer and Rachel Reeves were allegedly saying no, no, no 2028 is fine, which is, you know, far too long when you're thinking about the next election. Never mind having to get to grips of social care. So, I think he really, really wants to sort of make this work.

And he talked yesterday and when he was sort of launching this fresh drive, he wants to see a National Care Service sit alongside a National Health Service. Fully funded. I mean, again, there will be a sort of a whole new podcast of how that is going to be funded and how that will take place. But he wants us to, to really work.

I think there could be barriers, you know, when you have a whole new system that, you know, obviously integration is already taking place at some level, but when you have an entire new service, which is going to be free at the point of use for anybody who needs social care, there are bound to be sort of, you know, to be friction on a frontline level, I think, between those two things.

So, we don't know how it's going to work. And I think Louise Casey will have to really sketch that out. And she's obviously done some work already on this, but we need sort of more concrete plans of how that's going to work, because obviously there's an issue of funding. You know, he doesn't like the idea of private providers, but you can't take private provision out of social care because it will just collapse.

So, will there be a mixed market? How will that fit in with the National Care Service? That's free. The point of view, will there be regulation? Will there be extra regulation needed? Will there be a cap on what private providers can charge? You know how all of these questions, I think, need to be answered before you can suddenly just announce that there is this funding for a shiny new National Care Service.

Adam Brimelow

Okay. And because time is short, but Jane, a very quick final one for you. The Prime Minister's committed, as you know, to a ten-year plan for Britain, but we're no more than three years away from the next general election. What do you think needs to be done in that pretty short amount of time to demonstrate meaningful progress to the electorate?

Jane Merrick

I think for voters, actually, that Labour is so associated with health that, you know, when Keir Starmer won the 2024 election, he did it on, he really platformed that sort of we will bring down waiting lists. Waiting lists are coming down. But actually it's quite sticky still, you know, it's a slow decline in waiting list. So, I think we need to see - voters will want to see real dramatic improvements in those waiting lists.

We'll need to see sort of, you know, an improvement in corridor care, which is now becoming, I think the Prime Minister mentioned this yesterday, corridor care is now becoming the kind of the year-round norm rather than just in winter. Those winter pressures actually are starting much earlier. So I think they will need to see, I think the sort of the experience, the lived experience of voters have with their everyday contact with health service.

Yes, there are some amazing pockets of brilliance and exemplary standards in the NHS that people experience all the time. But there are some really difficult parts, and I think that's sort of those crunchy ends that will have to be improved. And as you say, yes, Andy Burnham has this ten-year plan, but there are only three years left.

Can he start to deliver his devolution agenda? Will that start to have real effects beyond just waiting lists? And can he present something to the electorate that says, if you stick with me, I can show you that, you know, this ten-year plan really will work, but it's going to take some time. And I think sort of this goes to the very heart of why he's prime minister, actually, that there is an impatience from the electorate to see results.

And Labour, as a party, felt that Keir Starmer wasn't delivering results more quickly. Andy Burnham has basically pitched his entire premiership on faster results. So, okay, now he's got three years to prove that.

Adam Brimelow

Okay, well the pressure's on there. That's really fascinating. Thank you both for your insights on Health on the Line. Mark Fisher and Jane Merrick. Many thanks.

It's summertime, but the living has most definitely not been easy for the NHS. Over recent years, we've become used to hearing about an NHS winter crisis almost as a calendar fixture. But even as plans are being put in place now to deal with rising winter demand, we're seeing a very different challenge emerging as a result of extreme hot weather and the impact it has not just on vulnerable patients, but on the ability of services and staff to deliver care.

Am delighted now to be joined by Matthew Hopkins, currently director for the NHS Alliance's Acute and Ambulance Network and previously a long-standing NHS chief executive of several trusts, providing leadership come wind, rain or shine.

And Dr John Martin, who's chief executive at the South Western Ambulance Service NHS Foundation Trust, previously chief paramedic quality officer and deputy chief executive at London Ambulance Service.

John's also a past president of the College of Paramedics. And John, I know you still go out on the road as a paramedic. What sort of challenges do you come up against when you step out on a blazing hot day?

John Martin

Yeah. Thanks, Adam. So, yeah, still really proud to be a paramedic. Keeps me grounded still able to practice. I try and do at least one clinical shift a month. But actually, in these extra heatwaves, we've all rolled our sleeves up to see the patients that have been waiting. And I think we fair to say it's pretty tough going working in the heat. All right driving to the calls with the air conditioning on, but the minute you step out into those 30 plus degree heats, well, I think we all know it. It's just more difficult to move your body. So especially when you get to having to, an extreme, if you're doing a cardiac arrest or doing chest compressions on a patient, but just a manual labour of moving patients around, talking to them.

I think we all feel a bit more, a bit more stressed, a bit more under pressure when all of our limbs just take a bit more moving so that that can be difficult in this hot weather.

Adam Brimelow

Yeah. So, lots of additional pressures there for your colleagues on the road. And we'll be getting into some of the details and challenges and the repercussions of that.

So just to kick off, really, Matthew, you all know that that last month a letter went out to the system on how the NHS should prepare for this winter. So, planning ahead for those winter pressures - is the NHS and its policy set is still too focused on winter pressures and not sufficiently prepared for what we're seeing as the growing impact of heatwaves?

Matthew Hopkins

Yeah, it's an interesting question, Adam, because of course, in the service, our members will reflect that we have winter. Winter comes every year. Whereas in recent years the increased prevalence of heatwaves, consecutive days of over 30 degrees temperature is a relatively newish feature. And yet we we're not seeing the same level of attention from the centre in relation to kind of summer planning per se. Although I think it's fair to say that pretty much every NHS organisation, obviously we've heard from John in relation to the ambulance service, but in terms of general practice, mental health trusts, community staff and hospitals are all now very much focused on making sure that business continuity plans are in place and that they're trying to be as prepared as they can for that period of time during the summer when temperatures will be high.

And we should, you know, not only pay tribute to John and John's team and the ambulance staff, but actually NHS staff across the organisation and their leaders have been really, really rising to the challenge and stepping up to make sure their patients are kept safe.

Adam Brimelow

So, John, when a heatwave sets in from an ambulance perspective, what changes are seen in terms of demand for services?

John Martin

Yeah. Well, an increase. So, in the same way as when it gets cold we see an increase in demand. Turns out when it gets hot and especially when it goes above 30 degrees C. So, we can manage in in the 20s but for every degree it goes above, we saw an increase in demand, and that happened around the country. Obviously varying amounts of temperature in the last three heatwaves that we've had.

For us that meant down here in in the south west, so the bottom corner of the country, we experienced our biggest day on record and that includes the Covid period and winters. So, we had in the June, so that's the middle heat wave, we had more 999 calls in a 24-hour period than we've ever recorded. So for us, that was just about 5,000, resulting in about 4,200 incidents. The same period last year, so back in June, we'd been running at about 3,200.

So, it says a big increase in the amount of 999 calls we had. A whole range of people phoning. We know when it gets hot our bodies struggle. Especially true if you are an older person, if you're in that bracket, 70, 80, 80 plus, was where our biggest increase in activity was. That age group being able to cope in the heat and maintaining the heat. Also little people. So, the other end of the spectrum, those five and under also struggle with maintaining their temperatures.

So, we saw essentially our increase in demand was fallers. So, more people falling over, especially the elderly, more faints and heat related. So, just becoming over overwhelmed. I went to one of the calls I went to in one of the heatwaves, was a runner who decided that going out to do a 10k run in the peak of the day was a good idea. Evidently not a good idea for you.

We also seen breathing and cardiac disorders get worse, and that's to do with how your blood responds when you get hot. So, we know that, you know, you're more likely to have that. We've seen higher acuity patients as well as that end of people struggling, that you might say a lower acuity patients.

I think we've noticed in the south west, I'm sure probably true across the country is an increase in water related incidents. So, we'll just do a safety pitch because I'm sure many people listening will have, especially children and teenagers and probably us ourselves, it looks very attractive when it's 35 degrees C, but we saw an increase in drowning-related incidents. And that is not nice and not good for people. Obviously.

Matthew Hopkins

John, in terms of the, I mean, I totally agree about the water-related incidents, but it used to be the case that the respiratory problems would come on a few days after the particularly hot days. Is that still a feature? So, it's not just those days where you've got consecutive 30 degrees, but actually the rest of the following week is sometimes that prevalence. Is that's still a feature?

John Martin

Yeah. So yes. Increasing certainly breathing difficulties continues. I think especially this last run of heat we've had you know the temperatures didn't drop at night. We didn't get that respite bit that we often get. So, it really changed seemingly in our weather pattern. And that has certainly seen, yeah, an impact on, like I say, breathing problems and cardiac disorders. So we've seen more strokes, more heart attacks, more cardiac arrests.

Adam Brimelow

Yeah. Because there's always been that perception hasn't there, that that summer is a quieter period for the NHS. I'm not sure if that's ever been actually true but is that the case now? It sounds like it isn't.

John Martin

Not for us this time round. So we definitely will say be seeing the same, same thing.

I mean, I think if I go back historically, I've been in the 26 years, there was a period where summer was, I think probably a combination of factors. I don't know that we have lots less demand, but other bits of the service running better, how you manage your and probably more in Matthew's maybe but elective flow, opportunities around that, annual leave, where you put your training through the year, etc.

So, I think summer generally did have a feel to it that we didn't have when you get to winter and ramp up, but certainly for us this summer has been extraordinarily tough and I expect we're in probably this was as a common feature now and demand across the year.

Adam Brimelow

And Matthew is that your sense from a more acute based perspective that summer?

Matthew Hopkins

Yeah, very much so. I think the years of that slight lull in urgent care activity as well. So the non-ambulance conveyed emergency work that doesn't really reduce at all across years. Pretty flat across the year including that sort of peak period during the summer and during the peak dark months of winter.

I think it's also worth pointing out that as the organisations have had that drive to reduce waiting times and reduce the size of the waiting list, every single element of capacity is being optimized in terms of productivity, where we've seen significant across our membership improvements in productivity and that's all year round. You know, annual leave management is much better organised now across the NHS. So that will be a feature as well. But the emergency and urgent care demand certainly does not have a summertime lull at all. In fact, as John has said, you know, peak months have been more in May, June and July than ever before.

Adam Brimelow

I suppose when you get in…

John Martin

I think…

Adam Brimelow

I'm sorry, John. Yeah?

John Martin

I think the other bit we've seen compared to history, and certainly, when I served the ambulance services, we had, I think you could call it latent capacity, but we had spare ambulances. You would go and see a patient, then you would finish seeing that patient and then you'd be available for the next call. Quite often you'd go back on standby.

We are in an era, and have been really since Covid and probably before, where actually there are there's always a patient waiting for the next one. And that actually means when you get a peak, so, like we've seen in these heatwaves, there isn't a spare amount of capacity. The way you then have to deal with that capacity is prioritising the patients that need you most and other options we take like moving everybody to respond clinically, which has other knock-on effects for us as an organisation. So, there isn't there isn't a headroom if you like a spare capacity that there once was.

Adam Brimelow

Yeah. And I guess that when you get a heat wave, then there are going to be issues in terms of the performance of the NHS, in terms of the ability of the buildings to stay sufficiently cool for equipment to work, staff productivity, you know, keeping the ambulance fleet on the road.

Is that your sense that there are all these logistical issues that come into play? Matthew.

Matthew Hopkins

Yeah, yeah, I mean, there's pretty good evidence that we've captured and gathered from our membership over the course of the last couple of months that the significant strain on ageing infrastructure across hospitals, across mental health units and GP surgeries has had a major factor.

I mean, we've heard from GPs that they've tried to change the times of elderly people that are coming in for appointments with their GP so that they're not coming in during the peak hot period in the day. So, they are trying to respond in that way.

We've also heard from members that cooling systems have come under significant pressure in relation to, for example, the dependence now on digital and IT and computers to run hospitals. They need big server rooms that have to be kept cooled -cooling systems under significant pressure when the temperatures above 30 degrees.

And we've also heard from our members where operating theatre cooling systems have failed, and therefore the operating theatres have had to be shut down. And inevitably that has an impact on patients, sadly, and also the overall productivity of the hospitals.

So, there are a range of significant impacts, both in primary care, in our hospitals. And I was going to ask John about how ambulance staff cope with wearing heavy, quite thick uniforms. We've heard a lot from our members, our community providers and our hospitals that the national uniforms now are really not particularly kind during really hot weather and that inevitably, I'm sure, is having an impact on staff. I don’t know where that's a factor for you, John, but we've certainly heard from a hospital and community members that's been a challenge.

John Martin

Yeah, I think we did issue shorts to our staff who wanted to have them over this period as a number of ambulance services did. A bit of a change in that. You may have seen some paramedics out and about, in shorts. So, I think that's new for this country.

It’d be fair to say, we have the same uniform all year round. It's a standard issue. It's a national procurement. So, we all have the same uniform across England. Well, I'm wearing it now. It is quite thick. It's not what you probably buy yourself as comfort sport wear. It's obviously durable. I mean there's a balance here. It's obviously good for infection control. It's durable. We can use it in all seasons. But I wonder if that is something we do need to reflect on. As an NHS organisation.

I mean, we obviously don't have buildings in the way hospitals do where we have to treat patients. We did experience, we use a lot of tech to answer phones quickly. We did experience overheating of some of our IT equipment. So even though we're in cooled rooms, struggling to cope in that period, I'm sure that infrastructure wise for the NHS something to think about.

We had quite a few breakdowns of our vehicles because they were just struggling, so we're trying to keep them on road. Our fleet technicians did extra hours to keep our ambulances as available as they can do.

And we don't have fridges on ambulances because we've never really needed them. So, because the drugs that we use in the pre-hospital environment actually cope well in heat and you'll know drug medication management commonly in fridge in hospital. But actually, some of our drugs certainly one we use for diabetic emergencies, glucagon, struggles, it would it becomes ineffective above 30.

So, we've had to throw some of that out because the temperatures have gone above where we would normally expect. So, there will need to be some reflection on. And do we need to change our operating environment, essentially the back of the ambulance in this heat?

Adam Brimelow

Yeah, it does make me wonder in terms of the preventability of some of the issues you've been describing. I suppose either for the service or the public themselves. Are there other changes that could be put in train that could help us to deal with these pressures and head them off? What do you think, Matthew?

Matthew Hopkins

Yeah, I mean, I think for a lot of our members that are running hospitals that are very old and where infrastructure’s really under pressure, many of those hospitals are carrying significant levels of backlog maintenance.

In some cases, some of our members tell us that, you know, that that totals, in some cases, more than £100 million worth of cost. And inevitably, those boards of those organisations will be regularly discussing and focusing on the risk management associated with the trade-offs that they're going to have to be dealing with, you know, fixing a roof of a building to make it, you know, safe and watertight for winter versus installing air conditioning and potentially the impact on the electrical infrastructure, though for three days in the past of 30 degree temperatures, which are now becoming potentially 30 days across the sun.

So these are the real trade-offs that that boards are having to deal with, which is why the NHS Alliance has been pushing hard for this continuing focus of government on increasing capital availability - not just for the, you know, for new scanners or for new mental health units aligned with emergency departments, but for that real challenge around backlog maintenance.

And I think it's fair to say that our members across all areas are really being innovative. They're thinking about the way in which they support their staff to work in different ways, the way they make sure their patients are kept safe and they're doing a fantastic job. But the reality is that when you're delivering care in the 21st century, from buildings that were built in the in the 1940s, in some cases even earlier, you're really - you're on a hiding to nothing.

So that's where I think the real focus is going to need to be for government is around that capital availability.

Adam Brimelow

Yeah. Interesting. You talk about capital investment. So I'm going to put you on the spot now, John, and ask you if you had one investment priority to make services more resilient to extreme heat, what would that be?

John Martin

I think I mentioned it earlier. So, it's the flex. It's the headroom you need to invest in services. So winter's maybe a bit more predictable. We know when Christmas New Year is going to be. We put plans in heat waves though. We're talking about the whole of summer. We're looking like we get like a week, a week and a half notice of it's going to spike, and often it's still changing the day before. Is it going to be an amber, yellow, red heat wave alert? We need we need some headroom built in. And that that does come at what looks like an unproductive, is genuinely saying you want to have some paramedics sitting around waiting for a call, but actually, if you want to be able to cope and ensure that we can get to those patients, that's where I would invest a bit of money just to create some headroom capacity, especially if we think it's going to be the spikes that come.

Matthew Hopkins

Yeah, yeah. And for me, I think I'm sort of taking a step back and thinking on the widest point. I was talking to one of our acute hospital chief executives only earlier this afternoon, who was reflecting that, you know, after the heatwave, she's managing 27 per cent of her bed base in an acute hospital with people that arguably could be cared for in a different setting.

So there's a real importance for us to continue to focus with all parts of the NHS across the year, not just during heatwaves, across the year. I'm making sure that that we're looking after people in the right care settings.

So really focusing on that neighbourhood care, really focusing on supporting general practice and community services in the right way, as John said, ambulance services as well, to make sure that there's the headroom to be able to make the right decisions around patients.

I mean, you know, John, not speaking on your behalf, but ambulance trusts have really increased the number of ‘hear and treat’ and ‘see and treat’ patients that you're seeing.

So, there's innovation and transformation going on everywhere. But I think part of the solution to increasing the headroom will be that focus on integrated care across a wider system. So people really only cared in the right place at the right time for to meet their needs. That's one, slightly tangential Adam, I'm sorry, but you know, I think that if we get that right, it’ll put a bit more resilience in for, for the hot weather as well as the cold weather.

John Martin

And I think those pathways being available.

So you're right, Matthew, I mean, I think here in the south west, generally about 20 per cent of our 999 calls, we managed to not send an ambulance to. So, we hear and treat is about one in five. The peak of the June heatwave, we got up to 41 per cent, so of our patients that we were referred to. So that did require partnership working, it required services to step up across the south west. But the more they can be available in normal times as well, that allows us to keep the ambulances for the higher acuity patients. But all patients reported. So there does need to be a service that is there to pick them up. There's very few patients that don't need anything when they call, they usually need something. And that often is another service. Sometimes we are able to do advice and close the case, but quite often it needs to be someone else picking it up.

Adam Brimelow

Okay. Dr John Martin, Matthew Hopkins, thanks very much indeed for joining us on Health on the Line.

Well, that's all we have time for this time round. If you've enjoyed the podcast, please subscribe and do share it with colleagues across the NHS.

Also, if you have a great programme of work that you would like to tell us about, please get in touch. We may cover it in a future episode. Just email us at healthcommsplus@thenhsalliance.org.

Health on the Line is produced by Health Comms Plus and brought to you by the NHS Alliance, which represents and supports the health and care system across England, Wales and Northern Ireland.

Until next time, goodbye.

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[Does the NHS have a leadership problem?]

Adam Brimelow

Hello and welcome to Health on the Line. This is the podcast for policymakers and NHS leaders brought to you by the NHS Alliance. I'm Adam Brimelow, a former health correspondent, director of communications and now with the NHS Alliance media team.

Today we're talking about leadership, not political leadership, though we will get on to that in our next Health on the Line edition, when we consider the consequences for the health service of a new Prime Minister and Secretary of State.

For now, though, our focus is on NHS leadership and plans to strengthen, support and develop it through the new NHS College of Leadership and Management, because the health service has always and will always need good leaders, never more than now. We'll hear from the chair of the college, Ed Smith, in a moment.

And then, six months since the passage of the new Mental Health Act, we'll look at a key step enshrined in the act to help ensure clinicians deliver the best possible care for people in crisis. More on that in a moment.

But first to Ed Smith, chair of the NHS College of Leadership and Management, well known to many of our members, of course, from your previous involvement with NHS improvement and as a non-exec NHS England. So that must have given you a lot of insight into the impact of leadership, good and bad, over the years.

Ed Smith

Yes, it did and it was great and enjoyable time because at the end of the day, it is one of the most premier and important public services in this country. And I went around hospitals every month or so seeing great leadership, great management at all levels in the organisation was great.

I mean, clearly there were accidents, their mistakes. But at the end of the day, it is a fantastic service and one that needs continued investment and continued focus on leadership.

Adam Brimelow

Yeah, and of course leadership is so important. But let's start at the real basics here. Why does the NHS need a college of leadership and management? What are you hoping it will achieve?

Ed Smith

Well, I think where we are at the moment is, has been a sort of undervalued approach to leadership and management, partly because of all the pressures of other things that have been going on.

But it's absolutely clear to me, not just through the role in my health service context, but in other things I've done, that excellent leadership improves staff recruitment improves staff retention, improves staff experience, improves - in NHS context - patient care, in other contexts, customer loyalty and some of the best organisations in the world in which I've lived always have a strong investment in leadership and management, and I think the NHS absolutely deserves that.

And I think where we are at the moment, if I'm honest, Adam, is outstanding leadership and management is really challenging in the current context. It's fragmented, it's inconsistent, and it's not high enough on the list of priorities of the service.

Adam Brimelow

Yeah, and it's certainly true, isn't it, that the NHS leaders, NHS managers have often been portrayed as a cost rather than an asset?

So, is the creation of the college an admission that that management has been undervalued?

Ed Smith

Certainly, where I sit, I think leadership management has been undervalued. It affects staff. It affects patients. It affects all the delivery components of the health service. And I don't regard investment in, or money spent on, managers and leadership as a cost. It's actually an investment.

And being an accountant and a businessman by background, you know, my view is you have to look at the return on investment in leadership and management in the same way that you do in other aspects of investment. It's no different to that. So maybe we'll come on to that. What is the return on investment? How do you actually benefit from strong leadership and management in the system?

But I do also want to say we do have exceptional leaders and managers in the system already. This isn't not starting from a zero base. Quite different. We just have a fragmented and patchy approach to what we need to do.

Adam Brimelow

Yeah. So, let's project forward a little bit. I'm interested in getting more of a sense of what success will look like from your perspective, to, you know, the number of people receiving training.

That's one aspect of it, isn't it? But really in terms of tangible effects, how will staff and patients, as well as people in leadership positions themselves notice the difference in a few years’ time?

Ed Smith

Yeah, and this is a really good question because I'm going to start by, not claiming, sort of, that it's not important, quite the reverse, but the college is not a panacea for everything in the NHS. So, what we need alongside what we're doing is stable organisational model for a period of time investment in what I call the infrastructure of NHS, which in addition to estates and equipment is investment in people.

And we need to harness digital and AI. And that's that forward projection of all of the contributory factors to an improved outcomes. Because ultimately my return on investment is improved outcomes, better performing service, longer retention of people, a greater pipeline of people coming through into leadership and management roles and clarity on what is expected in those roles.

So progression, retention and clear pathways are things that I think I can say are outcome measurements of the college.

Adam Brimelow

Yeah. And in terms of delivering those outcomes, delivering that kind of progress, what's the place for to recognise standard qualifications and continuing professional development?

Do you see NHS management becoming recognised as a profession in the same way as other colleagues in the health service? And what does that mean for people already in leadership roles?

Ed Smith

Yeah, I think to go back to where I started, which is this is the premier public service in this country, and it's highly regarded. It's absolutely pivotal that we get it right. So, I think, you know, standards are really important. Competency frameworks are really important. What we're trying to do with the college, and what we will do with the college, is bring together in a single framework, the leadership and management expectations of what excellent leadership looks like.

That will be our North Star, our guiding star for everything we do, for all the programmes that are run by us or by accredited providers and for existing leaders, that means that they will have something to look at about what they might do, what they need to do. And for people coming up through the, as we say, step in, step upwards and step on, as the three dimensions of a career gives them the next level of which to aspire to against a framework.

And, you know, that framework then helps people with self-assessment as to where they are. It helps the development conversations they have in part of their performance appraisal. It helps with what we hope will be a 360-degree appraisal process, which includes development as opposed to development being a separate byproduct of people management.

Adam Brimelow

And, Ed, one aspect of this that we haven't yet touched on, but is potentially very important, is the fact that governments previously set out its intention to introduce regulation for NHS managers.

How do you see the relationship between the college and regulation? Are they complementary, or do you think there's possibly a risk that one becomes focused on development while the other focuses on compliance?

Ed Smith

Yeah, there is a risk. And I think it's clear that from my perspective, the regulation sets a floor around competency, around behaviours, around the way in which one expects people to do their work. And that is not a college responsibility. But setting that floor is an important aspect of the NHS.

What I want to do in the college is set a ceiling, which is what to aspire to, how to get there, how to increase the pipeline of talent coming into these roles. From the graduate management training scheme all the way through to the c-suite, the executives and indeed the board. We just launched a board, non-executive board programme to try and encourage the, new applicants into the boardroom from a whole range of diverse backgrounds.

So, I think regulation’s necessary. I think it's more, you know, I wouldn't have, personally, wouldn't have a register of all managers and leaders. I would use the regulation of the sparring tool rather than anything else. But that's probably beyond my pay grade to determine.

Adam Brimelow

Ed it’s interesting, you were talking about, you know, looking for aspiring leaders and offering support because certainly it's true, a criticism of leadership development in the past has been that opportunities often come once people have already reached senior positions.

So, you say the college is going to support aspiring leaders, particularly people leading services departments and neighbourhood teams. Presumably that's a key priority for you.

Ed Smith

Yeah, I mean there's an ice hockey player, Canadian, called Wayne Gretzky and he said skate to where the puck will be rather than where it is. And I know that's a bit of a simple simplicity, but we have to have a college and a framework that looks to the future.

So, neighbourhood. So, it's the three left shifts of hospital to community, analogue to digital and treatment to prevention that are inherent in some of the skills and some of the adaptation that's necessary in the leadership cohorts.

Coming back to your point about at all levels. There are two things that I've sort of lived my life in business. One is leaders, developing leaders. So, you don't just send people off on a course and expect them to come back magically different. Most evidence would show that, courses amortize at around about 50 per cent of their value within six months. So, this is leaders developing leaders in the workplace as an inherent part of their job.

And secondly, it's leadership at all levels. It's not just the c-suite. It's all levels of organisations have leaders. It's identifying them, developing them, creating the talent pipelines.

And the college, one of these measurements will be, have we increased the pipeline of flow through the system from early-stage leaders through to c-suite leaders?

Adam Brimelow

Yeah. So clearly, you're thinking about a long-term approach, a strategic approach to leadership development.

Many NHS leaders, of course, will worry about adding another layer of requirements at a time when they're already stretched, dealing with the day-to-day pressure.

So how can the college raise standards without creating more bureaucracy or taking leaders away from leading?

Ed Smith

Well, I think leaders leading create leader and always really great leaders always find the space to have the leadership component.

What we're doing is actually simplifying some of the pretty fragmented, difficult, defined, patchy programmes and things that exist into a single spine framework, which is quite easy, which is quite self-assessment orientated, but actually is part of the integrated approach to people management.

So, I would hope early indications from last week's read out of what of leadership management framework that we launched is, you know, early days, but at least it's there.

Let's make it work. Let's look to the positives of it as opposed to say, no, this isn't fit for purpose because actually it was developed with over 1,000 people contributing to the framework from all parts of the service. So, I'm genuinely hopeful, and my expectation is that it will be well received and well implemented.

Adam Brimelow

Yeah. And it's really encouraging and positive to hear you sketch out that very positive vision.

Of course, there will be some, though, who are little sceptical, need persuading. So, what would you say to convince a sceptical chief executive or clinical leader that this will genuinely help them to deliver better care?

Ed Smith

One of the things that is pivotal about the way I work, the way our team will work, the way Steve McManus, our chief executive will work, is very, very strong engagement with the service.

We are there at the behest of the service to support the service. My board will be comprised largely of people from the service. I'm going to have a clinical senate, which we'll be looking at the radar screen and anticipating what needs to be done. So engagement, engagement and engagement, which I know is a simple word, but actually is part of the guiding light that everybody in the college will operate within.

And listening, you know, I mean, the standard thing, we've got two ears and one mouth -better to use the two ears than the one mouth. And we'll listen actively to the service and particularly restructures as we move to a, I suspect, more devolved delivery of healthcare.

Adam Brimelow

Ed Smith, thanks for joining us on Health on the Line. And good luck to you and your colleagues at the college.

Let's turn now to mental health and a step to help people set out how they would want to be treated if they become unwell and need to be detained in hospital under the Mental Health Act.

I'm talking about advanced choice documents, or ACDs, which have been shown to reduce involuntary admissions by up to 25 per cent, as well as helping to address racial disparities, empower service users and improve therapeutic relationships.

Under the act, which received royal assent last December, integrated care boards have a duty to let people at risk of detention know they can make an ACD and have support to do it. Clinicians must consider these documents when providing treatment. As a result, all trusts will eventually need to offer them.

So, I should say in advance. The conversation coming up includes reference to suicide.

Maudsley Charity has funded the largest implementation and study of ACDs in Europe at South London and Moorfields he NHS Foundation Trust and is now developing support for many more trusts to embed their own ACD programmes. I'm delighted to be joined now by the charity's chief executive, Sarah Holloway, and also by Steve Gilbert, who's a lived experience consultant and chair of the Mental Health Advisory Group of the NHS Race and Health Observatory, which is hosted by the NHS Alliance.

Steve has worked over many years to combat racism and enhance outcomes for people living with mental illness.

Steve, could you just tell me a little bit about the work that you do in that field?

Steve Gilbert

Yes. I'll try to keep this concise. I think it's probably first most important to say that I, you know, my experience is that of a person the lives of bipolar disorder. I live with complex PTSD. I'm a suicide attempt survivor, and I've been in adult mental health services since 2008, and I've been detained with the Mental Health Act.

That's what led me into this work. And it was by accident. But turns out I'm pretty good at policy work, pretty good at arguing. And yeah, really found my feet at the intersection of serious mental illness and particularly those experiences of black men.

And that ultimately led to me being one of the vice chair of the Mental Health Act review. So, for me, that's what lived experience kind of consultancy looks like, just know that looks quite differently for other people. Other people have different journeys and different experiences. But I think it's important to say that, you know, many of us had our lives diverted and then actually many of us find our way back and, you know, are happy to kind of work alongside all of you. But we don't necessarily have a job title that is, is that easy to understand.

So, I think it's an important, you know, an important question. And thank you for asking that, Adam.

Adam Brimelow

Well, you know, fantastic that you bring the skills and experience that you have to bear to make such a positive contribution. So, Steve, could you just tell us a little bit more about advanced choice documents, when and why they're used?

Steve Gilbert

So, in short, an ACD or advanced choice documents are a way of recording a person's wishes and preferences when they are well. So they are initially going to be offered to people who have previously been detained.

So, we're talking about people that we know their mental health has got to a point where they required inpatient care. They will have an understanding of what worked and crucially, they would understand because what doesn't work.

ACDs are not a new thing. So, people might have heard of the term kind of ‘advanced directives’. What is different moving forwards is that they now have a more statutory footing. So, there is the right to be able to get one.

But essentially, they are a way of ensuring that at that point, especially when you're heading into crisis and you may or may not have capacity, but what we know is that during those times of crisis, patients are routinely not listened to. Patients’ rights and their opinions can be quite easily disregarded. So this is a way of safeguarding against that.

I think one of the important things to really bring in here is that they are a really key measure that came out of the 2018 Winter Health Act review to start to redress the disparities that exist around race. So they are the only intervention that I've been shown to have a really significant impact on reducing rates of detention for people from black, Caribbean and black African ethnicity.

So, they are documents, and I think that's quite important. And that really relates to the fact that we're going to be recording a whole range of information there.

The starting point would be treatment and medication. So, what's going to be really important here is you will not have the right to say, I don't want any treatment at all. That's not the case. But what you will have is, a right to refusal.

So, if you've been detained before and actually you were on medication A, which works for the majority of people, but for you gave you really, really bad side effects, you'll be able to say, actually, that didn't work for me, but I know that drug C in the past has worked. As long as it's NICE approved, you know, it's on the list and in that conversation in preparation, so you're preparing your ACD, you've discussed this with your psychiatrist, with your care team, if agreed, that is what you can put into that document there.

So, then what that means is that if you are detained, you've got that preference recorded. Now, it's not to say that the clinicians that are responsible for detaining you have to follow that regardless. They still have to use their professional judgment. But what should happen is, is that ideally everything's okay, you're given that drug. But if you're not, that a really good explanation and reason has to be recorded as to why.

So again, you know, it's one of those safeguards and again, a really important part around voice.

The other end of the spectrum might be you have a cat and actually you're going to find it very, very difficult to be taken into hospital if you don't know what's going to happen to your cat. Now, in discussion, you might have said, actually, I've spoken to my neighbour Barry. Barry's offered to take the cat, but when it comes to it, actually Barry's not in a position to be able to take care of your cat.

We can't legally force your neighbour to take your cat, but I think that one of the things that's really, really important is that ACDs are relational and they get beyond just the kind of the core parts of care. They really get into what's important in your life. And it could be anything. So, you know, which relationships are really important to you, which parts of your life will need attention?

I'm self-employed, so actually if you're going to detain me, you've got to call my accountant because the bills still have to go out. And actually, you know, my assistant will need to know. So, there's things that are really, really specific to me. There are family members I do not want involved. There are people who don't fit into any family structure who are absolutely key.

How we’re addressed, cultural preferences. Believe it or not, when I'm depressed, I'm completely mute. And so again, kind of, how do you get a sense of what Steve like when he's in a crisis? So there's, there's a whole range of information that we're looking to capture there.

Adam Brimelow

And Steve, you mentioned there and talked about them being particularly relevant for people from black communities. We know this is aimed at reducing inequalities in mental health care.

Sarah, tackling inequalities that's a big priority under the Mental Health Act, isn't it?

Sarah Holloway

Yeah, absolutely. We know that rates of detention are so much higher in black communities, and that's a situation that's got to change. And at the moment, the most evidence-based way we have of doing that is implementing and using advanced choice documents.

And as Steve said, they're so much more than just a kind of a document or a piece of paper. It's about fundamentally shifting the relationship between a patient, a service user, somebody in crisis and their care team. And we also know that other approaches are necessary if we're going to really tackle this longstanding inequity in mental health care.

At the Maudsley Charity, we're really focused on funding innovations at the intersection between the NHS and the voluntary sector, because we know that's where different kinds of care can really be delivered there. There are ways in which care can be delivered in the voluntary sector, which the NHS just can't do, can reach into communities that NHS alone, can't reach into.

So we're really passionate about advanced choice documents, yes, but also if we're serious about addressing that long-standing inequity and mental health care, it's about partnerships between the NHS and the voluntary sector.

Adam Brimelow

Yes, because this is clearly, I mean, we've heard something of the benefits to be allowed here for service users, but we've got a mental health system under enormous strain and this is something that could really make a difference for the NHS. Is that what you're saying, Sarah?

Sarah Holloway

Absolutely. And we know that the need that's out there fundamentally outstrips the capacity of services to respond. So, we have to find new ways of delivering mental health care.

There was data out from the mental health charity Rethink at the end of last year that put the number of people waiting for a mental health treatment at 1.8 million, and what was really interesting in that same piece of data analysis, was the fact that the number of people waiting more than 18 months for a mental health treatment was 12 times the number waiting more than 12 months for a physical health treatment. So, we we've got that real inequity there at the moment.

And at the same time, you've got a situation where the share of the spend on mental health out of the total NHS budget is declining. And that's the situation that we really want to see systems reverse.

Fundamentally the challenge that mental health systems up and down the country will be grappling with is how do you rebalance the provision of care from the acute and crisis end of the spectrum and put care and support and treatment where people want it, which is in the community.

So it's really how can you shift resources into the community, foreground the therapeutic relationships in the community, prioritise evidence-based interventions and treatments that we know work and bring in the kind of broader psychosocial support that people living with severe mental illness need in order to stay.

That's not an easy shift. That is the job of decades of transformation. But we're seeing really positive examples of where it is happening, and we know it can be done.

 We're obviously talking today about advanced choice documents but there is another really promising shift in the mental health system that we're seeing at the moment and that we're involved in.

Just to kind of underline and point to one other, there are these really exciting 24/7 neighbourhood based mental health hubs, six of them across the country. We're involved in supporting and funding a very special one here in Lewisham at Heather Close. And the ethos in those hubs is fundamentally different to what we've had in community mental health teams. The ethos is one where people are members of the model, the members of a kind of community, rather than patients who are kind of referred into and then discharged out of a service.

So, it's about a membership, and it's about people being able to move in and out of support flexibly without that cliff edge that can so often send people into crisis.

Adam Brimelow

Yeah. So good to hear about the work that's going on that's making such a difference on mental health in the system where we often hear about the so much of other challenges and difficulties.

So, what is what is Maudsley Charity doing to support more trusts to implement ACDs?

Sarah Holloway

So, we're really fortunate at the mental health charity, at the Maudsley Charity, sorry. We partner with some amazing organisations in mental health, and we believe that we can find innovations that work here for really diverse communities. And then we're really committed to sharing and spreading that learning.

So, we know that the road ahead for implementation of advanced choice documents is, is long. We're really - the good news is that the legislation exists. The Mental Health Act reforms have gone through royal assent. They've had all their approvals. But the provisions around advanced choice documents haven't quite been switched on yet, which is good news, because as a system, we've got a window of time to really prepare for their implementation.

And we have recently run an online session with mental health trusts and integrated care systems to understand their readiness to deliver advanced choice documents. How do they feel? What are they already doing? And then what kind of support might they need in order to get ready?

And the commitment to advance choice documents and the commitment to delivering kind of relational care differently was really palpable on the call. And we're going to be following that up with an offer of support to mental health trust and systems that we're shaping up right now. And it could include things like e-learning modules that share the basics of what advanced choice documents are, so the entire clinical teams can hear the ethos behind them. There might be facilitation training. Advanced choice documents is a really skilled process. It's not just filling in a form to develop an advanced choice document. It's a really skilled process. So we’re hoping to be able to provide training for facilitators.

Other elements of the support offer might be basic things like job descriptions. What's the job description for an advanced choice document facilitator? Templates for what is the advanced choice document.

But also we're really keen to explore how we can link up mental health trusts across the country who are doing this work. Because there's such a value in learning from each other. Learning what works in one system and seeing how it can be adapted into another. So all of those elements of support we're hoping to shape up over the coming months.

Adam Brimelow

So, Steve, you've touched on this, but why are they so relevant for people from black communities?

Steve Gilbert

Yeah, I mean, I think it's a really important question. I think for that you've got to sit and look at the scale of the inequity there. And the fact that it's so stubborn. So, just a couple of kind of headline stats there:

·       Detention - so, it fluctuates slightly, but you are at a minimum three and a half times more likely if you are a black person as a white person to be detained in the Mental Health Act. So, we're looking at roughly 228 detentions for every 100,000 black people, compared to 64 for every 100,000 white people. And this is not because black people are more mad. There's no evidence for that. So, something's going on there.

·       When we are getting into inpatient care, we're then seeing higher rates of restrictive practice. So, if you're a black person, you're more than four times more likely to be the subject of restrictive interventions. So, you're already in a hospital with a locked door, which for anybody is a significant thing. And, you know, I'm firmly under the persuasion that use of the Mental Health Act is the most draconian act the state can take for people who, by and large, have never committed a crime.

So, we can argue the rights and the wrongs of it. We can argue that, you know, for me, it saved my life. It's still a significant intervention that we take. And then to think that you're meant to be in a caring environment and then because of your ethnicity and your skin colour, you're much more likely to have what we class is restrictive within restriction. So, this is things like being put in isolation. This is things like being physically held and even things like injections.

·       Then we start to think about what's happening within the confines of the Mental Health Act in the community. So that's a community treatment order. They are massively overused for black people. So anywhere between eight to ten times more likely are you if you're black to be on a CTO [community treatment order]. So again, that's still that control. That's still that infringement on your liberty there.

·       And then on the opposite side of that is the, the lack of visibility in primary care. So not only are black people and, you know, people of racialised ethnicities much more likely to kind of show up in our mental health system in that more, you know, secure end, but we're not showing up and we're not being cared for in primary care. And I think that this is really important. Sarah started to allude to ACDs not kind of existing on their own, and there's a whole suite of changes that were recommended in the 2018 review and has started to come into being since then. One of those is the patient care race equality framework, which is hugely important. This is a way for organisations to really get to understand their locations, start to really understand what does life look like from the point of those communities that have really been underserved, and then to start to move towards trust.

So for me, the silver lining through all of the reforms is how do we get to the point of trust? Because there are very good reasons as to why people from black and racialised communities don't want to come in and engage in your services. Part of the problem is that by not engaging, the mental health need doesn't go away. And actually, the later you present, the more likely you are to kind of end up being detained and then to kind of enter into that set of experiences.

So, there's lots of moving parts to this. But there is a very, very clear need for ACDs in general, but especially for the communities I've just spoke to.

Adam Brimelow

And, Sarah, we've heard a very powerful depiction of the problems people from, particularly from black communities, face over the use of detention in this way. But ACDs, the evidence tells us are part of a solution to this.

Sarah Holloway

Yeah, yeah, there's some really promising evidence, and I guess that's why they've been included in such a prominent way in the Mental Health Act reforms. So, if you - academics have done a meta-analysis of all the studies out there, including some randomised controlled trials, and they point to the fact that people who can make and have access to and use an advanced choice document, if all of that is in place, we could reduce the number of involuntary admissions to inpatient care by up to 25 per cent.

Now, we all know there's a gap, isn't there, between what we find in studies and real world implementation everywhere. But that's a really significant reduction. And that points to massive improvements in the quality and experience of care that will really shift patients’ outcomes and lives. And as Steve talked about earlier, there's that experience of people's lives being interrupted by detention. If we can reduce some of those detentions, we can really, really change people's lives.

But also, there's a resource argument there, isn't there? Because the more that we can reduce our reliance on detentions and on inpatient care, the more we can shift those resources into the community, as we talked about earlier.

At the moment, we have a system whereby over a third of our spending mental health is at that acute and inpatient end, but that's on sort of like 2 to 3 per cent of patients in contact with our case. There's a really big imbalance there. And the more that we can use tools like advanced choice documents to kind of shift relationships, the more we can shift power and resources into the community.

Adam Brimelow

Sarah Holloway and Steve Gilbert, thank you for joining us.

So that's it for this time. Health on the Line was brought to you by Health Comms Plus and the NHS Alliance, which represents and supports the health and care system across England, Wales and Northern Ireland.

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So until then, goodbye.

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[Are NHS trusts losing the heart of local government?]

Adam Brimelow

And welcome to Health on the Line. This is the podcast for policymakers and NHS leaders, is produced by Health Comms Plus and brought to you by the NHS Alliance, which represents and supports the health and care system across England, Wales and Northern Ireland. I'm Adam Brimelow, a former health correspondent, director of communications and now with the NHS Alliance media team.

Ask almost any NHS leader what is the most important resource the NHS has to draw on. They'll tell you it's their workforce. Helping health service leaders develop and support a sustainable workforce is the core task for NHS Employers, a key role at a critical moment. I'm delighted to say we'll be joined shortly by the brand-new chief executive of NHS Employers, Ben Morrin.

But first, we're back on the health bill beat, looking at proposed changes to foundation trusts that go to the heart of who runs and who is accountable for local services. The government's 10 Year Health Plan praised the foundation trust model for its ability to harness the benefits of reasonable autonomy to make decisions in the best interests of local populations. It said all providers will move to FT status by 2035, but under the health bill, the proposed transfer of power to the Secretary of State, such as FT board appointments and authority to set revenue spending limits compromises that independence. So is the government talking good game about devolving decision-making, while at the same time suffocating local autonomy? 

To discuss this, I'm joined by Ken Jarrold, former chair of the Council of Governors and board of directors of the Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust from 2018 to 2023.

Ken, I gather you've been involved in the NHS in that and many other roles over more than five decades, so you've well and truly earned your NHS badges.

Ken Jarrold

I've had that great privilege and if I were 21, I would try and do it all again.

Adam Brimelow

Well, that's a great commendation for a career in the health service.

Rebecca Hainsworth welcome. Rebecca is a specialist commercial healthcare lawyer and partner at Browne Jacobson, advising all types of healthcare organisations across the sector. Thank you for joining us.

Coming to you first, Rebecca. The health bill proposes some big changes to how foundation trusts are governed, including more oversight and control from the Secretary of State. A lot of our listeners might not be too familiar with the detail here. So can you describe what those key changes are overall for foundation trust and why they matter so much?

Rebecca Hainsworth

Yeah, of course Adam. So I think the, and I'll sort of not go into too much detail but try and keep it a high level. So, the big one that I think everyone is talking about, and it was certainly the thing that people were talking about when the ten-year plan came out, was removing the Council of Governors.

So these are the sort of quasi democratic body that you have in place, elected from members of the trust to represent the views of the patients and the wider public and staff as well within the trust.

And so they will be completely gone under the health bill, as will the membership as a whole. And as you've already referred to, many of the decisions that sat with the Council of Governors previously have now reverted back to the Secretary of State.

So that's things like the appointments of the chair and non-executive of the trust, approving changes to its constitution, so its main governance document, powers in relation to approving transactions - those have sort of been incorporated into the wider transaction regime. And also the Council of Governors previously had a duty in relation to non-NHS spending and being able to increase the amount of non-NHS income that a foundation trust can receive.

There are some other changes in there as well around audit committees, bringing those more into line with NHS foundation trusts. And then a removal, I think again this is one that's been talked about certainly in the health press, around the removal for the requirement of medical director and a chief nurse on the board.

But I think if you kind of take those changes as a whole, it kind of creates this sort of existential question around what is a foundation trust? Because actually the changes that we have or that are planned to come through in the health bill will mean that although foundation trusts still exist in name, there isn't really much difference in terms of operationally and the degree to which the Secretary of State has control over a foundation trust compared to an NHS trust. And in fact, in some respects, I would say that actually they have less autonomy than an NHS trust.

So it is a big shift in terms of what does it mean to be a foundation trust and how do you operate, even though some of the sort of legal underpinning still remains.

Adam Brimelow

Rebecca, thank you for that. Let's just walk through some of those changes. Ken, as we heard from Rebecca there, the health bill proposes to abolish the requirement for FTs to have councils of governors. And in do so, this will give the Secretary of State the power to appoint and remove FT chairs and non-executive directors, something that the Secretary of State can already do for NHS trusts.

So is this loss of autonomy for FTS a problem from your point of view, and how might that play out in the way that they run services and spend their money?

Ken Jarrold

It's an absolutely massive problem, and it comes at the end of a long process in which any independent scrutiny or governance has been steadily removed from the NHS by politicians and managers at national level, who wish to control every detail.

First, we lost the old health authorities with their wide membership and working for them, you felt accountable to the local community.

Then we lost the community health councils abolished during Alan Milburn time, which were organisations which represented many communities extremely effectively and have not been replaced by any of the bodies that have followed.

And now we're going to lose the last element of independent governance and democracy in the NHS and give all that power to ministers. And I think this is a great shame and any talk of devolving power is a nonsense because it is actually a power grab.

Adam Brimelow

So, you're saying really that councils of governors have been really important in giving patients, staff and wider communities a voice?

Ken Jarrold

Yes. Like every other organisation, Adam, they vary in effectiveness, but a large part of their effectiveness depends on whether the chairman actually works with the Council of Governors to fulfil their potential, which is what I tried to do.

Many chairs, unfortunately, ally themselves very closely with the chief executive and the board, and just cut out the Council of Governors from any effective role. And of course, if that happens, they don't make much of a contribution. But if you value your accountability to local people, and I felt it very keenly indeed, and I'd had the privilege of sharing both a non-foundation trust and the foundation trust, and in the FT I felt much more accountable to the local people. And that began with the appointment process, which was so different.

And if we lose this, we just lose the very last element of local independence and governance and accountability.

Adam Brimelow

Okay. Well, the bill also seeks to grant the Secretary of State the authority to set limits on how much revenue a foundation trust can spend, for example, on things like staffing, diagnostics, beds and community capacity and their ability to invest in service redesign.

Given the shift, that clearly is a priority towards more preventative and neighbourhood models of care, Ken how might this be a problem? Or do you think there's some sense in which that could actually potentially be helpful?

Ken Jarrold

Well, I've been listening to the coming of prevention for 50 years and I have yet to see it happen. I cannot count the number of times I've been told that money would be moving from the acute sector to prevention. It's never happened. The only way that will happen is if the new Prime Minister, perhaps Mr Burnham, really believes in prevention and directs for it to happen. It won't happen any other way.

So these changes are just part of the desire to control. And it's a very sad thing that some politicians and some managers at national level just don't want to trust the local NHS with any freedom whatsoever.

Adam Brimelow

Okay, so we're giving a pretty gloomy prognosis at the moment.

So Rebecca, are there are there checks and balances that could be introduced to the legislation to soften some of the concerns we've been exploring here?

Rebecca Hainsworth

Yes, so I think there are. And I think there's a well and it's not just the legislation. So, sort of a suite of options that can be looked at in this respect.

And I think, Ken you’re absolutely spot on that. You know, this is something that the conversation, you know, you have different acronyms and different sort of slants on it. But it's always the same conversation, isn't it. And at the moment we're talking about IHO - integrated health organisations - and how they're going to move – we’ll have the left shift moving out into the community, having this preventative agenda.

But actually making those work is quite difficult. And certainly there's nothing really in the health bill that that leads to a suggestion that there will be a really strong integrator role at the moment. And that is essential to guide the patient through the pathway, to be able to ensure that we don't see what is, you know often happens, which is that the large acute trusts are kind of pulling all of the funds and resources, and particularly if they have the lead provider type contract, that they are then in charge. And that can actually result in a, you know, if we're talking about the left shift, it's a right shift, it's movement back into the hospitals because they are, you know, responsible for these integrated health organisations.

So I think there's some key questions there around, you know, where does that fit? Is it in the policy, is it in the legislation?

And linked to that, the role of the ICB as the strategic commissioner and the levers that the ICB has, particularly around the governance of these arrangements, you know, the KPIs, what is going to happen in terms of contract management and sort of at a local level.

And then we've got that kind of national picture, which is around the regulation, the licensing and how that will operate. And at the moment I say in the bill, that's all going back to the Secretary of State. Now, I will disclose my sort of conflict of interest here that I did for many years work for Monitor and what was then NHS Improvement, and obviously that was established as an independent. It was the independent regulator of foundation trust. And then when it became NHS improvement, it became both a regulator of trusts, NHS trusts and FTs. And I think that a lot of the conversations that I've had recently, since the bill came out and sort of prior to that, with the ten-year plan coming out, was this question around, you know, do we need some sort of arm's-length body? Now, that doesn't necessarily mean reestablishing monitor, but certainly it's that how do you have that separation within all of these powers that will sit within the Secretary of State? How are they affectively managed so that there is this sort of degree of arm's length that gives the sector, you know, confidence in terms of the regulation and how powers are being exercised.

And I think that that is something that certainly, you know, many people I speak to in the sector are really keen that that the government potentially explores that option to look at how there's going to be a, say, those kind of checks and balances on the Secretary of State's powers to ensure that there isn't a conflict of functions.

I keep on referring to, you know, when we're at Monitor, we had a statutory duty in relation to when a conflict of functions could occur, because it would recognise that Monitor was being asked to do lots of different things. And there were circumstances in which one part of Monitor and what it was being asked to do could be in conflict with another part of Monitor. And I think that under the bill, we sort of see a similar picture with the Secretary of State.

So, it's just those questions around how can that be managed, whether that is in the legislation or whether it sits more at the policy level? And that's something that I think it'll be interesting to see what happens in that respect.

Adam Brimelow

Yeah, I mean, it does feel like there are a kind of crosscurrents at play here because it feels like a potential downgrading of the status of foundation trusts in this legislation and statutory freedoms are being withdrawn. But the government's also introducing a new status for NHS provider organisations that are high performing, the advanced FTs. So NHS England has said AFTs will be given additional freedoms and will have a more hands off relationship with their regulator.

Rebecca, do you think this AFT programme will address any of the concerns about the reduction of FT freedoms?

Rebecca Hainsworth

So, it's interesting you say a downgrading. I think that that's exactly it. It's what we will see in the health bill as it stands, is a sort of levelling down of the autonomy of FTs to create the space for an AFT.

Now, the bill itself doesn't actually refer to advanced foundation trusts. We're not creating a new vehicle. They are entirely a product of policy. But what we will see is that how they, the FTs as a sector, are regulated and how that creates a space for the AFT and the freedoms that they will have. So, things like and say - there's actually very limited sort of freedoms that come with it.

Obviously there is the again, sort of contract element around the IHO contract, but if we just look at the sort of legislative framework, then certainly there's freedoms around participation in companies and various kind of vehicles. At the moment that is very highly controlled by NHS England. And that, again, it's a policy structure that NHS England can and has to review changes to subsidiary companies and the creation of new companies, which really confines FTs autonomy in that respect.

And I think what we will see is a continuation of that for foundation trusts. But if they have the AFT status, then there'll be a sort of looser regulation and oversight. They will have more freedom to participate in companies and to make changes within those companies similar with income generation.

As I said, that's something that's going to revert back to the Secretary of State. So again, it's will the AFTs have greater freedom to be able to increase their income from non-NHS sources? And again, around the spending limits that you've referred to already. Again, there's a question there will AFTs have greater autonomy in relation to spending limits.

So there's no additional sort of changes or body that is created in respect of an AFT. It is those FT freedoms. But what we will probably see is that, say, existing FTs won't have access to them unless they achieve AFT status.

Adam Brimelow

Okay, so Ken, if you were still on a foundation trust board today, you're taking all these changes, proposed changes, in the round. Is there anything that that makes you think, yeah, that's a that's a definite positive step in the right direction, at all?

Ken Jarrold

Absolutely not. This is a totally negative policy inspired by the desire to control. That's all it is. And AFTs are just another, yet another, illusion being dragged across the NHS. I remember the original days of FTs, when people were very keen to be FTs because of the freedoms they were promised, and a lot of chairs and chief execs I knew didn't want the Council of Governors, didn't want the complication of local governments, but accepted it in order to get the freedoms.

Well, the freedoms soon disappeared and they were left with the governance which many of them still don't like, but which I would passionately defend because an NHS that has no element of local democracy or accountability or governance is a very barren, sterile place that will separate itself further from the communities it is supposed to serve.

Adam Brimelow

So, you talked in some ways about the intended consequences. What the government is, is setting out to do. Do you think there are unintended consequences that could evolve from these steps that perhaps haven't been given proper consideration?

Ken Jarrold

I hope that one of the unintended consequences will be that council of governors will try and retain a local level, some informal structures and involvement linked to whatever other local bodies exist post Healthwatch to watch the NHS, if anything exists. So, I hope that one of the unintended consequences will be a little bit of rebellion in communities of people saying they actually want to hang on to their local NHS in some meaningful way.

Adam Brimelow

You were smiling there, Rebecca. Can you see that happening?

Rebecca Hainsworth

Yeah. And well, I was just going to say that certainly I was quite surprised when I saw the bill when it was published, because we were expecting there to be something that retains that engagement, as Ken says, it's so important.

And, you know, yes, you can remove the council of governors as this kind of formal structure within a trust. But we were certainly expecting to see something that, you know, would be some sort of consultative body, some way of retaining that connection between, you know, the top level of the trust, the board, with its community, with patients, with other stakeholders. And at the moment, there isn't certainly on the legislative picture, there's nothing that retains that connection.

But, you know, I know from conversations that I've had with trust leaders who are exploring that because they recognise the value of it in order to be able to, you know, establish something within their own trust that does allow them to do that, that as I say, doesn't sit within the legal framework or the policy framework, but allows them to continue to have that really important input.

Adam Brimelow

Okay. Rebecca Hainsworth there. And Ken Jarrold, thank you very much indeed.

On now to the brand-new chief executive of NHS Employers, Ben Morrin. This is a key role at a really important time as NHS organisations look to develop and support their workforce through a period of transformation and of course, very challenging external pressures, not to mention the continuing threat of industrial action, despite the good news on resident doctors.

Ben, welcome to Health on the Line. This is your first interview in post. You're very new in post, aren't you? So what are your first thoughts and immediate priorities as you look to the weeks and months ahead?

Ben Morrin

Well thanks, Adam. Yeah, it's day two for me. First impressions. I'm joining a really great team.

I think I've already experienced through meeting colleagues individually and in the London and Leeds bases for the Alliance and NHS Employers in the last few weeks, and some great colleagues doing super work. So that's the first thing that stands out to me, just the quality of the welcome.

And as you say, there's a massive agenda in front of us, thinking about how we could best support colleagues who work across the NHS, achieve the best they can for patients, and there's great opportunities coming along to do that, both to support and add to the power of government decision-making.

And it's crucial to think about what we can do locally, how we can help individual employers, partnerships, neighbourhood level, at place level too.

So really looking forward to getting stuck in.

Adam Brimelow

Yeah. You say massive challenges ahead. Let me put you on the spot straightaway. What do you see as the biggest workforce challenge facing NHS leaders over the coming years?

Ben Morrin

I think the biggest challenge is motivation. So, we've got people who are brilliant at what they do. But I think if we look at the most recent evidence we got from the NHS Staff Survey, from local Pulse surveys, from independent analysis, about how people are feeling in the NHS, we've got people who feel as though they're at risk of burnout or experiencing burnout. Lesser motivation not in every NHS employer, but in many. And we're not seeing the signs of improvement we expected on inclusion, on diversity on equality either.

So it's a good time with the upcoming ten-year workforce plan to reflect and think about what are the ingredients and the context of the next decade that are going to make the best difference for colleagues working to provide care, support, and provide care, and to improve outcomes of patients to the public, too.

Adam Brimelow

Yeah. So there are a number of challenges there really, aren't there? And what's the difference that NHS Employers can make to make things better for leaders?

Ben Morrin

So, I think there those four key things that we can do. So, we I think had really good relationships with leaders in every NHS organisation that's employing colleagues. We've got really well-established networks, allow us to talk and earn with those colleagues, and we've got good and developing relationships with government and colleagues who shape government policy and across employer policy too.

So, we've got a really unique selling point and standing to help make those connections.

And, and I think I'm succeeding leaders who've been great at doing just that in terms of Danny Mortimer and Dean Royles. So we can act in confidence in informing government policy and challenging it where we need to.

We can work to support leaders, secondly, who are at the coal face providing care and leading change. We can provide practical advice, over 5 million hits on the website last year and up to I think about 11 million users of it.

And finally, we can nurture and plan for the needs of the future. I think this is really critical that we owe it to our successors to be really clear about where we expect the system to get to and five, ten, 15 years and plan for that as well, to be on the front foot and thinking about what's going to need to be distinctive about the way we employ and support and develop colleagues.

And we've got the analytical capability and in NHS Employers and the brain power to do that really effectively, too.

Adam Brimelow

Yeah. So I see a really important contribution to be made there. So let's turn to one of the issues that's really been sort of overshadowing so much of what's been going on in the workforce space recently. This is an industrial action. You know, it continues to be a significant challenge for the NHS. What do you think it will take to move from a cycle of pay dispute to a more stable and long-term workforce settlement?

Ben Morrin

Well, I think first of all, it means that we need to show respect and calmly reflect about what's led us to this point in the future, because I think people have felt scarred by former industrial action.

I certainly remember when I was working in University College London Hospitals, UCLH, what about a decade ago as a workforce director, that former disputes had scarred colleagues who had been working in consultant level. They remembered decades formerly, when they were striking and the inequities they felt and experienced around that time. So people don't fail to remember when they needed to take an industrial action.

And although on occasion I think we disagree with why you've done that, we need to respect the choice individuals make in the first place. And we also need to recognise that it's worth making every effort we can to reflect and think about why someone being a union colleague or an employer might have a different view to us that matter around pay or none pay too.

But I think it also means we need to be resolute in respecting the fact that there is always a limit to what any employer, whoever they are, can afford. And when that limit’s reached we owe it to the public and employees to think about patient safety beyond anything else, and the action that you take to prioritise the care that you need to.

So, I think it's that balance of being respectful, thoughtful, thinking about the past as well as the present in terms of what might be informing people's behaviour and action. And, crucially, then thinking about how you can develop trust with colleagues locally, regionally and nationally. And I think there's some great, committed colleagues around the social partnership forum which I'm looking forward to co-chair with Helga Pile at Unison, who are really intent to bring that spirit of working to how we think about the challenges that we’ll need to address in the next five to ten years.

Adam Brimelow

Yeah. And, Ben, can I bring you back to a point you were emphasizing a little earlier? And this is to do with inclusion. We've seen a lot recently around racial discrimination and abuse. The impact this is having on frontline staff, some of whom said they feel worried about going to work because of what they've seen reported in the media.

What can employers across the NHS do to better support and reassure their staff who are experiencing this?

Ben Morrin

Well, I think Adam I’ve sought to place emphasis earlier on in this interview on safety for patients. And I think the first priority for employers is to think about safety for patients and staff.

So whatever the risk that's leading to people feeling less than safe, I think there could be no greater priority for employers and thinking about that. And I think you're absolutely right to raise it, because there have been some pretty appalling recent incidents where colleagues who have not experienced racism in the way that they have recently have endured it on the way to work around work, on the way back to a car, to a train, to their home.

And it's pretty appalling. I think in 2026 that people having to suffer that in any walk of life. And so dispiriting about the fundamentals, I think many would expect, you know, of our communities and other communities, including NHS. We need to make a fundamental distinction between the fact that it isn't the NHS responsibility to judge, take a view about people's views in their day-to-day work, but their behaviours at work and their behaviours that are affecting others - be safe are absolutely of our interest and our responsibility.

And I think we've got to uplift our expectations of each other to tackle this. If you look at the Workforce Race Equality Standard and the data we use to assess race equality or inequality, the signs aren't encouraging. And I think that means, given that standard’s been around for close to a decade, we need to look afresh at what action we need to take across the NHS to best confront the causes of racism locally, regionally and nationally. And I'm really keen that we do that.

I’ve spoken to Ciarán about how we bring leadership to our agenda across the Alliance, and really excited at the prospect of doing fresh work in that regard. But I think the employers who may be listening to this would know as well, that they’re best placed and it isn't going to help them for me to say something about the action they can take in response to equality issues, which they are very well able to deal with on a day-to-day basis.

And I've seen some outstanding action, really positive action where people have shown exceptional care to individuals, not only just a few hours or before or after incident, but through the weeks and months afterwards to check in and check the nature of the way that plays into effect in colleagues in the medium term and long term, because they do, don't they still gain resonant supportive of action from their employer.

And I think that's crucial, that you're not just thinking as a colleague at a trust level. And what am I doing today or tomorrow about X, who's have experienced that terrible incident? But how am I showing enduring interest in their experience, involving them in the way they may wish to inform what we do for others who are at risk of the same?

Adam Brimelow

And Ben, can I just bring you back to another area there, which we've been hearing so much from NHS leaders about, which is in terms of financial pressures and what that means in terms of being able to support their workforce at a time when there potentially cuts to services, cuts to jobs and so on. With the financial constraints tightening, how can NHS organisations continue to invest in their people while managing those constrained budgets?

Ben Morrin

Yeah, so I tend to think about the financial challenge in a way that may cause others to be upset. But I'll put it over you, Adam, and welcome your view.

So I think those of us who who've worked at executive level in NHS trusts, employers,

have, you know, are privileged. We have a responsibility with large budgets to provide health and care and to employ colleagues. Many of us working in these contexts will have and do now have that have that opportunity across multi-million pound budgets. So we start from a position of having significant assets. I'm not suggesting that the challenges that come with that aren't easy, but I think there was a fundamental opportunities to just step back and think about, for example, an employment budget and are we using the best way?

I'll be open with you. I've been responsible on three occasions for the workforce, in the trust I worked for formerly and if I was asked a question, am I confident that every single one of the colleagues who work in the organisation at this point are in the optimal roles, working in the optimal way, I could never say yes to you.

There was always an opportunity, always thinking about the more productive use, use of the resources we had that was open to me and colleagues, and I was keen to think through, and they had some great ideas from colleagues as well. And I think this is where the rubber is, particularly for clinicians. The clinicians see ineffective, unproductive process or care. They're often, I think, very reasonably say this process should be easier for me and because it should be easier for patients. And so we have a massive opportunity to think about more efficient ways of providing models of care.

One example of that's live at the moment is outpatient care. And, you know, there were times where we're seeing people four or five times where they should only be seen once. And the benefits of rethinking through improvement efforts, that type of approach with patients, with colleagues who true patient engagement and staff engagement I think could be multiple and really beneficial. Of course, it gets to a point in other occasions where the numbers can't square and where the evidence is really clear on that. Of course, that's the type of thing NHS Employers, the Alliance will do, will talk up really clearly and effectively for I'm sure, and we'll need to do that too.

But yes, first, in my view, be clear in the backyard that we're well utilizing resources, the same resources we've got.

Adam Brimelow

Okay, Ben, I'm just, because time is tight, I want to just develop that point about, you're talking about new approaches, fresh thinking. I've got very much in mind that the prospect of a ten-year workforce plan, which we're told is, is going to be published, we hope soon.

What are you hoping, what would you like to see in such a plan that could stand the test of time?

Ben Morrin

So, I'll be the first I should say, Adam is I haven't seen the ten-year workforce plan in any form at all. So, I look forward to seeing drafts of it. And you're absolutely right, it'll be great to have it out, because I think the ten-year plan that we gained last year was a brilliant document, really clear, cohesive and unifying plan for the future. And we need the workforce plan to be aligned to that and reflective of the interest of the NHS to go further, faster for patients.

What I'd like to see in that are idea that are well informed by employers, by colleagues across England, I'm sure and it will be. But I think the learning inflection for me from recent ten-year plans, going back to when I started out in the NHS 28 years ago, is the publication of the document itself isn't as important as to follow through.

If we asked ourselves two, three, four, five, six years after a ten-year plan was published, is it still real in the way that it's informing our work, our practice, our thinking? That is the crucial test. And so, in effect, I'd like to see a plan that had that longevity to it, that was regarded in effect the Bible for us for the true decade, as opposed to something which was questioned far earlier in the decade that follows its publication.

Adam Brimelow

Ben Morrin, thank you very much indeed, and best of luck in your new role.

Ben Morrin

Thank you very much. Really nice to see you on day, two for me.

Adam Brimelow

Thank you. Ben Morrin. Thank you and very best of luck in your new role.

Just time to mention NHS employers forthcoming Strategic Workforce Forum, which will provide a secure and confidential space for NHS workforce leaders for dialogue on future strategic workforce planning and the advancement of the people profession.

Of course, Ben will be there as one of the key speakers is on the 13th of October and you can find all the details on the NHS Employers website, under events.

And if you enjoyed the podcast, please hit that subscribe button and do share it with colleagues across the NHS. And remember, we've covered a lot of the key aspects of the health bill in our most recent episodes, and there's likely more to come over the next few weeks as well as that legislation takes shape.

Of course, if you have a great programme of work you'd like to tell us about, please get in touch. We may cover it in a future episode. Just email us @thenhsalliance.org

So till next time, goodbye.

Ottro

You've been listening to health on the line, produced by Health Comms. Plus, we're a creative, full service communications agency brought to you by the NHS Alliance. With deep sector knowledge and a shared commitment to improving health outcomes. We help NHS and public sector organisations to connect, engage and make an impact. Any income we generate is reinvested into our work, supporting NHS organisations and the wider health and care system. To find out more, contact Health Comms Plus at the NHS Alliance.

 

[Interview with health minister Karin Smyth MP]

Andy Brimelow

Hello and welcome to Health on the Line. This is the podcast for policymakers and NHS leaders. It's produced by Health Comms Plus and brought to you by the NHS Alliance, which represents and supports the health and care system across England, Wales and Northern Ireland. I'm Adam Brimelow, a former health correspondent, director of communications and now with the NHS Alliance media team.

In recent weeks, we've been taking a look in some detail at the health bill, which is fundamental to the government's ambitions set out in the 10 Year Health Plan. There are major structural changes, including the abolition of NHS England, that transfer of significant powers to the Secretary of State, change governance and responsibilities for NHS organisations. The scrapping of Healthwatch, steps to create the single patient record and much besides.

So now the bill's begun its passage through parliament. Some of the key concerns are starting to surface, and I'm delighted to say, for this special extra edition of Health on the Line, the minister charged with overseeing its progress, Karin Smyth, joins me now. 

Karin, you're unusually well equipped for this task in many ways. You have a strong NHS background, you've crossed the divide from the NHS team, as a former health service manager and non-executive director, to a politician and minister now reshaping the NHS. Is that a smooth and seamless step or a total shift in skill set? 

Karin Smyth

I don't think it's seamless, but I guess what I'd say is that I've actually been very active in the Labour party, in politics, for all of my adult life, and I joined the health service when I was 24, in 1989.

So, I've done both sort of alongside each other. And I mean, people might have heard me say this before, but when I was a manager or a non-exec, at different times in my career, kind of been in and out, I was often told, Karin you're a little bit too political, and I'm always told in the Labour party, and by many of my colleagues, that sometimes I'm a bit too managerial.

So, I think I've got it about right. So, it wasn't much a switch of skill sets. I think I've used both, and personally it's just the most enormous privilege to be a minister of state in, for me, a Labour government at this particular time. And then, as you say, the opportunity to steer in the right direction, it's a great honour. And I think I lean on both of those things. I do NHS-speak sometimes and I do political-speak, and I think that's helpful. 

Andy Brimelow

Well, it must give you a kind of insight, a depth of knowledge that can only be helpful as you get into the details of some of these tricky changes that you're overseeing.

You're coming up to two years in now has a government. There's clearly huge change going on at the top of government. The impact of that isn't yet clear. But reflecting back over the last couple of years, how would you assess progress to date in the NHS? 

Karin Smyth

So I think one of the things that I have brought with me is the enormity of the task, and I've followed very closely \[the] NHS. And so I think I'm acutely aware of the scale of the challenge. And that has not surprised me, I guess, in terms of how big a challenge is to get through. But I think, I do think we've made progress. I think we have been able to, I mean, I sometimes say, 'arrest' the decline. I hope we've been able to put back in some hope and lift some morale. I'm really conscious about morale and we might come back to that later. 

But stabilizing the system, starting to turn the corner in things like the waiting list, access, rising patient satisfaction, I think, demonstrate actually good progress in two years. And I think the 10 Year Health Plan, which, you know, guides us now for this period, was that coming together after Darcy to say, actually, there's a consensus about what we want to do here. We want to do some bold things. And generally, people agree with that. And I'm sure we'll come on to it. It's the 'how' do we get there? 

But I think we've made good progress and I'm really proud to have been part of it. 

Andy Brimelow

Thank you. So, you've acknowledged there are there are big pressures and big ambitions for the coming years, aren't there. And as you said, a lot of these are set out in the 10 Year Health Plan.

What would you say is that the biggest test of the government's credibility in terms of the NHS over the next 12 months? 

Karin Smyth

We have to deliver. So we've stopped the, you know, the rising waiting list, the decline in access, the lack of grip on the finances. We've stopped that and we've started to turn it round. And some of that has been felt by patients in the public who are very impatient for change. And that alludes to some of the wider political environment that we're in. 

But we have to keep we have to keep progressing on that. And access and demonstration of improvement of that quality of service to patients and the public is critical to that, as is in parallel, the lifting of morale and the pressure on the workforce.

The workforce, for me, across the entire piece, is one of the biggest is - it is the biggest issue. So, you know, stabilizing that, hopefully having a better industrial relations landscape and demonstrating to the public that we're on the right trajectory is really what we need to be doing in the next six to nine months.

Andy Brimelow

Right. Well, let's look at the health bill, now. 

I think it's on you to steer that through parliament for government. So what would you say is the problem that this bill is fundamentally trying to solve? 

Karin Smyth

So it's, and this is the first time I've done this. So, it's quite a big deal for me. I've obviously sat as a member of parliament on bills and I did I did the last of the last NHS bill that Ed Argar took through. But it's very, very different doing it as a minister in a government.

And, you know, your listeners will appreciate this, when you are fairly senior and then you take on yet another big task - you've got some skills to approach that but, you know, every day is a school day. So I'm quite enjoying that. But it is a huge task. 

And the problem we're solving really is the implementation of the 10 Year Health Plan. Now, that's what the bill is doing in terms of particularly the single patient record and some of the implementation of Penny Dash's review into patient safety. And obviously, having then made the decision about the abolition of NHS England as a body, it brings into legal, in legal effect, the consequences of that decision, which obviously in legal terms and in terms of the size of the bill is pretty big.

Andy Brimelow

Okay. So how do you see this legislation affecting that important balance between central control and local autonomy? We've had some interviews on Health on the Line suggesting that, you know, there's an instinctive 'centralizing' tendency in this bill which too often overrides an impulse towards giving out greater autonomy and devolving decision-making. 

Karin Smyth

Well, it's a subject that has taxed people from the start of the NHS, isn't it? And I'm on record frequently as saying that I've always been more Morris than Bevan with regard to how the health services is run, and that does run through the 10 Year Health Plan and the bill that our intention, and our aim, is to devolve as much as possible locally. And I understand some of the discussions that have in, and I think we'll continue to have them over the coming months. But there is a consequence of abolishing NHS England as a central body means that many of the powers and duties naturally have to come to the Secretary of State in name. That's where they are, that's where they have to be, and that is where they were in the many years before the 2012 Act. 

So I understand this sort of feeling that it's a centralization. Some people use the word 'power grab'. I probably shouldn't have said it out loud. I don't accept it. It's a debate that we are trying as much as possible to minimize the centralization to the Secretary of State. But there has to be proper legal governance and accountability on that. 

And then we want to put as much into ICBs as strategic commissioners. That's a step for them as well. And obviously there are changes there and indeed the provider sector to cooperate and work together, particularly focused on neighbourhoods. That's our journey. That's what we're intending. 

Andy Brimelow

Yeah. So that's the journey as you describe it. Presumably, though - what's implied is there is an openness to safeguards and checks to ensure that that becomes a sustainable outcome for the future in terms of guarding against an over-mighty Secretary of State in the future, be that Labour or Conservative or Reform or whoever is in charge.

Karin Smyth

Well, I've had this discussion with various people in the sector, who worked very closely at the Department of Health and Social Care, official, and personally myself, have met with many organisations in groups, including the Alliance, to discuss this in the passion of the passage of drafting the bill.

And ultimately, it's up to the people of this country who the Secretary of State is, which political party they're from, and any Secretary of State, any parliament can change legislation and the law. That is the fundamental nature of our democracy. And I think we need to hold that in our thoughts at any one time. 

And now I understand in terms of this sort of operational, political sort of debate, that's where people start to go. But let's hold the fact that this is a democracy, a long-standing one. We're very proud of that. And this is a public service that spends £200 billion of taxpayers money. So whoever the Secretary of State is has that power. And ultimately, if the Secretary of State has a majority in parliament, they can change that. And that is up to the British public. 

But we want to have legislation here now, and this is what the aim of the bill is to be as flexible as possible for the future, to anticipate as much as one can in the future, to minimise centralisation as Secretary of State and to empower the system locally. Crucially, with a single patient record in particular, empower patients in the public. And there is, we may come back onto it, there's also a drive, and in parliamentary terms for your viewers and listeners who follow this closely, there'll be a lot of amendments and people coming forward. And every lobby group and think tank and charity etc. have their own amendments to sort of put a bit more prescription into the system.

And we really are trying to avoid over-prescription. That is one of the failings of the Lansley reform - too much do this, especially with NHS England. Too much tick boxing, too much feeding beasts. So as flexible as possible, technically correct, as you know, guarding against impropriety, good governance, all of that stuff is the balance we're trying to strike.

Andy Brimelow

Yeah. So one emerging area of concern is, I'm sure you'll be aware, is the scrapping of Healthwatch England and local Healthwatch and transferring their functions. So what does that mean for patient safety safeguards and accountability?

Karin Smyth

So I think those are two areas, and there are others in this sphere. And obviously patient safety is uppermost in our minds. And this is a difficult one to navigate, to give confidence to the public and patients that where we want to get to. And Penny Dash's review outlines that. And we accepted that in the 10 Year Health Plan is the right place - so I'll come back onto the specifics - but bringing patient experience directly into the Department of Health at that executive level, and then to have a different way of working public in the patients at ICB level, rather than this plethora of bodies and organisations that are, you know, in this area that have grown up over time for good reasons, for good intent.

And I think it is worth revisiting Penny Dash's review for understanding one why we did that and to some of the conclusions she comes to. But we do have to build confidence with people that that it is the right way, because the problem with the bill is because it's a legislation, it removes things, whereas the putting in place runs alongside that with the development of the new department and the new organisations. And that's quite a step for, certainly the public, to understand. We have to be able to explain that to people.

So there are examples of really good work locally with Healthwatch, I think good people. But I think and I'm actually on the record in the HSJ many years ago saying they weren't set up, you know, they set out to do a very big job and so - but it's outside the system. And I do think it's right, and as a former commissioner, I think it's right that commissioners have to involve patients and the public at the proper stage of the commissioning cycle, and it has to be integral to the organisation. They should not be outsourcing it. They, of course, have to find ways of bringing impatient voice in different groups of communities. And, you know, with technology, different forms of access, there's all sorts of ways that we can do this much more inevitably in the future, and that's what we're aiming to do. 

The discussion, again, really strikes the heart of people's concerns about safety and that discussion, whether you can have a regulator and investigator in the same body and protect same space. We think that you can in legislation, I understand, and I've spoken to both bodies about that. And they're all matters of public debate. I think we'll have more debate about this. But I think the opportunity for the shared learning across the piece, to change those organisations for the future is a good one that we should explore.

So I hope we would have some good debates in the coming out and I know there's going to be some lively debates, because it's a difficult one. I don't resolve from that.

Andy Brimelow

Yeah. It is a difficult one as we've been hearing from some ICBs, there's a concern about a conflict of interest with those functions being transferred into ICBs of local Healthwatch and just the feasibility of doing that, given the way resources that ICBs are so stretched already.

Karin Smyth

I think, so the two things are separate, but it is the core function of an ICB as commissioner to not only understand the needs of the population but also the experiences and the overall quality of that population. So it is part of their core functions. And I think as we move to them being more focused as strategic commissioners, that will become easier because at the moment they have all these different sorts of functions, and obviously they've grown in a way that hasn't worked with confusing roles. So I think that will be right. 

With regard to [unclear] , I do think this is important. And I think the concern that strikes me, I think you can make it work, otherwise we wouldn't be bringing it forward. I think this concern does strike as a culture issue. And we've obviously recently had again, the report in Nottingham in maternity, is that the ability, the willingness, the listening of people to speak up, to be heard and to be acted on, you know, has to be preeminent as we go forward in thinking about this and I understand, I hear the concerns that people say, well, people won't do that if they think it's tied to regulation. I think you that doesn't have to be the case, ultimately, that lends into the culture. And if we're going to change this culture, it's a big step. We have to bring people with us. But I do think that's the way to do it. And, you know, there have been far too many small steps added organisations responses, quite rightly, in response to shocking events, to add more layers and use a new commissioner, a new ambassador, something that will make it work.

As a constituency MP, as a patient, as a member of the public, we all understand that. But I think we need to, if we can step back and look, where do we really want to get to? I'm quite passionate about that. And just to say, I also feel it as a member of parliament and as someone who understands the system, I struggle to help my constituents when they faced issues, either complaints or safety or outcomes with health services. I've struggled to really navigate them to the right place, and I'm someone who understands it. So, you know, that's the goal. But we'll keep talking to people about how we best achieve it. 

Andy Brimelow

Right. Well, let's move on then to another area where there's clearly a gathering debate. And that's on the single patient record. I think there's a pretty broad consensus, isn't there, on the objectives.

But concerns over privacy, security and safety of data and also who controls and is responsible for it. And we know digital patient data sharing in the NHS has had a pretty torrid history. So how do you avoid it repeating itself? 

Karin Smyth

So I think you used the word 'gathering' - one should never disagree with the other conversation and its course. 

And we remember, and many other people remember, it's been a rolling debate hasn't it, for a very long time and I was working in the system for care.data. So am very acutely aware of that. 

But again, look, the prize of this is huge, isn't it? The prize is huge. For public, for patients, particularly who already think this happens. And for all the clinicians I speak to all the time. I mean, if there's one thing that sticks in my head about all the places I've visited in the last two years is, apart from some of the shocking estate and facilities that people are working in, which is truly dreadful in places, is the 'I've got to log on to eight or nine different things, and I don't know who's in front of me and I can't tell you no, I haven't got the information I need'.

So, the prize is huge. We have to keep that in our mind. The bill itself, simply - this is my part of my get out of jail card, Adam - the bill itself simply gives the government, in legislative terms, the ability to bring forward something called the single patient record. So it's not the thing itself. And people agree with that. The Conservative and the Liberal opposition did not oppose this bill - that's quite a big step for a health bill. I was just going to own that little bit of success. You know, you say things are gathering and it's obviously controversial in places, but they didn't oppose it. They know it's the right thing to do. So we obviously have to make sure that the overall architecture is right. 

So this bill will give the permission from there we have to engage in the debate on exactly how it's formed, what it is. And that comes through in what's called secondary regulations. But of course, and again, look, you know, the concerns on cyber, the concerns on access and privacy. What does it do? We're going to have to bring people with us. 

But I would say I'm very impressed with the work that's gone on in the Department and NHS England. I covered this area in my first 12 months as the minister, up until last September, directly, so I was really impressed with the work that they've done on access, working with people, things like to develop the app in particular, but also to look at all of these issues, work with industry, really understand and a lot of public engagement. So that has informed us so far. So we do know that. 

But things like this, we want clinicians out there talking about it, what it can do. Absolutely we need to reassure people. But of course, we know and your listeners and viewers know it's already working in some parts of the systems, people are doing work arounds. And it is not right that some people in some parts of the country don't have this, and we want to make it across the whole country.

Andy Brimelow

Okay. Well, let's just go back to that headline measure, which you, you referred to earlier, the abolition of NHS England, which is in train. But it is a massive move, isn't it? And I just wonder how realistic it is to expect that this will be sorted by next April, which is when it's meant to be done. 

Karin Smyth

So, we are both accused and I have been accused during the passage of the health bill of both going too quickly and going too slowly. So I think it's right the Prime Minister set an ambitious timetable that it would be, you know, completed by April of 2027, and we absolutely need to hit that date. 

For one, the governance of the system has to be right. And again, people listening to this absolutely understand that in terms of all of the governance arrangements. And I had to explain that to my parliamentary colleagues and the people that manage House of Commons business. You know, we need we need the organisation to be safe, stable and legal and by that date. And in parallel, then develop the overall architecture of the system to make that happen.

That is ambitious. And we've been clear, former Secretary of State, was clear that we would have wished that after that announcement, we could have moved faster last year on the architecture and the redundancy issue. I understand how difficult that is for people. I have been through that myself and do regret that. And I wish that that was different.

But as they say, we are now where we are, so you need to move with that. It is ambitious, but I think everyone would agree that we need to move as fast as we can, obviously safety, to get it in place and the bill is obviously that's up to parliamentarians. 

It will go to the House of Lords, hopefully in the autumn, and there'll be some interesting debates there. There's some pretty good experts in the House of Lords that we're looking forward to engaging with on this. But that's what we're aiming to do to get that, to get that legally passed in legislative terms, there'll be some follow up legislation and regulations to make sure that other pieces are in train. And that is that is the deadline.

And, you know, I'm a manager at heart. So, you know, that's the deadline, you've got to meet it.

Andy Brimelow

You've got your timetable. Okay. Well, let's move on from the bill. And as you'd expect, we're in close contact and dialogue with our members. And they've come back with some pretty hard-hitting messages for the months ahead. Big financial pressures forcing some very difficult decisions and trade off.

And they said specifically in their feedback that they need political backing to make those tough decisions. Will they get it? 

Karin Smyth

Yes. Well, I think this is there are always tough decisions for the people, the leaders that are on this, listening to this, and I think Ciarán said this at his presentation of evidence, very clearly on behalf of members, in case members didn't know, very good advocacy, absolutely. 

And again, I'm on record over many years on this issue. Look, the grip on the finances... and I meet with the finance teams across NHS England department. And I met weekly for a long period and then we meet fortnightly to understand where the issues are. And I've been very clear about the need to have more transparency in the system, and I've produced packs of information for members of parliament on their local systems.

I've encouraged members of parliament to talk closely and understand the pressures that leaders are under. And I have to say, I've had some really good results. I think people have responded to that. There are examples where MPs are trying to contact and talk with people about this issue, and they don't get a response. I've said that before, so anybody listening, please do respond.

I think it's a mutual thing, this to educate and support. MPs represent about 70,000 people. People come to us with questions and demands and they are the taxpayer. So I think it is incumbent on MPs to become educated and for the leaders to help with that as well. 

In terms of hard decisions, I think you probably mean things like changing services, moving services. So my view...

Andy Brimelow

...I do. And also cuts to clinical roles and that sort of thing as well.

Karin Smyth

Well, I mean, look, there are going to be changes in this system because we want to move. And people generally agree with the move. But it hasn't happened over decades. And in order to make it happen, there were people will move into neighbourhoods, into community, using technology.

I do hope that we can get the workforce plan out imminently, is the official term. I think that will, you know, will show the way forward. And you know, that would be good to get it out soon. Should the powers that be, be listening, that people will be working differently. And we are in this state, aren't we?

Got a grip of the finances. It's the first time in a decade that the NHS has not gone back to the Treasury. I think six years in the Treasury for more funding. We are looking at phasing out deficit funding so we understand where the real problems are. We're very clear on sort of support then into the system, whether it's CHC or electives or urgent care, whatever the problem is, to try and gripper that because I think it has been covid didn't help, but it has been allowed to not to not be managed.

So how do we do it? I was part of the Bristol health services plan 20 years ago. We worked very hard as a system, clinically led, to go and talk to the public, to make those cases, make those arguments, provide MPs with the data, the information. 

You know, the clinicians are absolutely key in this and trustworthy information that explains the problem. Everyone understands limited resources. We know this is not a limited part. And I think you have to know from transparent conversation. 

Yes, I know some people will stand outside with a banner saying don't close this, don't close the anything. There's no way around this apart from to have a conversation locally. And that's why I'm so keen on transparent information sharing. And I do think we need to support a generation of leaders now to be able to do that more, because I think one of the issues with NHS England, no one individual's fault, is that that sort of central hierarchy looking up, meant that local leaders did not look out to their local members of parliament, counselled and local representatives.

Some are very good at it, but some do need support with the skills about how to have those very difficult, robust conversations locally. And yes, I would certainly want to support them and how they do that. 

Andy Brimelow

Okay, well, can I bring you back now to something that you really emphasize at the top of this interview - the state of staff morale. As you know, something that on Ciarán Devane talked about in his inaugural speech at our recent ConfedExpo conference. He's called for a national campaign on respect for NHS staff, developed in partnership with staff and patients. 

How do you think we can we can create the conditions where staff want to join and remain within the service? 

Karin Smyth

Well, the second part of your question is actually right, because people do want to join and come forward. So we need to hold on to that. And I encourage my constituents to join as well. Good terms and conditions - I know people in the unions, would like better - and a pension. It's a great career and a varied career, and lots of my constituents don't get those opportunities. So I'm very passionate about that.

But it's the keeping them in. It's the retaining. I think to the second point of your question. 
I think the staff standards was help, again, lots of very good in the department and NHS England and with the trade unions around creating the staff standards, a very explicit intent and we need to make sure that happens. I think things like the ten-point plan that we had as part of the resident doctors discussion, I mean, it is shocking, and we've been very explicit about the way in which some of the resident doctors, you know, found themselves in this situation in some places. I've been around the country and seen the state of - no restrooms, nowhere to go. 
Moving on the capitalist state, the rebuilding, the new hospital programme. I think all of those should we should take heart. I know some of them feel like a long way away, but that is what I meant at the top of this saying, we've started to turn the corner and develop that.

So, I do think it's the biggest issue workforce. Many other leaders will say it's the money. And but I think that whole morale, we see that from the service. And I think, you know, Sir Jim Mackey's been very explicit about this as well. 

I'd also say, shockingly comes across my desk and from the very beginning, the levels of sexual harassment, sexual violence and racism, you know, the NHS is not separate from the rest of society and getting a grip of that for me personally is huge. I hear from people all the time, and I see the examples coming across my desk and we have to change that culture, that is about the overall culture as well in places as well, and we need good leaders to help us do that. 

Andy Brimelow

Absolutely. Okay. Well, one more question, which is I suppose there's an unreasonable one in some way. We’ll try to pin you down on this. If you had to come up with just one, what would be one ask of NHS leaders listening today for the coming months? 

Karin Smyth

I've not got… one question. We do need you. And one of my personal drives has been on the leadership college and working with Jim Mackey on this, I know feels passionately about it as well, he said.

I said this at the beginning I do NHS speak. And I said, this is really important. We made it a manifesto commitment, a leadership college for a very good reason. We know we need good leaders to drive some of this change. We want to encourage people into the system, and we want to give them skills to support them to do that.

They are different skills, partly, as I said earlier, around public conversations, you know, not being an internally NHS-focused organisation - be proud of being part of the NHS and leading and going outwards. Now, when I go around the country, I think people are up for that. So, you know, stick with it. I know we're going through rocky times, but I think we are going in the right place, going in the right direction. And I think the prize of some of this is really vast, which is to maintain a publicly-funded NHS that's free at the point of use, that does deliver on those standards that the public expect that we did have, that I think we can have again. So stick with us, please. 

Andy Brimelow

Great to talk to you. Karen Smith, health minister, thank you.

Karin Smyth

Thank you. I really enjoyed it. Thanks, Adam. 

Andy Brimelow

That's it for this special edition of Health on the Line. I hope you enjoyed it. If so, please hit subscribe and share it with colleagues across the NHS.

Remember, there's lots more on the health bill and some of the issues we've just discussed with Karin Smyth in our recent episodes and will continue to keep you in touch with developments on the bill.

There's just time for me to tell you about a webinar plan for the 23rd of July, looking at a really important element of the shift from treatment to prevention, improving vaccination rates. There will be some great examples of innovative collaboration and use of data to transform vaccination services. Members can find all the details and book on the NHS Alliance website under training and events. Exploring cross sector collaboration to improve vaccination delivery

Finally, if you have a great programme of work you'd like to tell us about, please do get in touch. We may cover it in a future episode. Just email us at healthcommplus@thenhsalliance.org
So until next time, goodbye.

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[After Healthwatch, who will listen to patients?]

Adam Brimelow 

And welcome to Health on the Line. This is the podcast for policy makers and NHS leaders. It's produced by Health Comms Plus and brought to you by the NHS Alliance, which represents and supports the health and care system across England, Wales and Northern Ireland. I'm Adam Brimelow, former health correspondent, director of communications and now with the NHS Alliance media team. 

We've entered a new phase of political upheaval, but the government still has a country to run and important changes planned for the NHS. We're tracking progress right here. Coming up, we'll be talking to the chair of NHS Online, John Browett about his hopes to make specialist care in the health service quicker and more convenient.  

First, though, we're going back to the health bill, which is now coming under close scrutiny from MPs. It’s clear the plan to abolish Healthwatch is causing significant disquiet. So a reminder, Healthwatch is currently independent, operating nationally through Healthwatch England and locally through a network of more than 150 organisations to gather and represent the views of patients and share feedback with government and local systems to inform and improved services. So, it's argued that transferring these functions to the department or, where appropriate, to ICBs and local authorities, will help to de-clutter the patient safety landscape, bringing the patient voice closer to decision makers and giving them a stronger, clearer voice at the heart of health and social care. 

Let's dig into this now with our panel of guests. First, the chief executive of The King's Fund, Sarah Woolnough. Sarah, a quick word before we go into the detail. Is there a problem here on patient voice that needs fixing at all? 

Sarah Woolnough 

Yeah. Well, good. First question. I think the government would argue, and certainly Penny Dash's review, argued that the landscape has got quite cluttered. There are lots of different bodies with overlapping responsibilities. And so the idea is to strengthen patient voice through the proposed reforms. I think our concern would be, and I'm sure we'll get into detail later, and that the current proposals risk weakening voice. And arguably, if you've got a system that is working reasonably well through Healthwatch, are you trying to fix something that isn't broken? 

Adam Brimelow 

Thanks, Sarah. And labour peer and a long-time NHS leader, Lord Philip Hunt. Welcome. You've already voiced some concerns, I think, about these changes. Would you accept, though, that there's at least a bit of scope for some improvement on the current arrangements?

Philip Hunt 

I think there's always scope for improvement. And I agree with the government that strengthening patient experience work within the Department of Health and ICBs is good and really support it, but I think you have to be very careful if you take away our rights as citizens and members of the public to actually have a voice, a proper voice in the way services are developed. 

And so it's not just the abolition of Healthwatch but losing council of governors from NHS foundation trusts is another way in which local people are actually now being excluded from having a proper say in the health service.  

Adam Brimelow 

Right. Well, let's talk now to Gita Malhotra, chair of Healthwatch Redbridge. Gita, one word that keeps coming back in this debate about patient voices - independence. Briefly, why is that so important?  

Gita Malhotra 

So thanks for having me. Look, every organisation has legitimate concerns to balance and interests, but independence matters because for us in in any local Healthwatch, the first question is really simply what are people telling us? And what does that mean for decisions that are being made? So it's highly likely that people won't always tell you things directly to the NHS itself. That might be out of fear that giving negative feedback will directly impact on ongoing treatment or services they’re receiving.  

So it's our job to have an independent service that recognises and understands people's experiences and brings those to bear into the rooms of decision makers. And that's all built on trust and confidence that there is a provision that has no skin in the game or vested interest, apart from amplifying their voice. 

Adam Brimelow  

Okay, so trust and confidence is key.  

Sarah, The King’s Fund I know has been looking into the merits, the strengths and weaknesses of Healthwatch. What have you found? First, in terms of local Healthwatch and then at a national level?  

Sarah Woolnough 

Well, I'd like to build on Gita's point. So, we did publish some independent research. How has Healthwatch fared both, both local and national, and what lesson and insight and learnings can we take for the future? 

And I do think this point about independence is absolutely critical, for all the reasons Gita has outlined, and Healthwatch has done a good job, you know, and it isn't the same everywhere. There are lots of differences between how local Healthwatches operate, but the ability to listen and hear things that perhaps the system isn't watching out for has been critical. 

Good examples would be dentistry and NHS administration, where it has been Healthwatch flying the flag and saying, look, there's a problem here. You may not have been asking specifically about this or listening out for it, but it's something you should take note of. So Independence.  

Trust is also absolutely critical. Local Healthwatch has built good relationships with seldom heard voices in our health and care system, built trust locally and then, as a consequence, been able to pick up a whole host of different issues that again, the NHS may day today, not always hear. 

There is also a related point which is collective versus individual. So, I think the way the NHS in part is proposing to reform is to say, oh well, there are loads of ways that people can give feedback via the App. They can, you know, offer direct feedback to their team that's been treating them. That risks giving very individual feedback on specific services and experience and the danger is you miss that holistic systemic feedback, which is so critical.  

So maybe, well, I could pause there, but there's an action that might be worth highlighting, which is we found that Healthwatch, both local and national, has had more power to raise issues and less power to act on them. And so one of our recommendations is that whatever follows absolutely should have the power to say, okay, here's a problem and you must do something about it. That is a genuine way that patient and public voice can be strengthened in the system.  

Adam Brimelow 

So, Gita, just to follow up on that quality of local intel that you can get at which is at risk here, you say. What sort of things have you been able to produce in your area that's really offered proper added value for your community and patients in your area? 

Gita Malhotra 

Yeah. And, you know, right across the country, every local Healthwatch will have their own examples of success or impact. And that's because of that hyperlocal nature of the work. And invariably, the workforce in a local Healthwatch is drawn from the local communities, so they will have a good understanding of the populations, the geography and the provision that's out there. 

And in Redbridge we've got a complex, diverse population, large population and a lot of inward migration. So, I think all those features are at play in terms of the kind of work we do. And the other thing before I get into some of the examples is our workforce, I guess, has real skill, real expertise in community engagement and a deep trust built over a long time with local communities, local organisations and invariably, I guess they often talk about kind of the hiding in plain sight communities. And actually that comes out of a proactive approach rather than a passive approach, you know, just waiting to be responsive.  

So, I guess a big focus for us, particularly over the last few years, has been around influence and impact. So it's much more than listening and just amplifying voices. But what are we going to do with what we hear?  

So most recently, I guess over the last year, three key areas and just to give you a quick flavour has been maternity at night at Whipps Cross Hospital, we had a team go in over a series of nights to do some observation work and speak to women and their families.  

And out of that, out of the findings and the recommendations they made, the departments at Whipps Cross have improved their escalation procedures. They've increased their permanent workforce at night with a shift from agency workforce. It is important for us in Redbridge improved their access to interpreting services at night. It's not just, you know, a service online, but actually something much more tangible that can meet the needs of women. 

We've had a women's health programme running over the last year that's looked at cervical screening, breast screening and peri and menopause services and barriers to access around that. And we've taken all of those findings, both to health scrutiny into the trust, into primary care and really affected, and actually working with general practice nurses, who are the people who deliver a lot of that screening work. And they've actually started to change some of their approaches, their information that they're giving women and just tailoring it a little bit more.  

And I guess one of the big-ticket items for us, we were the only Healthwatch in the country to host the MNISA role, which came out of Donna Ockenden’s work. And so that's maternity, neonatal advocacy work. And we have really given voice and amplified the experiences of women and their families post neonatal births. And the work that we're seeing has also translated into Baroness Amos's interim report and the forthcoming report.  

So just but a lot of equity of access focused on health inequalities, looking at prevalence and looking at trends. So, I really think that speaks to Sarah's point around it's much more than the individual. But looking at what patterns are emerging and how do we take what we find into the room, a bit of truth to power, where decisions are being made and it is easy to say, tricky to do, but so that’s just on what our goal is. 

Adam Brimelow  

Just on that, taking those perspectives into the room, let's say those advocacy functions are transferred into an ICB. What's lost? And also, would you acknowledge that some Healthwatch local organisations have been very effective. Evidently yours one of them, but others less so. 

Gita Malhotra 

So to speak to the second point, I think, look, I can only speak for Healthwatch Redbridge, but, you know, Healthwatch England's reports had shown that there's a lot of variation in quality, and that's no doubt, you know, find an organisation across the country replicated that doesn't have variation. 

And but, you know, invariably there's a really big feature around why that is. And that has been, there has been no, in real terms, increase in funding since 2013 for Healthwatches. So it's being done on a shoestring. And I think that's a really important factor to pay for staff, to pay for venues to pay for space. And you know, I also think change is not a bad thing. Something that was that worked in 2013 at the inception of Healthwatch, has to evolve and adapt and work into the future. 

And so, you know, it might it might be that anything that attends to independent voice has to finesse and, you know, become a bit more dynamic. But the whole point of preserving independence has to be at the heart of all of this.  

And I think in terms of the shift to ICBs marking one's own homework, policing the police has never really worked. And, you know, that is one of the biggest things that's going to be lost is that high-quality independence that says that, you know, we're not afraid to speak up, advocating for our residents and our populations who are much more than patients - they are full, full-blown lives and meaningful lives.  So yeah, I mean, I've more, I'll say about that, but I'll pause for now. 

Adam Brimelow 

Philip, I saw you were nodding your head there. I mean, we've got a starting point. We're told that the patient safety landscape is cluttered and fragmented and obviously Healthwatch in its national and local manifestations is part of that. Imposing a bit of order on the system, including by clarifying transparency and accounting, that's a good thing, isn't it? 

Philip Hunt 

Well, first of all, I'm a bit puzzled as to why Healthwatch is kind of put in the patient-safety bracket. It’s got a much wider role than patient safety. It's there to act on our behalf as patients and members of the public. Of course, patient safety is a responsibility in the organisation running services and the regulators like CQC or HSSIB. I think just to push Healthwatch into this general category and say it's confused is a bit much. 

I just listened to Dita. I mean, you know, there are many Healthwatches who are doing similar things, writing really good reports, often actually about the way ICBS work, not just about the way services are provided, but a lot of it is around the rationing of services, things like dentistry. Who is going to do that in an ICB when the ICB is overall responsible for the running of the health service locally? 

This is where it doesn't stand up. And I think Dash got really confused about this. Of course, you want organisations running things to have strong consumer research, but Healthwatch goes much wider than that. It's got a much wider role in holding to account, scrutinising what is happening locally in the health service and ICB. Unless you absolutely within an ICB ring fence, the patient experience work, you make the staff not accountable - the chief executive perhaps to the chair of the board - I cannot see how an ICB can really effectively monitor and scrutinise a lot of the services it actually has to take responsibility for.  

Adam Brimelow 

Yeah, and I know that that's a concern that's shared by us here at the NHS Alliance.  

I guess as part of this discussion, we shouldn't lose sight of the strategic functions of Healthwatch England as well. And Sarah, this proposed transfer of those strategic functions to the department, do you have misgivings about that as well?

Sarah Woolnough 

I think there would be a similar concern, which is, you know, okay, you've got national Healthwatch around the main departmental table. How easy in practice is it going to be to say, hang on, you know, I'm going to levy direct criticism at colleagues around the table. It's really helpful to have some independence.  

So, our worry has been what's the status, what's the level of ability to act, what's the reporting requirement? Because there is something about publicly showing your working as well of any patient experience director. And what's the remit? It's an awful lot to put on one person who ultimately is accountable within the system. That's the worry.  

I there's just another point to make about splitting health and social care. So, so much of what we hear from members of the public and patients is they struggled at the interface of health and social care. And if you're splitting local Healthwatch and you've got social care reporting to local authorities and NHS-related issues sat within ICBs, there's a worry that you make the system more fragmented rather than less. 

So, my overall worry is we'll end up spending with a lot of opportunity cost, recreating something very similar to the model that we've got now because the model has evolved this way for good reason.

Gita Malhotra 

Yes, agree. 

Adam Brimelow 

Yes. Gita, could I ask you how motivated do you find when you have conversations with colleagues locally, how motivated do you think the public and patients are on this issue? Or is this a this more of a sort of, you know, health experts and activist type of issue, people who are interested in the passage of legislation and so on?  

Gita Malhotra 

Yeah. So all of our communities and voluntary sector organisations and our residents and patients, you know, often say, we didn't even know that we would be heard. We didn't even know there was a place to actually have a voice. And so there's the lived experience.  

I spoke to the fear that some people have about speaking up and for fear of impacts on a service provision or the quality of the treatment they're going to receive. But I would flip the question, because actually, the question is, what's the appetite amongst ministers to hear and then take on and affect change once they hear a residence voice or a person's voice and their experience and, you know, the onus and the burden of responsibility isn't on whether there's an appetite solely on our local populations, it's surely about the appetite to actually listen in keenly, have something that that says, actually, you know, this might mean we change our approach to a local pathway. It might mean we have to institute a different kind of mechanism to make sure that we're not just listening and banking data in having a good catalogue of feedback, but we're actually going to do something with it. 

So yeah, I kind of challenge the premise of it.  

Adam Brimelow 

Okay. Sarah can I just come back to you in terms of, you know, the journey that the government wants to take us on now or thinking about whatever replaces Healthwatch, what would you say must be the key ingredients for success?  

Sarah Woolnough 

Yeah, I think the absolute key ingredient is to retain an independent voice. 

I think we have a history of quite a paternalistic system that isn't always very good at listening, particularly to the hard things to hear and then act on them. So this ability to, you know, for people to speak truth to power and it be acted on, I think is absolutely critical.  

And I would say building trust because we hear time and again where there's a patient safety or a patient experience scandal or something goes horribly wrong, people haven't been listened to. They've often felt fear. And there isn't that trust between the public and the public service.  

So, I suppose overall our worry is that what the government has proposed so far relies on a system behaving quite differently to the culture that we're used to.  

Philip Hunt 

I must say, listening to Sarah, I’ve just been reading, I haven’t got through it all yet, the Ockendon Inquiry into Nottingham. And of course, one of the big issues coming from that is people will not listen to.  

And this is where I think you do need to have some kind of external voice that allows people to go to them to seek advice, to be signposted. But, you know, you can't just rely on the NHS itself to somehow substitute that, because a lot of the issues that Healthwatch raise are about how bodies like integrated care boards actually do their job. 

You know, integration is one of the big issues. Well, if I ICBs are not responsible for integration, I don't know who is. Will they publish a report that criticises the way that they have integrated services in their own patch? Will they publish a report that it criticises the way they've commissioned dental services and NHS access? Well, I rather doubt it. And I think this is what we could be missing.  

Adam Brimelow 

So I'd like to close now with a pretty unreasonable question.  

We've got a moment of massive political upheaval and uncertainty at the moment, but it's clear that this issue in the health bill is generating a lot of heat. So, you know, gauging the temperature of whether the government is likely to be in listening mode, I'd be curious to get a sense from you on where you think this will come down to land. What do you think will end up with? Starting with you, Philip.  

Philip Hunt 

Right. So, the bill’s in committee stage in the Commons. Healthwatch abolition and Council of Governors abolition were mentioned in the second reading, which is a debate in principle. These will be debated and committed hopefully in the Commons.  

But nothing I think will probably happen at that point. It's when the bill reaches the Lords in the autumn that we'll see, first of all, whether the government is prepared to move. I hope they are prepared to move and listen to the concerns. But also, the government is in a minority in the Lords and they could be outvoted. 

The key question is how much are the government prepared to listen and move? And if they are determined to abolish Healthwatch, partly because they want to get the number of bodies down, you know, the colour of the quangos, can they recreate the kind of Healthwatch approach within ICBs, where they are sufficiently ring fenced, so actually, the people working for it do feel safe in actually representing and putting forward the views of the public in an effective way, and in the way that we've heard from Gita and other Healthwatches do at the moment?  

Adam Brimelow 

Any thoughts from you on this, Sarah? Where who's going to come down to land?  

Sarah Woolnough 

Well, I think Philip is the expert in one sense. I mean, I've given evidence to the Health Select Committee in the Bill Committee and it and it came up extensively in both sessions. There's a lot of noise. There's a lot of interest. I really hope the government listens.  

And if you bear in mind what else is in the bill, you know, we certainly believe the big prize is the single patient record. And rather a lot else in the bill doesn't necessarily take us much further forward. So, you know, perhaps if I were in government, I might like to think again about some of these measures. Because as I said earlier, I fear we'll end up, you know, if the government listens to an extent, you end up with a model not too dissimilar to the one we've got. 

Adam Brimelow 

Yeah. And Gita. So what's very evident from this conversation is your commitment and passion for local Healthwatch and the work you do. Presumably there's a good strong head of steam behind you in terms of seeking to defend the arrangements we have.  

Gita Malhotra 

Yeah. I'm not for preserving the purpose and the focus of independence. And I just want to echo something that Sarah said earlier around the risk of splitting. It goes counter to integration. It goes counter to the direction around neighbourhood development. But I think the direction of travel is clear in terms of where we need to land. There's more integration, more accountability and more demands for voice that actually changes things. 

And I guess the big question is whether the health and care system evolves in a joined-up way, or it just continues to restructure itself without fully resolving the tensions of how these things connect. And I suspect the real test will be not what structures we end up with, but whether our populations and people can see how their experience of the system is shaping decisions across the entire system and is not just data being collected. 

Adam Brimelow 

Gita Malhotra, thank you. Also thanks to Sarah Woolnough and Lord Philip Hunt. Thanks for joining us on Health on the Line.  

Just before we move on to NHS Online and its chair, John Browett, I'd like to let you know about a free peer learning event on the 7th of July about digital leadership across different collaborative models - the opportunities, the challenges and the lessons learned so far. So, whether your organisation is part of a formal group exploring closer working or trying to drive collaboration without a structure in place, this event is for you. It's being delivered as part of the NHS Alliance's Digital Boards programme. Go to our website to book at www. the nhs alliance.org 

So now on to NHS Online, which from autumn next year will allow patients referred by their GP for specialist care to connect digitally with expert clinicians across the country through the NHS App. They'll also be able to book scans, tests or procedures, track their prescriptions and get advice on managing their condition. All part of that big NHS shift from analogue to digital, and the aim is to provide up to 8.5 million virtual appointments in the first three years for a range of common conditions that will be gradually extended over time. 

Now, John Browett is the first chair of NHS Online. John has an impeccable digital pedigree. He launched Tesco.com back in 2000. That was one of the world's first grocery online shopping services. He's also been chief executive at Dixons, Dunelm Monsoon, where he presided over a huge expansion of their online presence. So do these experiences and skills translate into healthcare? 

Let's ask him. John, you're not the first leader from retail to dip your toe in the waters of healthcare, but can it really give a good grounding, do you think, for digital development in the NHS and if so, what do you think are the lessons? What's the key lesson to bring across?  

John Browett 

Well, I'm hoping that will work because I don't know a huge amount about the NHS and be very kind to me on this interview because I'm very new to the all the acronyms and all of the ways in which the NHS works. 

But yeah, I think that one of the lessons from the digital transformations is to be very customer centred. And if you look at all the great services which have, whether or not it's Uber or Amazon or Tesco, etc., what they've done is they've created a very seamless service, end to end, using the ability of a, you know, online presence to make that work. And the opportunity here is to actually effectively make a very patient-centred customer journey or patient journey so that people actually know where they are standing as they go through things.  

And that can be done at virtually no cost to the clinicians. It makes it much, much easier for the patient, but actually also makes it a much simpler operation for the clinicians, and therefore, we think significantly more effective and efficient for the NHS. 

Adam Brimelow 

And there's something about your experience in retail that that enables you, offers the insights to help deliver that.  

John Browett  

Yes, I think that's right. I think there are parallels, although you have to be bit careful because what the NHS does is a degree of complexity in terms of the operation compared to what I would be doing in terms of picking groceries in the store. 

But the fundamental point is the principles are the same - that you have to really understand how the patient journey works end to end. What you can do to use technology to make that experience seamless, easy for the patients, but at the same time presenting the patient to the clinicians in a way which makes an effective for the NHS. 

So, for example, we can actually do very much a lot of the work on that patient journey, asynchronous, because you don't need the patient to be in front of the doctor to look at test results and everything else. And similarly, if those test results are uncontroversial, you can just send that information directly to the patient without the need for a patient to go into a hospital, etc. 

So these are significant areas where we can dramatically improve efficiency and effectiveness.  

Adam Brimelow  

Yeah. And they're the sorts of improvements that I know the NHS has been looking at, talking about, for a while. But why do you think the NHS needs an entirely new national trust, rather than asking existing providers to deliver more virtual care?  

John Browett  

Well, that's a that's a very good point. And I think there's lots of great work which has been done around the NHS to virtualise appointments, etc. However, the process which we can do NHS Online is we can get that service to be consistent across the whole organisation. The scale and capability of what we can do in NHS Online be much better than an individual trust. I mean, obviously there are 200 trusts or so in the UK. 

And then the other bit which we can bring is to actually use the resources and the staff across the whole country, and that means that we can actually have a much more flexible approach for the workforce, for the clinicians, and that means we should be able to dramatically improve the quality or consistency of quality across the whole country, but actually use all the pockets of resource which are out there, which at the moment may not be able to get to patients. 

Adam Brimelow 

Yeah. And I suppose another question about this kind of model - some of our members, including those in the provider sector, may be wondering whether NHS Online is a partner, a competitor or even a disrupter. How do you see your relationship with other NHS trusts evolving?  

John Browett 

Well, very much as a partner. I mean, in the end, what we're providing is the pathways and reconfiguring the pathways to make them more efficient, effective. 

But the services themselves are actually going to come from the NHS trusts and from the people working in the trusts. And therefore we have to do this in a way which works for the trusts and works for the clinicians, and therefore everything we will do is to try and actually improve those pathways rather than actually getting in the way of the trusts themselves. 

I mean, just to give you an example of that, we're thinking about doing some work with Moorfields. Moorfields, obviously world-leading eye specialist. What we can do is by working in partnership with them, we can actually give access to diagnostics to the whole country.  

Now, of course, that doesn't mean that you will have to do that. It will be always an optional service. But the point is that it can, and your actual treatment may well be done locally, but we can improve the diagnostic process dramatically by working in that way. And that's a partnership model rather than one which will actually upturn everything that's going on.

Adam Brimelow 

Yeah. And I suppose approaching the same concerns from a slightly different angle, there will be leaders listening who are worried that an online hospital risks fragmenting care or weakening local services. So what would you say to convince them that this is a solution to a National Health Service problem?  

John Browett 

Well, I think there's the opportunity actually, is to stitch together quite a lot of the things which go on in the NHS and therefore strengthen the pathways. And to do that in a way which is low cost, low administration, that gives a much better feel of quality. 

I mean, if you think about, for example, something like Uber. Why is Uber such a great experience for the patients? Well, because you actually know what's going on. And even if you have to wait for five minutes for a taxi, you actually feel very happy about that because you actually know that they're coming.  

And a lot of the issues which we see in the patient journeys is that people don't know what's going on. And because this will be done through the NHS App, they'll be able to actually see where am I in the process? When is my appointment? When of my test results coming back? When do I actually get reassurance that I'm in a good place or I actually need to go for treatment?  

And that is the fundamentals of all of this. It should actually strengthen the NHS dramatically.  

And of course, there are many times when there are great services available in the NHS and there is no way to get to them across the whole country. So particularly if you're actually outside the big metropolitan centres or urban centres, then you actually often find it quite hard to access these services. And our job is to actually virtualise that so you can access from any part of the country. 

Adam Brimelow  

So, in terms of that access, it's my understanding that primary care is going to be the front door into this service. So how will you be designing NHS Online so it reduces the potential for friction with primary care, rather than creating another referral route that clinicians have to navigate.  

John Browett

Yeah, yeah. Some of the GPs have said it to me, “Oh my goodness, is this going to be more work for us?” And that's no; completely the opposite of that. And in fact, on my board I have Nikki Kanani and Omar Din, both who come with very good primary trust experience, but primary experience, and they are there to make sure that that doesn't happen.  

But the reason why I'm comfortable about that is that actually for the GPs, the main way into this service will be through ERS. So it will just be literally a button on the ERS system, which will give the GP the option to refer patients on to a virtual pathway. Doesn't have to be that way. And then we will be able to of course give all the information around how  that patient journey is going back to the clinician. 

And quite often what happens is there's quite a lot of confusion between patients and the doctors as to where people are in the process, because this will be a, you know, an Uber-like process, you'll be able to see where you are. The GP will be able to see where you are. We'll be able to actually return really good information to the GP as to what happened in that secondary service, in that specialist service, and therefore how the patient has been treated and what what's been going on so much, much better updating of patient records, we hope for the GPS. 

Adam Brimelow  

Yeah. And just in terms of that patient experience, every digital initiative faces the challenge of exclusion. How will you ensure that NHS Online doesn't inadvertently widen health inequalities for people who may struggle with technology or have limited access to online platforms?  

John Browett

Yeah, I think, I mean, that's a very important issue. But I would say before we get on to the digital access issue, there are, of course, quite a lot of people who actually find it very hard to physically access the NHS at the moment. 

So if you are elderly, infirm or if you've got big care commitments, either with children or with elderly relatives, actually getting to a hospital for an appointment for a physical appointment is often very difficult. And what we can do here is we can actually give people an option which actually for many people will be significantly better and improve access. 

And I was talking to Omar Din, one of our board directors, about this. He comes from the Muslim community, and he thinks this actually will dramatically improve access for many ethnic populations, even though they live in actually in an urban centre.  

And then I think the other bit, of course, is that we will try and design this to actually minimise exclusion as much as possible. This will be a mobile phone first service. It will be that in that sense, because lots of people have now got access to a smartphone. They may need help from a friend or relative to actually push the right buttons, but that is, and I've certainly seen this - as I funnily enough, I was at Moorfields yesterday and they were explaining how that works and has been very effective for them. 

And then secondly, we will actually have screen readers and a number of other things in order to improve access. Very funny you should bring this up because when I was doing Tesco.com, I got some, you know, well-meaning people saying, you know, you're going to cause a problem. You know, it's unfair that people can't get their groceries delivered because they can't access Tesco.com 

Until we pointed out that one of our big patients, or one of our big customer groups, was actually people who were blind. Now you can imagine the difficulty of accessing groceries if you are blind. You literally, the physicality of going to a store is really problematic. But of course, we were able to use a screen reader and therefore people were able to do their own shopping. I mean, that was just a tremendous thing to be able to do.  

And it's the same with your, you know, you've got very heavy pear commitments. Again, Tesco Online was a mechanism by which you could actually do your shopping in a very convenient, easy way. And you didn't have to necessarily go down to the supermarket and take all that time. 

So, I think there are very many analogues which we can do here which will improve access. But of course, you're right, we will have to make sure we design out as many of the issues as we can.  

Adam Brimelow 

And of course, these issues around population health reducing inequalities, that's a that's a focus for integrated care boards. What do you need from ICB leaders to make NHS Online successful? What should they expect from NHS Online in return?  

John Browett

Well, I mean we obviously want to have a genuinely collaborative relationship with the ICBs. I mean, they're a critical part of, they are essentially where the money is going to come from in order to fund this service. I mean, our priority is to make sure that we offer very clear, consistent and cost-effective routes for patients to be treated.  

We will engage around how the pathways work so that they actually understand that. It's very helpful to us now that there is a, you know, there's a consolidated group of ICBs. And if that works well, we think we can actually bring consistent quality of service at great low cost to the ICBs, and we would love to work with them over time to show how that that that can be effective.  

And we will do it pathway by pathway. So,  we'll start in a some of the relatively easy areas. But over time we will do more and more complexity in order to actually make sure that the NHS has value for money.  

Adam Brimelow 

Yeah. So your passion for this really comes across, John. I suppose you know question when you get to the nub of it, is this is about transforming care or really sort of digitising existing services? 

If it's about transforming care, which I think is what you're saying, what's the test you set yourself for when you, you've cracked it? 

John Browett

Well, the real test is if millions of people are using the service every year, of course. And we've got high satisfaction and we're also getting to better quality outcomes for patients.  

And we would love this to be able to be a mechanism by which we can really blitz the queues within the NHS, and we think that's possible. We think that probably at least half of the people on the queuing system, if they were able to get to a specialist, would actually find that there's no further treatment required.  

And so there is huge opportunity to triage customers. Sorry, triage patients. I'm sorry. Of course coming back to retail language. But to triage patients in a way that that they actually can get at least initial understanding of what their condition is doing to them so that they can actually move on with their lives. And I think that will be tremendous success.  

So millions of satisfied patients and a lot shorter queues in the NHS will be, I think, a major contribution, if we can do that. 

Adam Brimelow 

That sounds a very good ambition. John Brown, thank you very much indeed. Lovely to speak to you 

John Browett

Adam, it's a real pleasure and I'm really looking forward to working with the team on this. It is a tremendous opportunity for the NHS to do something really quite special. And actually, interestingly, uniquely, probably we're the only country in the world who can do this because we actually have this a national service where we can actually make this work.  

So it will be a wonderful example of being Britain First as well. So let's hope we can get this going as soon as possible.  

Adam Brimelow  

Excellent. All the very best John Browett. Thank you.  

So that's it for this time. If you enjoyed the podcast please hit that subscribe button and do share it with colleagues across the NHS. And of course, if you have a great programme of work that you'd like to tell us about, please get in touch. We may cover it in a future episode. Just email us at Health Comms Plus at the NHS Alliance. So, until next time, goodbye.  

You've been listening to Health on the Line, produced by Health Comms Plus. We're a creative, full-service communications agency brought to you by the NHS Alliance. With deep sector knowledge and a shared commitment to improving health outcomes, we help NHS and public sector organisations to connect, engage and make an impact. Any income regenerate is reinvested into our work, supporting NHS organisations and the wider health and care system. To find out more contact Health Comms Plus at the NHS Alliance.  

[Live from NHS ConfedExpo]

Adam Brimelow

Hello and welcome to a special edition of Health on the Line. This is the podcast for policymakers and NHS leaders. It's produced by Health Comms Plus and brought to you by the NHS Alliance, which represents and supports the health and care system across England, Wales and Northern Ireland. I'm Adam Brimelow, a former health correspondent, director of communications and now with the NHS Alliance media team.

If you're noticing a tremor of excitement in my voice and a bit of background hubbub it's because today we're at NHS Confed Expo with a live audience right in the heart of the biggest and best health conference of the year. We've had more than 10,000 delegates registered for this event, and there's a huge buzz here in the exhibition space.

There have been some incredible speakers, discussions and debates, which, as you can probably tell, are continuing around us even as we speak. And I'm pleased to say we have some expert guests with us to pick over some of the best bits of NHS Confed Expo 2026. 

Let's have a quick introductory word before we get seriously stuck in. So Lord Victor Adebowale, chair of the NHS Alliance and previously in the same role with NHS Confederation.

Welcome, Victor. You've been on this beat for quite a few years, but I think this is your debut on Health on the Line. So, Victor, finally, at last you've arrived.

Victor Adebowale

Thank you very much. Yeah, thanks for inviting me. It's cool. Yeah.

Adam Brimelow

What took you so long?

Victor Adebowale

[Laughing] I don't know, you had more important people to talk to, frankly. That's fair enough. 

Adam Brimelow

Surely not. Well, we're certainly delighted to have you with us here today. 

Shaun Wooller is health editor at the Daily Mail, covering a whole host of topics including NHS policy, public health, medical research and government decisions affecting health care. So Shaun, plenty here for you to chew on so far. 

Shaun Wooller

Absolutely. So many people here to see, speak to, lots of stands. Lots of busy things going on. So yeah, always a delight to come to Confed Expo.

Adam Brimelow

Excellent. Well, that's good to hear. 

And Laura Hughes is public policy correspondent at the Financial Times, covering the intersection of politics and public services, often with and investigative or analytical focus. So Laura, any particular themes you made a beeline for here?

Laura Hughes

Well, I would say this because I hosted the panel, but there was a really interesting conversation that was going on and has been going on post this session about the US deal that was done with pharmaceutical companies and the trade offs that could kind of mean for the NHS. That's something that I've been talking to lots of different people about because obviously there's this impact assessment, journalists are very keen to get their hands on. So I've been I've been desperately going around trying to find anyone that has it. If anyone's listening and you have the impact assessment...

Victor Adebowale

They don't, in case you're wondering.

Laura Hughes

...on the US drugs deal. Please, please come find me.

Adam Brimelow

Okay, well, use this platform as best suits you, why not. Let's get on with the podcast then. So let's start with you, Victor. This is the very first NHS Alliance conference. It's the start of a new era, isn't it?

Victor Adebowale

It certainly is.

Adam Brimelow

And is it living up to its billing from your point of view?

Victor Adebowale

So far. But I always reserve my own judgment because my judgment doesn't matter. I'm biased. It's the judgment of all the people who are listening to this as to what matters. And so far, what I've heard is there's a buzz around. People are enjoying it. People are learning. They're building new relationships. It's the biggest one you've ever had. So I think we were nearly 10,000 - I'm looking at my colleague - registrations. So if you're going to judge it by numbers and buzz and people, you know, it's a good launch for the Alliance. Yeah.

Adam Brimelow

You really see that, don't you? Just looking around this space to other sort of auditoriums in this exhibition space, of places in the round. So great to see. So, Victor, you opened the event and you used a really powerful, interesting phrase: leadership is the treatment - to making the point that leadership rather than policy initiatives or structural reforms, that's what's key to delivering change, tackling inequalities of care and supporting the workforce.

So you're calling for brave leadership. Victor, are you seeing it?

Victor Adebowale

I'm seeing it in some places. I think, frankly, if you're going to be a leader in the NHS, you've passed the bravery line, that's for sure. But I think we need to do more to support leaders. We need to understand. 

So, you know, in the private sector, not that I'm making the comparison directly. If you're running an organisation that served a million people a year and employed over a million people, and you were anywhere near the governance of that organisation, you would be absolutely focused on the quality of leaders, what they're doing, how they're doing it. What do they need? Because you'd be also focused on the culture and things like alignment. How do you get leaders to align behind the issues that matter? 

I think we don't do enough of that, and I think we need to do a lot more of it. And I think that at the end of the day, all we've got are people, you know, you can have as many policies as you like, but they all have to be implemented or turned into something by people, and leaders have to lead literally that. So yes, I do see brave leadership, but I see it somewhere. We need to see it everywhere, frankly. We really do.

Adam Brimelow

Yeah. So Laura and Shaun, you've obviously been attending lots of the sessions here, talking to a lot of people. Any standout moments for you? Starting with you, Shaun.

Shaun Wooller

I've got to say, Victor's speech, given he's here today.  [Everyone laughs]

Victor Adebowale

I keep buying the paper. [Laughing]

Shaun Wooller

No, I agree with what you were saying about a leaders having to have courage. I think all too often there are examples of some leaders who are doing great things and don't necessarily come out and champion what they're doing enough. 

Or they could be a little bit shy and not want the media attention. Or they're scared of what might happen if they come out and say something and show what they're doing, which might be slightly different to the norms.

And I feel that there are examples where they need to come out and back themselves a lot more, and maybe not necessarily be too concerned about a potential backlash, because if they have a lot of faith in what they're doing and they think they're doing the right thing, then, you know, stand firm.

Victor Adebowale

I'm with you, actually. I think the NHS is a public service at the end of the day. And I think transparency and openness is the key to retaining and improving public support. I do agree with you and it's nice to hear it, actually. I like, you know, I'm always a bit skeptical about, can I say that?, I suppose a brave thing to say about journalists, but I think that hearing that you want us to say more and be more transparent is not a bad thing.

Adam Brimelow

I'd like to get into that a little bit more. I think yesterday when we were hearing from Jim Mackey on day one of the event, he flagged the progress that we've seen in the NHS and he thanked leaders for what's been achieved. He said whichever way you look at it, people have achieved a huge amount. Do you think that when the NHS makes progress or does something really good, the media gives the credit? or our journalists and their editors more interested in the bad news? Laura.

Laura Hughes

I think it has to be a mixture of both. We would not be doing our jobs if we simply regurgitated press releases and gave our readers examples of wonderful things happening all the time. I very much see my job as one that is designed to hold this enormous public institution, which is, you know, attracts a huge amount of taxpayers money, holding it to account, seeing what is happening.

However, on the flip side, I really do spend a lot of my time trying to get into hospitals, into clinical settings, talking to actual staff working on the front line. And in doing that, I am telling a story, a positive story, about the things that they're doing. And that's really interesting to feed readers is to understand what new things are happening. And a way to get a journalist to do that is to offer them something that a no one else maybe has written about before, but be giving them that direct access, opening the door and saying, come in and have a look, and not being terrified that we're going to spin it in a negative way for the purposes of spinning it, to generate a more exciting news story.

So it's a mixture of both. And it's a fascinating thing covering the health service as a journalist. I used to be a political reporter, and that was much easier because you're sat in Westminster, you're chatting to MPs, you're in it, you're seeing it. We can't, obviously, wander around hospitals and walk into GP surgeries willy nilly every day. We have to be invited. It's a very strange relationship. And, Shaun and I were talking about this yesterday, there has been a real shift and I think it's come or it came from our former health secretary, Wes Streeting, really sort of opening everyone's eyes a little bit and accepting actually things really are not perfect. They're broken. There was no gloss.

And in doing so, I think it did install trusts with a bit of courage and confidence to say, actually, we are going to we're going to let a journalist come in and see this hospital, which is completely dilapidated. I've seen some horrendous things. They've invited me in, but there's a serious point to doing that, which is this is what the government needs to do. This is the policy change that we need. And you can only really write those serious pieces if you're seeing the bad. And yet we're not going to write puff pieces. 

When NHS England send out a generic press release to everyone about this wonderful thing, that's not of interest to a news desk. If you say, hey, Shaun, Laura, do you want to come and see this really exciting new trial we've got going and, you know, a new way of treating depression, for example? Yeah, I'll say yes to that. That sounds really interesting.

Adam Brimelow 

So I'd like to follow that up and just look under the bonnet in some ways of how a story happens, Shaun. Because there's a really important conversation that's invisible to us as news consumers, isn't there, between you and your editors about how a story runs and the line that you're going to take and you've got to pitch it and make it happen.

How does that work? And is there a bias towards running what's going to say rubbish NHS once again?

Shaun Wooller

Absolutely no bias. We don't want to be going out and bashing the NHS. You know, there's a lot of national pride and passion for NHS and I'm a massive supporter of everything it does, but it doesn't mean it does everything right. You know, we get emails and phone calls from patients all the time telling us about bad care that they've received or the difficulties they've had accessing a GP or accessing an ambulance. And the reason that sort of stuff makes the front pages and makes the newspapers is because, thankfully, it's less rare than getting good treatment. 

You know, if we have a stage where you have front page news, that man goes to the hospital and comes out alive, that is an absolute tragedy, you know? So we're fully aware that there's a lot of great stuff happening within the NHS and we do cover it. We cover the fact that there are new drugs coming to market. We cover the fact that waiting lists are coming down, although obviously today we've seen that there's been a slight rise. So we do try to keep all of that coverage very balanced. 

And when I'm choosing the stories that I'm writing, I'm thinking very much about the readers. You know, we're thinking about the reader themselves, you know, their husband or their wife, their children, their parents. We're trying to think across all of the age spectrums. And you're looking at are they getting the access to the care they need when they need it? And that can be access to drugs. It can be access to primary care, secondary care, you know, and that is the primary focus that we tend to look at.

Adam Brimelow

So you're looking for access to what's going on in the NHS. You're too often, by the sounds of it, running into trouble getting that access. 

So Victor, do you think there's any link here between what you've been talking about in terms of leadership and what we're hearing from Laura and Shaun, showing the leadership, maybe having the courage to work with a journalist to get an important evidence-based story out there, being ready to take that risk.

Victor Adebowale

So there are three things about what's been said that I think are important. 

First of all, in a democracy, people have a duty to be skeptical. And I think journalists have a duty to lead that skepticism. And there's a big difference between skepticism and cynicism, as you know, and I think I invite that skepticism. It's very important if you just believe what you've told what's the point? Right. So I think that's important. 

The second thing to say is that one of the things that I think we lack sometimes, not as a general statement actually, you're specialist journalist, but I have noted because I've read some of the things that you've written. And this isn't a criticism, by the way, but generally stories in the press lack nuance, and it's very difficult. Nuance is a difficult thing these days. People want black, white. They want to be disgusted or made angry or whatever, and social media feeds that sort of stuff. But I think the NHS often is a very nuanced service. There's a lot of nuance going in there. And so I welcome journalists who want to engage in the story, you know, the truth in a way, as opposed to just the story.

And the third thing I want to say is that every time there is a mistake and something horrible happens, and I note this in terms of my mental health colleagues, these episodes are hugely traumatic for this frontline staff in particular, who, you know, and for the managers and the leaders as well. And the key thing about these incidents is that do we learn, right? There are operations taking place every day on people's hearts, on their livers, on their lungs. Most of them will go right, but there might be a small percentage that will go wrong. That is inevitable in an organisation that deals with a million people a year, a million people a day. 

The question is, do we learn and are we allowed to learn? And the second issue is, are we held accountable for that learning so that those incidents are not for nothing? So that's my response to what I've heard. 

But in response to your question, I think it's absolutely critical that leaders are transparent. In other words, like they have to lead the communication often and they have to do that. And I was talking to somebody earlier today about leaders in the NHS. There's two things. One, and this is a personal view, but I think if you're running an organisation that employs 20,000 people and manages a health for a whole community, they have got a right to know who you are and what you believe in. I think they do. You know, people might want to disagree with that. But more to the point, journalists have a right to understand what you're doing and how you're doing it. And you have - one of the skills I think you need is to be to tell that story in a way that is understandable and clear, because in this day and age, you're either telling the story or you are the story.

So I think leaders have to be brave. You don't have a choice. I understand that it can be scary, I get it, but that's why you get paid the big bucks.

Laura Hughes

If I can give some actually some quite recent and very specific examples of this. So I've been writing a lot about the rollout of the federated data platform, and a lot of that reporting has been me sat at my desk having calls with people who don't want to be quoted on record. It's all anonymised. And for a very long time I was saying to NHS England, please, can I come and see how it's working in a hospital?

And it took a long, long time. In the end I was saying, you know, at the moment what I've got are a load, 20 people saying negative things about this. I really want balance. I really want nuance. If you give me access to a hospital where I can sit down with clinicians and they can show me how it's working and benefiting them, which is what you're saying, it's going to actually make for a much more balanced piece.

And it sort of worked in their favour. And actually they did grant me access. And it was I know it was a huge political risk, and everyone was very nervous about me going into this hospital, but I couldn't, as a journalist, you can't actually ignore the counterfactual that you are presented if it doesn't fit with your. I know, of course some journalists might, but I felt responsible, covering the story that's so contentious and politically toxic to do an honest job. And if you, NHS England, give me a chief of nurse that says this is completely transformed the way I deliver care, I am going to report that and I think that was win for them.

Victor Adebowale

It is important because, and I've read your stuff and the FT's not one of the papers that criticised. But if you don't do that, then the denial becomes the story. And it's kind of and I know these judgments are sometimes fine, but I'm with you. I think better, better to err on the side of nuance and telling the whole story than having a partial story told, which includes you basically saying, we're not going to.

Laura Hughes

Yeah, because then you...

Victor Adebowale

...look like you're hiding something.

Laura Hughes

Yeah. It's one of those things that's just not engaged with the journalists. But then I think, oh, what are you hiding? It makes me want to dig more. It makes me want to try and find more people to talk to you.

Adam Brimelow

So hopefully conversations like this will help to build a little bit of trust, a little bit of courage as part of the exchange.

Victor Adebowale

Can I just say one thing though? We are talking to quality journalists. I don't mean to blow smoke here, but you know, there's another kind of journalism which people are generally terrified of, which is the kind of, for want of a better term, citizen journalist, the person who turns up with a camera at hospital to film people trying to save lives, to prove something that they've already decided, deemed, intend to prove.

And I've had note from colleagues about that kind of stuff. And that stuff is genuinely scary. So there's a nuanced element of this where, you know, social media can be utterly brutal. And staff, we have a duty of care to staff, we have a duty of care, and we just need to bear in mind that it's not always quality journalism. You know.

Shaun Wooller

We certainly wouldn't operate in that way.

Victor Adebowale

You certainly don't.

Shaun Wooller

We wouldn't turn up to a hospital without prior permission. 

Victor Adebowale

No of course not. 

Shaun Wooller

Going to go snooping around wards.

Victor Adebowale

But that's my point. I'm making the there's a big difference between you two and the people that you work for and another kind of journalism which is less professional, frankly.

Laura Hughes

Okay. Yeah. And we, you know, we obviously when you're going into a clinical setting, it's sensitive that those are those are real people. And no, no proper journalist is ever going to go straight up to the family of a patient in a traumatic situation. And I'm so I am genuinely so grateful to the hospitals that have let me in.

And I have stood in A&Es where patients have sadly died, and I have watched some really horrendous things that I obviously don't report, that I stand back and observe and appreciate. That's not a moment to be throwing the mic in someone's face. Like most journalists seriously, at mainstream newspapers, they're going to do a sensitive job. We are human beings too.

Victor Adebowale

Of course, and that's what the Alliance would want to work with you to continue. I'm just making the point about it's not all great.

Shaun Wooller

And I think with that, though, when you are doing a story that's critical of a trust, you know, you are very upfront about it. You maybe speak to people, you know, that work at hospital first to see if they've got previous examples of it as well. And then you would go to the press office and you were very upfront, you'd say, this is what we've been told. This are the facts as we understand it and what we're looking to write. Do you have something to say about this? And if they can come back and they can show categorically that what you've got is not true. Yeah, we will scrap the story. We won't run it. Or they can try to mitigate the story by telling us, okay, that bit might be right, that bit's wrong. And then it's a backwards and forwards to try and figure out, okay, what can we do that remains the essence of the story as we've been told it, if it's true...

Victor Adebowale

Tell the story

Shaun Wooller

...and what can we do to work with the trust to make sure we get their message across as well? Because there is always background to this stuff. So even if the story may well end up being negative about the trust, we're going to work with them again in the future. We want to have a good relationship with them.

They need to have the courage to accept where they go wrong and cough up to these things and go, yeah, okay, we should have done better in this case. We've made changes to this. Hopefully it won't happen again. Rather than trying to close the curtains and say nothing to see here. Because we're not stupid, the patient is not stupid. If they're going into this hospital and they're seeing people waiting on the corridor, waiting for care, or they've got relatives that have had bad experience, if we're going out there and saying nothing to see here, this is fantastic. Everyone ends up being silly and nothing improved.

Victor Adebowale

Totally agree with you. And if you look at the history of some of the hospital scandals that have occurred, I think more openness and transparency with journalists may would have would have prevented some of that from happening in the first place. And I think there's far as the Alliance concerned, we do work with journalists. Yeah, I do and we very keen to continue that.

And I think, you know, I'd rather work with professional journalism that holds standards ahead of the less professional 'journalists'. No, they're not journalists really, who seek sensation. And so, you know, I'd rather you be in front of the story than and that alternative.

Adam Brimelow

That's the benefit we have with the NHS, working with specialist journalists who are really into the detail and covering the stories seriously as we know you do. 

Can I get on to some of the sort of content that's been discussed here at this event? Inevitably, of course, there's been a lot of focus here on the Health Bill. Something we've been following closely on Health on the Line. It's a really wide-ranging bill in scope: the abolition of NHS England, centralisation of power, the single patient record, patient voice. It could go on and on. Victor that's a rich, complex brew of a bill. How fundamental do you think it is to delivering the 10 Year Health Plan?

Victor Adebowale

Well, it's pretty fundamental because the plan is to abolish NHS England next year, right. Now, I'm a crossbench member of the House of Lords, don't hold it against me, but there is a kind of, this is a 400-clause bill, right, this is not some little bill to close. This is a 400-clause bill.

And I can tell you now I am skeptical about the fact that it's going to be all done by April. You know, I mean, the abolition of Healthwatch, for instance. I know because I've seen the ticker tape from colleagues in the House is quite controversial. And there's other things around the patient safety infrastructure. Now, you know, I just think it's going to be a bit tougher than we think.

I also think that, you know, on the centralisation point, obviously the closure of NHS England, you know, we're going to move - 25 sort of things that NHS England do are going to go into the department and will effectively - so 23 of the 25 things that the NHS England does and now going to be in the hands of the secretary of state, and we're now on our seventh, and most of them have said they want to devolve power. Now, it's going to be a very brave and leader, for want of a better term, secretary of state, who then distributes that power as, in my view, they're going to have to do to get the 10-year plan moving, particularly around things like neighbourhoods, population health, standards, you know. So it's challenging. It's challenging politically. It's challenging administratively, you know, to get this bill is not straightforward in my view.

Adam Brimelow

So one key part of the bill, as you know, is the single patient record. And Laura, you obviously hone in a lot on digital developments in the health service here at the NHS Alliance. We support the single patient record, albeit with concerns particularly over control of data. Previous NHS data sharing schemes have run into trouble, to put it mildly.

Where do you think this story is heading this time?

Laura Hughes

Do you know what my - obviously there is a long history of failed data infrastructure projects in the NHS. So everyone is going into this with a degree of oh, here we go again. Even if they broadly support what is happening. My concern, I think, is that there are some really important questions that I don't think anyone has actually quite answered yet. And that's where it might this bill might run into a little bit of trouble. So who is the data controller for GP records, for example? This new bill is giving the secretary of state new powers. Essentially, they can ask GPS and hospitals to hand over these patient records. So I'm still not entirely clear who owns them.

And the reason that matters for many people is could this data be shared for financial gain, which again, you could argue was a good thing? Why not capitalize on this this rich data resource to help fund the NHS? You know, this level of control, what does that mean for patient trust when they go to see their GP or go and see their doctor?

And all of this is, of course set against a background of Palantir's role in the NHS. There's a lot more conversation happening now about patient data, how it's secured, who's seeing what, and the political winds are changing. We're seeing what's happening in America and people are really asking quite sort of deep, meaningful questions about what a future government might do.

Let's say we have a Nigel Farage government. Then you start to ask proper questions. What would that government do with health records and that and that I actually think, is why this, it's all very techie, but it does matter. And people are genuinely really concerned. And I've asked many times who's going to be the data controller. What does this mean? And they're like, oh, we haven't quite work that out yet. We'll work it out as we go along. But for a lot of people this is a no go. And we know GPS are already saying we are not going to hand over these records. And there's obviously a long history and tension between GPS and Whitehall. But this is a real-life thing happening, and I don't think they've ironed out some of these issues yet. And they really need to.

Adam Brimelow

Yeah. Shaun, we're going to hear from the new secretary of state, James Murray, shortly. He's stepped in clearly at a tricky time. So what would the Daily Mail and presumably its readers want him to prioritise as he gets up and running in these next few weeks?

Shaun Wooller

Well, he's got big shoes to step into, hasn't he? You know, if you look at the character of Wes Streeting. So we'll see this afternoon whether or not he can do that. I think we are going to be keen to see him continue to tackle the issue of access. You know, people struggling to see their GP, people worried that they're going to have to wait too long for routine care. Is an ambulance going to turn up if their relative is having a heart attack or stroke? And I do think that they are the main things that people care about. 

And we talk here a lot about reorganisation and restructure and new acronyms coming up every day. But most people don't really care about that on the street. You know, they want to be able to see a doctor or a nurse when they want one, and who it is that paying for it locally, in terms of administratively, it doesn't really matter to them, you know? And I feel that sometimes the tendency for us all to get a little bit too hung up on what's happening with that, rather than realising what matters, is our patients getting the care they need.

Adam Brimelow

It's interesting you really emphasize those immediate issues. It strikes me just following events that this conference, there's a real appetite here to talk about transformation of services. But day-to-day media coverage obviously tends to focus on performance pressures in the here and now. And you can understand why that's the case. Would you accept we need to look more at the bigger picture in long-term goals. Or is that really unrealistic in today's media environment?

Shaun Wooller

No, absolutely. I think we only have to look at the state of the NHS estate and how the hospitals are crumbling to realise what happens if you don't actually think to the longer term. And it's that with the short political cycles and the short tenure of NHS leaders, why they're more obsessed with what's happening here and now. And if you've got someone sitting in front of you in A&E and they need treatment, you're going to be focusing on them, you know, rather than necessarily the people that have got longer-term issues and complaints.

But I do feel that's a very shortsighted way of going about dealing with the NHS and with the government finances. You know, if you spend so much money on the here and now and you don't plan for the future, ends up costing you a lot more in the long run. And I think when you look at the use of drugs, and I write a lot about weight loss treatments, and we've seen the benefits that they can have. You know, I'm not saying there are no side effects. We've written about them as well. But there are massive health gains to be had with the weight loss drugs and NICE approved them. But they're being rolled out so slowly, and that means that there's a lot of people out there that could benefit and could get real long-term health gains that are missing out and aren't getting them as quickly as they potentially could.

And I understand that the reasons for that is we've got the cost and the amount of time it would take for GP's to be processing them, but we need to start looking at novel ways of funding these treatments. You know, could we have a situation, for example, where we say to the drugs firms, we'll give these drugs to people that need them now we'll expand how quickly they can be given out, but we'll issue basically a form of bond where we'll pay you for them in five or ten years' time. Once we've seen if they do actually have the benefits you claim they are having, and then we're going to start to see those benefits coming through hopefully a lot quicker. We're going to reduce the cost to the NHS in the long run, but we're not going to have that cost immediately up front, which means the money that's around now can be used for doing the immediate things, and hopefully that will then save us money down, you know, in five or ten years' time that can then be used elsewhere.

Adam Brimelow 

Laura, is there from your perspective, a sort of trade off, long-term, short-term priorities and getting the stories out?

Laura Hughes

Well, actually, I think the GPL ones is such is such a good example. I also write a lot about how Whitehall, the message from Whitehall is let's roll these out. This is part of our preventative health care agenda, 10-year plan. And on paper it makes total, total sense. But actually what's happening on the ground is ICBs, they're changing the criteria which you qualify to access these jabs to basically limit them because they can't afford to give them to people.

This is like the most beautiful example of we know something that works that's going to save the NHS in the long term. But everyone is sitting here today going, but we can't afford to do that now, so how can we actually achieve this, this lovely idea that everyone agrees is the right thing to do without making these financial sacrifices maybe somewhere, or finding ways of doing it, or getting Treasury involvement, getting by and across government? I wonder if that's the kind of thing that we might start to see. Is other departments coming in on this and it not just all being put on the NHS and the ways in which politicians are now talking about the NHS and it being part of the kind of bigger economic story of the UK, will surely this burden has to be shared. It can't all just come from the NHS.

Adam Brimelow

Yeah. And Victor, thinking about that, that's what attention that you see between short-term imperatives, long-term goals. And you've got that rare thing which is a continuity of perspective, I think six years or so, longer give or take.

Victor Adebowale

Six years with on the board of NHS England as well. Hence the grey beard. But there you go.

Adam Brimelow

So just looking forward a little bit. How optimistic or pessimistic are you for the NHS in another six years as we head towards what will then be, you know, getting towards the end of the 10 Year Health Plan?

Victor Adebowale

Well, I'm far too lucky, as everybody in this room is, to be pessimistic, frankly. And so I'm always optimistic. I just want to say, I mean, there's a couple of things. One, the lack of a long-term view is the reason for short-term crisis. And as you made that point with the capital, you know, last time it was last time I looked, we're looking at 14 billion. But that's because we did a lack of planning, a lack of which has led to short term. I always admire journalists who can who can incorporate that in their story. There's a reason why these things are happening, and I think people need to know both. And you can put both in the same paragraph pretty much so, and I think that's important.

The GLP ones are a good example. And I think it's complex, more complex than we think. So GLP ones aren't just a weight loss drug in that sense. They weren't designed for weight loss actually. So they become a weight loss drug and the experience of them is very differential depending on where you are. You know poor people, they're supposed to be part of a weight loss plan. They're supposed to, you know, they're supposed to be part of health coaching. There's a whole load of stuff there that might not be happening, but I think the point you made is a really good one. So, you know, when we when Whitehall makes these statements, they're often made without thinking about the system effects, by which I mean, what do we have to do to ensure that the front line can actually apply this?

And I'm fond of noting and this, you know, that even in the best organisations, the people at the top understand about 20 per cent of what's going on. The people in the middle understand about 30 per cent. But the people on the front line, they understand the remaining 50, right? And I think there is something about and it's the work that the Alliance does with our colleagues is ensuring that we have the full sight of what's going to happen when we say some thing's out there, we're going to do something when it hits the front line.

And it's the kind of conversations that we have with journalists about actually, our view is it's a great idea, how is this going to work? And we talk to our leaders in our front line, not just in the NHS as well, actually, because some of this has implications for people who work in partnership with the NHS in the not for dividend or the voluntary sector.

So there is a problem about how government sees public services, frankly, which I'm fascinated by, which is things are said up here for political reasons, but there's a disconnect between the operational reality, and that's a real problem and the understanding of how it actually impacts patients in the first instance. And on your point, Shaun, which is a really good one about, you know, people want to know whether an ambulance is going to come when they call one, of which we've made some improvements. People want to know, you know, whether they're going to get to see their GP in a certain time. I'm a real believer in, at the end of the day, all this process that we sometimes get fascinated by needs to have an intention. And I think again, I'm really interested in the journalists that talk about the process, but connect it with the intention and actually are brave enough to say that some of the processes aren't connected to an intention, you know, like, why are we doing this? Like, if we could stop it tomorrow and nobody had noticed because the intention cannot be articulated. So I'm with you in the sense that we can make things simpler. And this is one of the things I liked about Jim's speech, you know, but we also need to report and talk about the connection between this process, which sounds all woolly new and new words and all that. What's the intention? What's the patient going to experience as a result? Like, is he going to change anything?

Shaun Wooller

There's also a failure though, when you do have a pilot scheme and you find a process that does work, you know, isn't then jumped on and rolled out nationally fast enough. So, you end up with a situation where there are trusts doing great things. Again, we'll talk about this earlier where they're not necessarily coming out and championing so other people don't know they're working. Yeah. And if you can look at a trust and you can see that one is able to do something for half the price of another, why isn't everyone looking to that?

Victor Adebowale

So the challenge, that's a really good challenge. And I get it. And I'm with you again on this, we kind of agreeing too much here. What's going on? So this isn't right, but I agree with you and I'm being fond of saying that asking the question how long did it take now, Bevan, from his first speech to the rollout of the NHS.

Anybody? Two years. Now we have a problem in that the solutions to the NHS challenges are happening somewhere and I've seen them, you know, I've seen them in Hackney, I've seen them in, you know in the north east of England, they're happening somewhere. The challenge is to get them to happen everywhere. And I think that is something about how we want, I don't want to, but how we learn short and think long, because when you roll something out in the system as complicated as the NHS, there will be mistakes, there'll be iterations.

But can you learn and spread at the same time? in the private sector, actually that is done. And you learn and iterate and you learn and iterate. In the NHS that's sometimes seen as risky. So it doesn't happen. And I think if we emphasise the leadership, the brave leadership, that's what it's doing. It's learning short and thinking long.

Adam Brimelow

Right, right. Well, time scales are tricky and we are running out of time. So Victor, Laura and Shaun, thank you so much. I've got to say that was a great discussion. Really appreciate that. Thanks to our audience here at NHS Comfort Expo. 

And if you've enjoyed this episode, some good news, there are many, many more to sink your teeth into.

You can find us on your podcast platform of choice, and don't forget to subscribe and follow us so you never miss an episode. That's what we've got time for. As I say, thanks for watching. Thanks for listening, and please show some appreciation for our guests here on Health on the Line. [Applause]

 

[NHS England, NEETS and Sir Jim Mackey]

Adam Brimelow

Hello and welcome to Health on the Line. This is the podcast for policy makers and NHS leaders. It's produced by Health Comms Plus and brought to you by the NHS Alliance, which represents and supports the health and care system across England, Wales and Northern Ireland. I'm Adam Brimelow, a former health correspondent, director of communications and now with the NHS Alliance Media Team.

We have a packed podcast for you. In a moment, I'll be joined by the new chief executive of the NHS Alliance, Sir Ciarán Devane, getting first impressions of his role, what he's been up to and his thoughts ahead of our NHS Confed Expo conference.

Then we're going back to the health bill. Remember last time we looked at the single patient record? Now we'll hear about the abolition of NHS England and what the changes in the bill mean for ICBs. We'll also be catching up with findings from the Melbourne Review, looking at challenges facing young people who are not in education, employment or training and asking what's the role of the health service in delivering solutions?

And before we finish, I did promise you a packed episode this week, I'll be having a quick catch up with Sir Jim Mackey ahead of his keynote address at the NHS Alliance's Confed Expo this week.

So let's crack on now. A warm welcome to Health on the Line to Sir Ciarán Devane.

Ciarán, thank you for joining us. You are now a few weeks into your new role at the NHS Alliance. I know you've been getting out and about visiting a lot of members. I'm curious to know what you've been up to and what are your first impressions?

Ciarán Devane

Oh, well, the first thing I've been up to is trying to get up to speed and just conscious that, well I've might have been observing the NHS and healthcare for the last number of years, I haven't been a remotely as closely involved as I used to be, so I'm just conscious that I have to get myself up the learning curve and that's involved talking to lots of people and reading.

I've been trying to get out and about. Yesterday, for example, I was in Epping, Saint Margaret's, who have a new community diagnostic centre and talking to the Princess Alexandra, which is the trust it's part of, and really trying to make sure I'm sort of learning and listening as much as I possibly can and getting ready for Expo, of course.

Adam Brimelow

Of course. And you obviously you're talking a lot to members. What are you getting in terms of a sense of the state of the NHS, how health leaders are feeling? And what do you think is the NHS Alliance's role in supporting them?

Ciarán Devane

There are a few things. The first thing for me is that the fundamental truths which are that the NHS has been and continues to be incredibly successful. And one of the consequences of that is we have an older population with a large number of frail elderly, for example, and which demands a different model and but also demands the continuing excellence of, for example, the existing ICUs and hospitals, because that's why we are likely to live longer as well. So those fundamental truths are there. So the reform agenda that everybody talks about, whether it's about neighbourhoods or it's about supporting hospitals to focus on the people they really need to focus on and taking some of the other stuff away.

Those truths are there, but they're much more urgent than they would have been, say, when I was back on the board of NHS England, in that the numbers are starker and therefore that need to move and to move now, not in ten years time is greater. So that's kind of one first impression.

The second first impression is, you know, we talk a lot about the money and we talk a lot about restructure. We don't talk enough about the people of the NHS. And whether it's the pressure that senior leaders are under, whether it's the pressure in the front line, and we really need to think about that. Um, because the other thing that people are saying and members are saying is, look, fantastic performance over the last 12 to 18 months. It's great that NHS England landed where it needed to land in terms of the money. It's great that we dented waiting times, but this year is going to be really hard. Some of that financial efficiency was worn off. So, you know, last year's numbers are not the baseline for this year. And because of the one off nature of some of it, it's going to be harder. It will mean some decisions around what gets resourced or not. Do services get provided or not? That will mean political cover locally and nationally if needed for some of those decisions as well.

And the number in the survey, which we released recently based on interviews with 250 odd of our senior leaders, the one number that really worried me was the one of 93 per cent of senior leaders saying they're really worried about staff morale, because if we're going to hit those numbers, it can't be asking people to run around their house to win even quicker. It has to be around, what are we doing to make life easier for you to do the great things, which then allows you to do this reform stuff as well? Because if we're going to make genuine transformation and have great neighbourhood care with, you know, the acute hospital integrated well with everything else, that's a different skill set. You need motivated people to do it. You need to be able to invest in your people to give them the skills to do that as well.

So all of that, I think, Says that we, as the Alliance, need to be very close to our membership and really understand what's going on, be able to articulate that well, not just in Whitehall, but also in obviously, Wales and Northern Ireland, in our case. Um, and to do that in a way which is direct but constructive and helpful as well.

Adam Brimelow

Ciarán, all those issues and many more, I'm sure will be popping up at our flagship conference, NHS Confed Expo, you mentioned that's just coming up very, very soon now, how important is this event to you and our members, and what are you hoping to get out of it?

Ciarán Devane

I think one of the great things is that this is where everybody gets together. So there's the formal programme, which is more expansive and deeper and more relevant than ever. For example, one of the people I was in the room with yesterday was talking about the session on the flow of money and how that needs to be managed. If we're going to incentivise true collaboration in neighbourhoods. You know, that kind of stuff about integration can't happen if the money flow doesn't work in the right way, and we need to face into that. So there would be real content, I think, which will be delivered through the event. And hopefully that will be incredibly useful to the 7,000 people who will be attending. So that's my my first hope.

My second hope is that some of that intangible stuff, that informal learning, the networking, the meeting up with people and say, how are you getting on with this? And you know what the Alliance does really well, get people together through our networks and through various workshops and so on that that will happen.

And the third thing I'm hoping for is that we begin to get some clarity around some of the things which can be truly useful to our members and more broadly, things which, look, if only we could do this, then this would enable this other thing to happen there. If we can get some granularity on that, then we can take that away as the Alliance and say, okay, you know, this is something that we might do to support people around cyber security, or this is something that we need to do to help people develop the skills that you need to operate in this kind of disseminated environments that people will increasingly find themselves working in.

Adam Brimelow

Yeah. And you've been setting out your stall a little bit in this conversation, but of course, your first major speech as chief executive will be happening at the conference as well. Any pointers to the sort of themes you'll be looking to address?

Ciarán Devane

Well, I think I've just begun to touch on them. I think there are a couple of big themes for me. One is we have to focus on performance, but we also have to make sure that this reform thing happens as well. And that balance. So there's a theme around balance. You know, we're all talking about neighbourhood, but let's not forget that the reason we have the luxury of talking about neighbourhood is because, you know, the true performance is consistently improving and high. And that's why we have a population which, you know, have as many years and healthy life years as it does.

There's also something for me around what happens if we don't do this, because we've been talking about a population which is getting older, for many, many years, but now it's beginning to get acute. And, if you'll forgive me, an example from my past, when I started Macmillan, we had this wonderful mission statement about improving the lives of everyone living with cancer. How many people was everyone? Turns out it's two million in 2010, three million in 2020, four million in 2030. Well, 2030 is nearly upon us. So the number of people who are alive and living with cancer will have doubled in that period of time. That requires very different cancer services to the ones which were required in 2010. And that's played out across many conditions and, you know, many populations. But if we don't do it now and we end up with a system which is designed for the past, not the future, then performance will slip, access will get harder, and the public really cares about access, whether it's to a GP or A&E or scheduled care. And then performance begins to slip and then public support for the NHS begins to go. And then the model of universal healthcare free at the point of use, begins to be frayed.

So I think the next five years are incredibly important, because it's when all these improvements that have been happening over the last ten, 20 years are delivering, but we're delivering it with an NHS which is based on the old model. So we need to work out what the new model is, and we need to grasp the thing that has never been grasped, which is how does social care integrate into this?

Adam Brimelow

And Ciarán, you talk about developments of the next five years, but we're right in a moment of turbulence, aren't we. at the moment? I suppose internationally, in government with the structural changes across the NHS and of course, the added complication of further industrial action looming as well. Is this is this a moment of jeopardy for the health service?

Ciarán Devane

I think every moment is the moment of jeopardy for the health service. There’s always been politics going on, there’s always been, you know, challenges in the economy, you know, one period, maybe more than another and so on. So I think it's not that per se, but it's this accumulated pressure, which where the increase in demand and the increase in public expectations meet a system which has been doing incredibly well, but all of us know, and this is shared across the membership and across Whitehall, all of us know that we need to do this reform thing.

So if the next few years is solely consumed by it's about short-term performance and not long-term reform, then we will be late. And that's the thing which I think puts the the kind of psychological contract with the public under threat, if the system were to begin to underperform. And therefore we need to start that work now. And I know in many places we are starting that work now, but this needs to become the focus. Both because it's the right thing to do, but also doing the best for the population is what motivates the staff of the NHS and and having that vision and that hope is incredibly important.

Adam Brimelow

Ciarán, thank you. Nice to catch up with you and best of luck at NHS Conf Expo.

Well let's turn to the health bill which formalises some huge changes, including that momentous decision to abolish NHS England, reallocating many of its responsibilities with huge repercussions for its staff and the work they do.

The government says it wants to reduce bureaucracy and free up resources to be reinvested in the front line. Is that what's going to happen? And there are also far reaching changes in roles and governance for ICB. Cue huge upheavals. But will it make anything better?

Let's talk now to Stuart Hoddinott, associate director at the Institute for Government, and also a warm welcome to Anu Singh, chair of Leicester, Leicestershire and Rutland, ICB and Northamptonshire ICB.

Anu and Stuart, thank you very much for joining us on Health on the Line.

Stuart, if I could start with you. Just going back to before the bill with the abolition of NHS England when that was announced, was that a call of right call, right time or right call, but at the wrong time or maybe just the wrong call at any time?

Stuart Hoddinott

It's an interesting framing. I think we would argue at the institute that this was probably right call wrong time, if you had to come down somewhere. By that, I mean that we agree with a lot of what the government says about duplicated lines of accountability, duplication of roles between the department and NHS England. So difficulty passing who you're responsible for as somebody in systems. But we would also say that there is a real opportunity cost that comes along with abolishing such a large organisation as NHS England, which the system is now experiencing. It’s very time consuming. It is very disruptive. It means a lot of attention is focused on that process rather than on more substantive reform. And given the government has got five years in which to make very substantial changes to the NHS, I think we would say that if you're looking to prioritise performance and driving your ten-year plan, it's probably not the right time necessarily to go ahead with a major top down structural reorganisation of the NHS.

Adam Brimelow

Yeah. And you've also criticised a lack of coherent vision behind the move to abolish NHS England. So now, more than a year on from that initial announcement, can you see that vision hoving into view at all?

Stuart Hoddinott

It's got clearer, I will say that. But that's also from a very, very low base. The government was almost completely incoherent really when it announced it. It was done in… it was announced in terms of cost saving measures. We're going to direct more money towards the front line, which we've heard that time and time again. I think that kind of falls apart a little bit on contact with reality because, you know, why does a tiny amount of, in reality, additional money for the NHS in the context of its total spending, really make a difference when we poured billions more in over the past five years and performance has got worse? So that kind of fell apart.

And then there was other narratives that have sort of come and gone. I think now we've settled on one which does make more sense, which is about that reduction in duplication between the Department for Health and Social Care and NHS England, and also the rationalisation of accountability lines between the centre and systems. I think that that is a more coherent message that is now being pushed by the government.

I'm not sure why it took them so long to get there. I think it also speaks to some of the sort of illogic in the way that they have approached some of the headcount cuts, for example, like they announced the 50 per cent headcount cuts before they really had a clear narrative for why they were doing them. And that does make it seem difficult now to justify why you're pursuing such extensive reductions in staffing. And it feels more like you're trying to squeeze retrofit a Department for Health and Social Care into a predetermined number of jobs rather than the other way around, which we would argue would be the correct way to go about it. 

Adam Brimelow

Yes. And Anu, ICBs, they've obviously been absolutely in the eye of the storm. They've had their own very real traumas to contend with over the past year. What do you think are the biggest challenges you face now and how are you adapting to them? 

Anu Singh

Yeah, I mean, as you said, it's a massive shock, wasn't it [sic]? So it feels like we're part of a of a bigger pattern. This happens a fair amount in the NHS. But we knew, didn't we as ICBs, that something had to change. But it's the quality and the species of that change. And I think, as Stuart has said, the way it was framed as cost reductions in the beginning probably wasn't that helpful. But we kind of, whether it was through good lobbying or the fact that the pieces were coming together at different times, got our story heard.

So our story was we've been trying to be good strategic commissioners since the very beginning. And actually we, we've had to deal with very random things such as, almost on day one, we had a management cost reduction, didn't we? So that was a 30 per cent. And we've been trying to live with that, as well as then having to deal with the operational pressures and the fact that our focus as strategic commissioners has been really stretched and it's been quite thin.

So the reframing of this as actually being really clear about us finding our space, being equipped with the national policy framework, the blueprints, etc., etc., has felt like it's almost redeemed the process. So it's been something that makes a lot of sense now and could potentially be quite helpful in terms of everyone on the pitch finding the right intervention for them, whether it's the ICB voluntary community sector, provider, social care. So hopefully, as long as we all, you know, continue with the kind of same direction, this could have a great coherence.

Adam Brimelow

That is good to hear. So a better story emerging there. But where does this bill leave the local relationships and partnerships that underpin system working and the shift to a neighbourhood health service?

Anu Singh

Yeah, I mean, we've been through a really horribly uncertain change curve, haven't we? And as always, the currency of relationship is what makes or breaks it.

So many ICBs, as included, had heavily invested in place-based relationships, community relationships. And actually that stood the test of time. So people have been really supportive. We've experienced tremendous amounts of compassion. So our staff have been, as you can imagine, knocked for six. Quite a lot of different things were coming on stage at unhelpful time frames, such as we knew that we had to make some cost reductions, that the redundancy visibility of the costings wasn't that clear. We knew we had to change roles, but the blueprint wasn't available at the time when we were doing some of that thinking. So our partners have really stuck with us. They've been really compassionate. They've been really understanding. So whether it's colleagues in local government, public health colleagues, elected officials or provider colleagues, actually, it's felt like they've been part of the change with us. And I know from speaking to fellow ICB chairs, it's been like that across the country. So that sense of actually we want to build something different together. So let's help and take our time and perhaps not be as impatient with the sense of not knowing the end destination as sometimes we are. So that's been really helpful.

Where it's been probably most problematic is we've had to deal with some tough time frames. So for example, we've had to put in potential structures in place where if you had your time, you would do it with working closely with communities, stakeholders. What do some of these jobs and roles look like for the future? But we didn't have the privilege of the time or the blueprints in place to do some of that. So obviously that has tested some local relationships. But to be honest, you've got relationships with currency in the bank and it's worked through.

Adam Brimelow

It's interesting to me that you are, to my mind, you know, really encouragingly upbeat about the way those relationships have withstood such a testing time. If you've been projecting forward a few months ago, would you have been so optimistic?

Anu Singh

No. I mean, it's simply that when you're in the heart of the tornado, then obviously things become not just confusing, but you also can't see your way through it. And nor can you help anybody else through it. But I think, as Stuart was saying earlier, the clarity around actually, what are all the different players in the pitch going to do? How are we going to take forward the ten-year plan? And it's emerged rather than been first out of the stocks. So once it started to emerge and we were able actually to to negotiate, to work out the different patterns, to work out where perhaps we needed to have some give and take. And we fed back to national and regional colleagues. So some of that emerging clarity has been incredibly helpful.

Adam Brimelow

So, Stuart, if I could turn to you now, the bill has had its second reading debate in the House of Commons, and the government wants this entire reorganisation to be concluded by April 2027. So how realistic do you think that is? And do you envisage significant opposition as this legislation passes through parliament?

Stuart Hoddinott

I think it is ambitious. It's as Anu just said, there has been a pattern of setting very, very tight timelines across this entire reorganisation process. And I think this is another one of them. There is less than a year to go now before everything will be abolished. I mean, there's still a fraction of the staff that have been made redundant that need to be made redundant to hit their their targets, although that has now sped up a bit, I think. So it is it's pressing.

I think there was some interesting themes that came out from watching the second reading that maybe hint at where there could be some future landmines that the bill could run into. Some of them were around patient data, particularly around single patient record. MPs were very worried about that. And I could definitely see that potentially come back to bite the government. That has happened in the past. Obviously GP DPR was an example of this.

There's also quite a lot of concern about in particular Health Watch and the Health Safety Security Investigations Board. If I got that right, I can't remember the exact way around, but those two organisations, the former being rolled into the department and the latter being merged with the CQC. I think there's a real concern about the extent of sort of independent voices outside the NHS holding the systems to account that I think MPs are worried about.

And the final one, which I think we would agree with, is the concern about the centralisation of power in the hands of the Secretary of State. This is a bill that gives a lot of power to the Secretary of State, and it seems MPs are worried about what that might mean for the temptation to sort of tinker politically with the NHS, which I think is legitimate.

I think the other thing to say is that this has been quite a interventionist parliament so far. The Lords have been attended to mend quite a lot of bills. And I think you can look back at twenty twelve and you can say, actually, when the NHS bill goes through parliament, it's not uncommon for there to be quite a lot of amendments, quite a lot of disruption, quite a lot of unforeseen sort of pitfalls that the government might not expect that causes more controversy than maybe they were expecting. So I think it's very early days still. There is a lot of possibility that this bill could be derailed or delayed. at which point the April 2027 deadline seems very, very stretching.

Adam Brimelow

Yes. And we could see it changing shape in the coming months.

I'd like to close now with a question for both of you in terms of where this process leaves progress on improving performance, balancing the books and delivering the 10 Year Health Plan.

If I could start with you, Anu.

Anu Singh

Yeah. I mean, it has been a painful process, but actually without the compass setting of the ten-year plan, I think it would be yet another painful reorganisation designed to reduce cost pressures.

I think the good thing is that we've seen a fair amount of political change, haven't we, just in the last few weeks? And it does not feel that the direction is one that they're veering away from. Because actually what we've been doing, especially with our partners at a neighbourhood level, is really thinking about now we all know our places on the pitch, what now do we as an ICB, need to do differently around population health, strategic commissioning and flatten some of those curves?

So again, with the neighbourhood model that's come out and being able to think very differently around place and what we might want to cluster around place, it's been liberating.

So in terms of the future, it feels like so long as there are no more derailments and some of the good promises, you know, comes to life. Lots of the work that's happening at neighbourhood level could well be the change that the ten-year plan is seeking to land.

Adam Brimelow

Anu, thank you for that upbeat assessment.

If I could put the same question to you now, Stuart, in terms of where this all leaves us in terms of improving performance, finances and delivering a 10 Year Health Plan.

Stuart Hoddinott

I'm going to be, I think, slightly more pessimistic than Anu, unfortunately.

I think it's worth remembering every now and again just how much the government is expecting from the NHS.

So you've got returning to standard for elective performance for 18-week performance. They have previously committed to and then dropped because they realise the rise is impossible. The same for A&E waits cancer targets. They're doing the ten-year plan which I mean again that's an easy thing to say, but it encompasses so much the shift to the community shift prevention, a digital shift, which would be a real change for the NHS.

And then alongside that, also new funding models with integrated health organisations, neighbourhood providers, and then also an enormous structural organisation.

It is just an enormous amount of things the NHS has to be thinking about at the minute. I think, honestly speaking, I think it's too much. I think it's too difficult to prioritise between all those different areas and make sure they are all achieved.

I think probably also the funding picture makes that very difficult as well within the envelope that the government has allocated. Those changes are very, very difficult to achieve.

I think then you've seen there has been some in practice prioritisation between those. I think there are revealed preferences that are emerging from the government and that is for realistically financial control and hitting their elective targets. Those have been the priorities for the government realistically since winning the election.

And, in some respects, they've done well. They've hit their interim target for this year for elective waiting times, albeit with some sort of slightly dodgy number movements. But they've hit the target.

I think the thing is I worry about is to what extent really is there going to be meaningful shift into the community towards prevention, all things that many governments have attempted to do for a long time and have failed to do because there's been a lack of commitment to it, a lack of real sort of meaningful resource allocation behind those priorities. I think there's a risk that the same thing is happening now. I still don't see a lot of evidence that they are really pouring a lot more additional resource into community in the form of general practice or community care, or into public health or into adult social care, for example. The bits of the system that are severely and have been underfunded for a long time, that would mean that you could sort of really make those shifts meaningful.

So I think they've set too many priorities, and they've now end up in a point where they have to try and realistically focus on a few, given the amount of money they have.

Adam Brimelow

No more money and a lot to do. So nice summary there.

Anu and Stuart, thanks so much for joining us on Health on the Line.

So let's take a look now at what's shaping up to be a seminal review dealing with one of the most pressing issues of our time, the rise in the number of young people who are not in employment, education or training, often referred to as NEETs.

Well, there are a lot of reasons why one in eight people aged 16 to 24 are NEETs. That's almost a million young people, by the way. Alan Milburn's interim report highlights health and particularly mental health as a central factor. Worryingly, the numbers are going up fast and while most of the NEET population have never had a job, the vast majority want one. Alan Milburn says we no longer have a labour market problem with a health dimension, but a health crisis with labour market consequences.

So let's pick this up now with Rebecca Gray, director of the NHS Alliance's Mental Health Network, and with Dean Royles, interim chief executive of NHS employers.

So Rebecca and Dean, thank you for joining us on Health on the Line.

Rebecca. If I could start with you. Looking at this report, the conclusion that young people want to work and need and deserve support seems to have landed us as something of a revelation. Really, has our society been guilty of overlooking or dismissing the real challenges they face?

Rebecca Gray

I think that's fair to say that. I mean, in all the work that's been done for quite a long time, this definitely points to a generation of young people who want to work, even if they're not in work, but people who have experienced mental illness, generally, when research has been done, mostly want to be in work in one form or another.

So and we know work is good. You know, the concept of work is good for you is not a new concept either. It's good for your physical health, it's good for your mental health. I think what it points to is what's been quite a binary view of young people, this kind of, you know, is it the snowflake generation of people, young people really unwell or is something else going on?

And I think this report paints a very bleak but a very clear picture that actually young people are being failed and they're being failed from, to some extent from birth really in lots of cases, through education, through health, through employment, and different bits of the system have got to kind of work quite differently to to respond to that.

It also points to some of the ongoing debate at the moment around the division between mental distress and mental illness and how to respond to those things which are really useful. There are some risky discussions in the middle of that, but I think a really useful exposure, the fact that mental distress is real. Young people are facing significant pressures that potentially were not felt by previous generations in the same way. And what we know is those in that distress, if not people don't get the right support, can turn into mental illness. And I think it's recognising that one can lead to the other is a really central part of the report as well.

Adam Brimelow

And where do you think the government's mental health strategy fits within its desire to boost youth employment?

Rebecca Gray

So it's interesting, isn't it? We've got lots of big reviews. We've got this prevalence review that's being chaired by Professor Peter Fonagy. We've got Penny Dash and her team looking at how the mental health system is working from within NHS England. And we've got this review. And I think there was that craziness, necessity to create a mental health strategy, to create some coherence to how the government is going to respond to these various pieces of work. But I think the fact that you can see this, that most of those recommendations will say things that don't just point to the NHS. It means it has to be cross-governmental. It has to be a strategy that speaks to the labour markets, to education, hopefully also to criminal justice and to other areas of the public sector. So the mental health strategy, we're now loading a lot of weight on this strategy that we hope to see by the end of the year. But if we don't see connected activity across public services, we're kind of failing communities. And we can see from this report what happens if you don't take an intentional approach to trying to support communities in their health in the broadest terms.

Adam Brimelow

Yeah. And Dean, looking at this through the employers’ lens with the role for the NHS as a major employer, clearly there's a need here, isn't there, for more opportunities, apprenticeships, training, long-term career opportunities. How well placed is the NHS to play its part for NEETs?

Dean Royles

I think the NHS organisations really do understand their role in the local communities. More often than their than not, they're the largest employer in the local community and they know that as an employer, as an anchor institution, if you like that, they've got a role to play in terms of helping with health inequalities, and as Rebecca said, you know, sort of good work, good housing, good education all really contribute to better outcomes for people.

There are things, I think, where the NHS can do more in this. So we've got many organisations that do have good connections with their local schools and apprenticeship sort of pathways coming in. But often it's, you know, not central to prioritising what it is that they're doing in terms of recruitment. So when we look at things like work experience, for example, which is so important to people. In many NHS organisations, it's sort of ad hoc or it relies upon existing members of staff that want to bring their kids in to get some sort of experience. And I think we could do much more around having sophisticated systems, working with local schools, you know, regular people coming in, regular times of the year, doing a proper induction for people, making sure that they're getting those work experience, not just something that's on the CV because they want to apply to, you know, health school or a medical school, but really to experience the full range of work that they've got.

And then I think also we don't tell a good story about the career opportunities within the NHS. So it's often portrayed in the media that the NHS is kind of low paid or entry level is low paid. But we all know all of us that worked in the NHS, you know thousands of people, that have started off at entry level jobs, but then have gone on to become senior managers. I know people that have started as a porter and have gone on to be a chief executive. You know, people that have started as cleaners and gone on to become clinicians. And I think we could tell that story of the opportunities that the NHS has for people when you come in that it's, you know, there is jam tomorrow as well as good solid employment for today. And I think we could be more optimistic about what we could do and sell that career opportunity much more than we do.

Also do lots of work with things like what used to be the Prince's Trust. But, you know, now the King's Trust and something like 10,000 jobs have come into the NHS through that in the last six or seven years or so.

Adam Brimelow

And, Rebecca, Alan Milburn signalled the need for changes in local government, education, of course in health and also employment. How how feasible is that? I mean, it's easily said in a sentence, isn't it? But actually putting that into reality, that's a huge challenge.

Rebecca Gray

I mean, it's the challenge that goes to the heart of lots of reform in healthcare, isn't it? It’s how do you join up the different bits within the NHS and the bits that sit outside? And it's not without its challenges.

If we think the NHS has challenges with its funding arrangements, local authorities are feeling the pinch even even more in a lot of cases. But it can be done and you can see that on a local level. So you can see, you know, there's some great examples, you know. Alan Milburn rightly differentiates between NEETs. He says they're not all one group and we shouldn't think of them as one group. But he also says that actually, when we're thinking about what support young people need, we need to recognise that that's different as well. So he says, you know, if you've got a young person who's dealing with, you know, major anxiety going into an exam period, their ability to cope with that and to stay well will be very different if they're in a in a secure housing with the supportive family than if there are, you know, somebody who's recently left the care system and is struggling with their accommodation. And and we need to then think about how do we connect up the different services and supports to focus attention in the right way.

We've got lots of examples of that within our membership. You know, really interesting. There's a really fascinating developments in both the north west and in Hertfordshire with specialist children's homes set up between the NHS and local authorities, particularly to support those young people who we often see with very complex needs, often appearing in A&E, in admissions, in units who, you know, we know where given the right support, can actually return to lives where they've been able to get back to education, able to get back to employment. But it does mean thinking quite differently, the ability to be able to pull some money, to be able to have a very focused approach.

One of the challenges he, I think is going to face is how do we take accountability for some of this stuff across systematic system boundaries. You can get lots of people in a meeting who will all agree and say good words about what should happen, but action can feel further away. So how do you actually have some accountability for how our communities are faring, which has ‘teeth’ across these different types of sectors?

Adam Brimelow

And just talking about sort of accountability in having teeth, at the NHS Alliance, we've called for a specific target, haven't we, to to generate a real focus on driving down waiting times for children and young people. Why do you think that that target is needed?

Rebecca Gray

So I suppose there's a slightly cynical answer to this, which is that we know that targets in the NHS drive focus. They drive support, they often drive investment. I think for a lot of organisations and people who work in mental health care, it is about parity. It's often a misused or overused term. But what you're saying, actually, if we think it's important that you get to have treatment in an acute hospital within 18 weeks, and actually a child who really needs help should start the process of that treatment within a month. And that's what we're saying the standard for CAMHS care should be that young people are start to get help within four weeks.

And I think most of the leaders in the mental health care system support that. It's not going to be without its challenges. There's great variation across the system, but an awful lot that we can learn from organisations that are doing well. Mersey Care is a good example – they've got some of the lowest rates in the country. And, you know, Trish Bennett, their chief exec, is going to be speaking at Expo this week about how they've done that and some of the approaches they've taken. Again, often working in partnership with the VCSEs or with local authorities or with acute sector partners to deliver a more integrated service that sees more children more quickly.

Adam Brimelow

And, Dean, when you you look at this challenge with what's been called ‘NEETs’, which is it's a terrible expression, but it's one that that people are using and that we understand. Is there a sense that in some respects there's an opportunity for the NHS here? A latent talent pool that needs to be helped and developed to lift their prospects, but also the prospects for a well-staffed sustainable NHS?

Dean Royles

Yeah, absolutely. And in terms of recruiting people from local communities is, you know, it's kind of a win-win-win because we can give people and sort of meaningful, stable employment, that people that are also taking, you know, good sound health messages home with them as well. You know, so we get the benefit from people that experience that when they go into the workplace.

I think there's also something that too often I think we talk about people that are NEETs are often those that haven't become able to go to university because they're not academically inclined. And in my experience, that's often not the case. People that you decide not to go to university or don't go to university isn't often because they're not academically inclined, it's that they haven't had the opportunities at home to get the extra lessons or the study – you know, they're equally bright, equally intelligent, equally able to stand up to the life opportunities.

And I think that's one of the great things about careers in the NHS is that we can bring people in into entry level roles. And where they do show aptitude, then we can help them develop their careers and go as far as they want to go, having missed out perhaps on university at a at an early age, or sort of those professional qualifications and those roles are available in things like, you know, HR and administration and finance and communications. And strangely, the the local NHS is often the largest employer of IT staff. And yet people still see sort of doctors and nurses. So a range of things there that we can bring people in into those pipelines.

Adam Brimelow

So a real opportunity there. Thank you Dean, Rebecca, thanks for joining us on Health on the Line.

And finally, let's catch up with Sir Jim Mackey, chief executive of NHS England, of course, ahead of his own keynote address at our Confed Expo conference.

So, Jim, thank you for joining us.

Earlier in this episode, we spoke to Sir Ciarán Devane, chief executive of the NHS Alliance, about the challenges and opportunities facing the NHS at the moment. And one year on from your last keynote address, how would you describe the state of play across the health system?

Jim Mackey

Good question. So I'm going through that process where I'm trying to get together what I'm going to say next week and stuff, and you naturally reflect on last year.

As I remember last year, it wasn't long after all of the announcements and the financial reset. It felt quite stressy, to be honest. The health plan hadn't been published and stuff. So you could feel the anxiety going in, about headcount reduction and how was all going to work, the financial reset.

It does feel a bit different now. I mean, there's still a huge amount going on and it's very busy. It feels a bit chaotic for people at times, but I think you can, you know, you can see achievements from last year. You can see joy locally, energy locally from people who've managed to achieve things last year. As always, you know, tensions and frustrations.

So for me, I'd really like people to kind of acknowledge and build on what was achieved last year with all that chaos and messiness and stress, etc. And this year stretch out a bit more with a bit more confidence and get a bit more into the more creative parts of the 10 Year Health Plan. There'll always be financial heavy lifting, there'll always be performance pressures, you know, etc. but I do feel like we've sort of come into a different phase with that.

Adam Brimelow

Good. And last year at Cofed Expo, you spoke about how you hoped the 10 Year Health Plan will release a lot of energy, releasing the ambition that exists across the NHS. And we're coming up to the one year anniversary now, so how would you describe progress in that time?

Jim Mackey

Yeah, I think it definitely released energy. I think it was generally pretty positively received. But there's a lot of that's just really not possible to argue with. Nobody would argue with. So the shifts, for example, the focus on neighbourhoods being really well received, difficult to do, but really well received. I was having an exchange this morning with a couple of colleagues about FT freedoms and that whole thing and the whole IHO thing.

So there's absolutely appetite and energy in all of that. So for me some of it a bit harder than it needs to be, you know, so still have frustrating conversations about what neighbourhoods mean and stuff. And that feels like we're having to keep going round it all the time and kind of keep clarifying and stuff. But I think what we're expecting to happen last year in terms of a release and energy that worked, I think it's absolutely been tempered at times with the kind of day-to-day heavy lifting and the organisational change and the financial stuff and industrial action, etc. But overall you can really see progress.

I joined a leadership event the other day for an NFT, with challenges, you know, difficult things have got to sort out. Most of the energy, most of the discussion was about neighbourhoods and integrated care and primary care and secondary care working together and stuff. So I think that's absolutely worked. But we're absolutely not in a position where we're cruising in fifth gear…and everybody's, you know, just really relaxed – we've still got an awful lot to do.

Adam Brimelow

Yeah. I mean, the feedback we've been getting from members is that last year was really tough and this financial year will be even harder. So obviously difficult decisions ahead affecting services and staffing. That's what they've been telling us here at the NHS Alliance. And there's also a further round of industrial action around the corner, as you say.

How worried are you that recent progress that we've seen could be under threat?

Jim Mackey

So I worry about it. And I talked in board yesterday about the interplay with between money, industrial action. I set up or having to get through it, the impact on performance targets, the distraction, you know, all those sorts of things. And we've talked to the Secretary of State a lot about it in the last couple of weeks – we're about to start engaging with government on it.

I think I need to take the strain on most of that nationally. And locally people have just submitted plans, the start of the plans, you know, starting to deliver in the new year, etc, etc. So keep everybody focused on that as much as they can. And frankly, we have to resolve the how does this all work nationally? And if something goes wrong with all that, you know, we'll talk to people and we'll rebuild it.

I don't tend to take too much notice, to be honest, of the whole this year I'll be harder than last because I can't remember a year we haven't said that. And I was actually in Ireland last week, and they've got 8 per cent growth in this year, 8 per cent, which is like us at our heyday under the Blair era, like phenomenal. Exactly the same conversation that we're having, exactly the same conversation about the tensions of money, workforce, or change and – they don't have industrial action – trying to bring their version of neighbourhoods to life, etc.

So it's hard, it's a worry, you know, etc. And I think this is an example where I have to do stuff with Elizabeth and other colleagues nationally with government, try and resolve the thing, get us a clarity on what's possible at a national level. In the meantime, people focus on delivering their local plans and don't get too distracted by it.

Adam Brimelow

Yeah. You talk about obviously establishing clarity and you've got great leadership experience. You've been chief executive of Northumbria and Newcastle, you know what it's like to be an NHS leader based well away from London.

How satisfied are you that local leaders are getting the support they need to do what's asked of them?

Jim Mackey

We had a bit of a discussion again in board yesterday about this tussle we've got around improvement and support and fundamentally I really struggle to get away from the action is local. The action is in the local board, the curiosity in the local board, the energy in the local board with local clinicians, clinicians and managers working together, primary, secondary care, working together, you know, etc.

And we've had very long periods of someone centrally will support you or give you help, you know, you'll get some improvement offer, which I just don't think it works like that really. I think we have to put relentless focus into rules, clarity, conditions for success, making sure people actually have the right capacity and capability in place locally, and then let them get on with it as much as we can, obviously within rules. And if you step out of it, it'll have to be an accountability framework and stuff for all of that. So I think in that setting, in that context, and I was still in the trust, I'm working from the trust today for convenience. I think that's all about the trust chief exec, with the council, with the university, with local trusts, with especially with primary care, etc.. And you get support from that network and from colleagues locally, more than I'd be in a national support offer.

That's not to say we wouldn't when we do try and support and I talked a lot of people there on a week, daily basis and other national colleagues do. But I really I think we've got to really keep shifting that so it feels like your work is more autonomous. You got clear rules. Your support is largely in your local networks. But then if you need if you do need something on a bigger footprint, you need something from region, you need something from national, it's there as well, but it's proportionate.

Adam Brimelow

Yeah. So as you acknowledged, there is a heck of a lot going on at the moment. The decision to scrap NHS England, to bring in medical structural reforms, including the roles of ICBs, that's playing out in real time right now. Are you comfortable with the pace of change and where things are heading?

Jim Mackey

Yeah, really good question. So our national change, NHS England and the HSE, we're at a really crunchy point now and I'm feeling quite anxious about it, to be honest. So there's a lot to do.

We've had a big VR process. We've lost a lot of people. We're starting to come to the reality of when you connect back into the department, what it actually means being a part of a Department of State again. And so we're all sort of drawing on the past and talking to colleagues from the past about how it worked and that and that feels difficult at the minute. And it's partly kind of timing in the cycle, but we've got some big decisions with Secretary of State in the next few weeks about about all of that.

I honestly, I still think locally, it's all taking too long. That'll feel weird because it's such a big change. The big regret I've got of this last 15, 16 months or whatever it is, is how long colleagues had to live with uncertainty and the ICB world, especially of the change process, how long it took to get the VR process agreed. And you know  in my experience, over nearly forty years of doing this, you've got to be able to do those things quickly, let people come out the other end quickly. Fairly good processes being people trust the process. The sooner you get in and out of it, the better, and then everyone can start to heal.

Adam Brimelow

Yeah. Jim. Just moving on to the Confed Expo conference now, which obviously the NHS Alliance runs in partnership with NHS England, can you give a bit of an insight into what you're likely to say in your keynote speech themes perhaps that you're going to be covering and what you're hoping to get out of this year's conference?

Jim Mackey

Yeah. No, because I haven't fully decided yet. So I've got, you know, Rob and colleagues to help me get me head around what I need to say. I'm doing a session with chief execs this morning. A bunch of chief execs will go together to just make sure I'm aligned with what's on the mind and stuff.

There's a sort of bit there's a bit of a broad theme we're working on about. We have to acknowledge what people have delivered last year because it's huge. Nobody believed we could as well, even in January, I told colleagues this before I was having arguments with people in January, this is not possible. Things that were possible and were proved were possible because they happened. So got to take some confidence out of all that.

There's a lot of learning in it as well for those places that moved a long way very quickly in this year. But this year has got to be about systematising that, scaling it, making it easier. And I think if I can't, I'm not sure whether I'll actually get into this properly – I did it with a session last week: remember the privilege that comes with these jobs and enjoy it, you know, spend so much time talking about the negative. And I do as well. You know, you have bad weeks and lots of arguments and that fantastic privilege that comes with these jobs. And if you're running a hospital or a primary care provider or a mental health trust or whatever, what comes with that is unbelievable. So let's focus a bit more on the good bits as well. And, there's always a lot of heavy lifting to do. There's always a lot of difficult stuff to do these jobs, but some really fantastic stuff as well.

Adam Brimelow

Oh, Jim, thanks for that. I hope you can enjoy the conference as well. We're really looking forward to seeing you there. Thanks for joining us on Health on the Line and all the best.

Sir Jim Mackey rounding off this jam-packed edition of Health on the Line.

And there's more coming your way very soon. We will be recording at Confed Expo, where we'll be among more than 9,000 delegates will be in Manchester for the biggest and best health conference in the UK. There's a real stellar line up at the event, including, of course, Ciarán and Jim, who we've heard from already, Lord Victor Adebowale and Dr Penny Dash, chairs of the NHS Alliance and NHS England, and the new health and social care secretary, James Murray.

If you're listening or watching ahead of Confed Expo, you can register online now or come along in person at Manchester Central. Details at NHSexpo.org.

If you enjoyed the podcast, please hit that subscribe button if you haven't already, and do share it with colleagues across the NHS. And of course, if you have a great programme of work that you'd like to tell us about, please get in touch. We may cover it in a future episode.

Just email us at HealthCommPlus@thenhsalliance.org.

So until next time, goodbye.

You've been listening to health on the Line, produced by Health Comms Plus. We're a creative, full service communications agency brought to you by the NHS Alliance. With deep sector knowledge and a shared commitment to improving health outcomes, we help NHS and public sector organisations to connect, engage and make an impact. Any income we generate is reinvested into our work, supporting NHS organisations and the wider health and care system. To find out more, contact HealthCommsPlus@thenhsalliance.org.

[Financial pressures squeezing NHS trusts and ICBs]

Adam Brimelow

Hello and welcome to Health on the Line. This is the podcast for policymakers and NHS leaders. It's produced by HealthcomsPlus and brought to you by the NHS Alliance, the independent membership body that represents and supports the health and care system across England, Wales and Northern Ireland. 

I'm Adam Brimelow and I'm delighted to be taking over in a podcast presenter's chair from Matthew Taylor, who's moved on to pastures new, and we wish him all the very best. 

I'm going to begin with a very quick reminder about a big event coming up soon. Do book your place at NHS Confed Expo, which takes place from the 10th to 11th of June in Manchester. You shouldn't miss out on what is an amazing breadth of content, incredible networking opportunities and, of course, the chance to speak to and hear from national leaders. So book now at NHSConfedExpo.org as places are going fast. 

Right. Let's focus now on the concerns, the challenges and also the opportunities faced by NHS leaders as we head further into the financial year 2026 to ‘27. 

How are they handling the pressures? What are they doing to stay on plan and at what cost? And what's the way forward to make things better for patients and staff in difficult times? We'll hear some frontline perspectives from an acute and community trust chief executive, Fuluke Ajai. 

But first, let's get a detailed overview of how financial pressures in the health service are making their mark. The NHS Alliance has been testing the temperature with members and has produced a report which draws on surveys, interviews and ongoing feedback from leaders to build a picture of what's being achieved, what's getting in the way of further progress and the risks of losing hard-won gains.

The report's called Targets and Trade-offs: the Cost of NHS Finance and Performance Ambitions in 2026/27. And here to talk about it, I'm joined by the NHS Alliance’s deputy director of policy, David Williams. 

David, welcome. What does this report tell us about the state and impact of NHS finances?

David Williams

I think it tells us that the financial situation in the NHS this year and reviewing looking back to last year is really tough. This report gives us a sense of the scale of the challenges that the frontline trust, ICB and GP leaders have been facing and will continue to face.

Adam Brimelow

So, David, a really tough picture there. It's in a context, though, where we've seen some significant progress on several fronts, haven't we, in terms of performance, finances, productivity, and all that achieved in the face of growing demand and, of course, industrial action. So there is a positive side to this as well.

David Williams

That's right. So if you cast your mind back to the beginning of ‘25/26, the service had a huge gap of about 7 billion between the resource that was being given and what it was initially planning to spend. Essentially plans had to be redone as a result of that last year. And that resulted in the NHS being handed the biggest financial savings challenge on record. It had to save about £11 billion last year.

And what the survey shows us is that, by and large, huge progress has been made on the finances. So roughly two thirds of people who responded to our survey were confident that they were going to hit their financial plans, which given where they were starting, is a really incredible achievement. And that's in the context of record activity levels across much of the service and some progress being made on some of the key waiting time indicators. And the beginning of a positive turnaround, in terms of public satisfaction with the NHS. 

So one of the stories of 25/26 is that the NHS collectively was set an enormous challenge to deliver, improve delivery and increase the rate of improvement and to control the money, and collectively responded to that. But the survey also tells us that the challenge for 26/27, in terms of the amount of money that needs to be saved, is the same or bigger next year. That's what members are telling us.

Adam Brimelow

So that's a huge challenge going forward. And what sort of steps are leaders considering as they see to square this circle in meeting their financial plans?

David Williams

The biggest one is they are looking to cut or redesign services. So we're expecting more of that in the year ahead than last year. So last year, only about a third said that they needed to cut the services to balance the books. And this year it's more like two thirds of ICBs and trusts. And the numbers are a bit lower for primary care, but it's a similar trend. 

So, more cuts and closures in the year ahead than last year. Also, a much bigger likelihood of services being redesigned, if not closed.

Adam Brimelow

So cuts to services, redesign, and that really translates, doesn't it, into a potential impact on care. What sort of changes could we potentially be talking about?

David Williams

So first thing to say is that trusts are really, really conscious of the importance of quality of care, the experience and the outcomes and the safety of services when you get treated. That is an absolute top priority and not one that trust or ICB or GP leaders are willing to compromise on. 

What they're telling us is that to hit the numbers in terms of the budget, they're going to need to look at services that aren't sustainable, for example, ones that are below the scale needed to be able to be run according to the budget or that are configured inefficiently, for example, across multiple sites. And they're going to need to change that. 

In terms of what people out there in their communities will notice, that might involve consolidating smaller units into larger ones or closing down services that don't generate enough income through the NHS payment system to cover their costs and that is just the consequence of living within their means. 

In terms of the things that our members are telling us that they're worried about this year, I think three things that are really worth focusing on: 

One is the patient experience. So more than six in ten of people in the trust and ICB sectors and three quarters of GPs are worried about patient experience in 26/27. 

And the final thing to think about is operational performance. And by that, we mean the amount of time typically that people have to wait to be seen or treated. 

So there was a lot of progress last year on performance against some of the key national targets for how long you have to wait. But order of four out of five trust and ICB respondents are concerned about both planned care and emergency care in the year ahead. And similarly, almost all GP respondents are worried about operational performance. Can you see people when they need to be seen? 

And then the final point I'd just like to pick out is the impact on staff morale. So one of the interesting things that the survey has told us is that in 25/26, one of the biggest impacts of the savings that people needed to make was that it had a bad effect on the morale of staff and you can completely understand why that is. They're expecting to make further cuts in 26/27, so we're likely to see more of that. But the problem is, apart from staff morale and burnout, which is there in the NHS staff survey, this is picked up in other sources too. Apart from that being a problem in its own right and disengaged, burnt out, depressed workforce is going to find it really difficult to go the extra mile to make further changes and further savings in the year ahead. So there's potentially a bit of a vicious cycle emerging of staff disengagement, cuts, making it harder to make further cuts, making people more disengaged.

Adam Brimelow

So David, real concerns there, as you say, for patients and for staff, but there's something more fundamental at play here, isn't there, in terms of the more strategic goals of the 10 Year Health Plan? How great is the risk that they could be derailed or at least put on pause?

David Williams

Yeah, the 10 Year Health Plan is a huge document trying to do multiple things over a really long period, right? But the three core principles that are going to be well known to people who are tuning in to this podcast, are those three shifts about moving from a hospital-based model of care to a community-based one, a treatment-based model of care to prevention, and from an analog service to a digitally-enabled one. And what we hear on those points is an interestingly mixed picture. So people say that because they had to focus on key operational targets and keeping the money contained last year, that some of the stuff that they would want to do, particularly around the shift to prevention, had to take a bit of a backseat last year. And I think people really want to get on with that transformation agenda, but they were given a set of priorities last year that they had to meet. And also, that the shift from analog to digital, the cuts they had to make actually helped accelerate that shift. So I think that's probably a result of people looking for things that are going to improve productivity, and the shift to digital is seen as a great enabler of that.

Adam Brimelow

So a slightly mixed picture there in terms of progress on the ten-year plan. Is there a clear message for national politicians from the centre in terms of the type of support that NHS leaders need to overcome the challenges you've been describing? 

David Williams

So, NHS leaders totally understand and recognise the importance and the scale of the challenge that they're facing. And they want to do their bit to make sure that the NHS continues to deliver, improves overall and also lives within its means. 

In order to do that, to play their part, they need political backing to make difficult decisions. So particularly, when it comes to reconfiguring local services. Normally we find that when people need to make changes, even where that improves the quality of care, improves the model of care, there is often public opposition. And when that happens, what local leaders need to do, they're willing to take those decisions, but they need political backing to do it, first thing. 

Second thing they need is that there are likely to be some unforeseen costs in 26/27, which weren't built into the budget when the budget was set last summer. For example, there are industrial disputes with sections of the workforce still going on. And we know that where industrial action is taken, that there are cost implications for that. And then there are also potentially inflationary pressures as well, which we're likely to see play out in the wider economy, but will impact the NHS just as much as everywhere else and that inflationary pressure might be beyond what was budgeted for. So where those pressures do come through, we need to make sure that there is appropriate support to mitigate those specific additional pressures. 

And then finally, they just want clarity and consistency from the government and national leaders on what they need to be prioritising this year. So what we don't want is a set of competing agendas. Or to be told by one section of the national leadership that you need to do this and then another section that actually know you need to be doing this. We need clarity and consistency and then they can get on and deliver. 

Adam Brimelow

David, thank you. A really rich picture there of the challenges that NHS leaders are facing and also what they need in terms of support from the centre. David Williams, thank you very much indeed. 

So let's get more of a flavour of how this is playing out in practice. Of course, there will be different perspectives in different types of organisations and this report is useful in teasing out commentary from a range of leaders, acute, mental health, community, ambulance trust leaders, and also from ICBs and GP leaders, as we were hearing from David. 

But we're going to turn now to Falouke Ajayi, chief executive at Airedale NHS Foundation Trust, which provides hospital and community services for a population of over 200,000 people across Yorkshire and Lancashire. 

Falouke, welcome to Health on the Line.

We know money's been really tight. How conscious are you of financial constraints in day-to-day decision making?

‘Foluke Ajayi

Hi Adam. Good to be here.

Yes, I think money has been very tight and day to day it is at the forefront of everybody's minds. Certainly in our organisation, we are very focused on making sure that we get the best out of the pound that we have. And so the decisions we make on a daily basis really is framed around the financial constraints and making sure that we get value in the way that we're working.

Adam Brimelow

So I suppose that's in some ways something you would bring to your job day after day, year after year. But is there something different now to previous years that you're up against?

‘Foluke Ajayi

I think that it's an environment in which the financial constraints have been ramping up over the last few years and I think every year has felt tighter and tighter. And therefore, last year was tough. The expectation is that they say it will be even tougher, and so continuing to reinforce the message to our colleagues, to the decisions that we're making, makes it really real.

The fact that we are maintaining a focus on our vacancy management and recruitment approaches alongside very tight control around discretionary spend and asking our colleagues to think twice before they spend any penny that they do and looking for alternative ways with every decision that we're making, I think reinforces the environment in which we're in.

Adam Brimelow

So you alluded there to some of the staffing decisions that you're having to make. Presumably that plays out in terms of the services you're able to provide as well?

‘Foluke Ajayi

I think we are thinking much more creatively is what I would say in our approach for service delivery and considering whether there are alternative ways for us to provide those services in a way that we minimise the impact on patient experience and that we certainly are very clear that quality remains at the top of the agenda for us. 

And so yes, we are having to think about the way we provide services. But also our experience is showing that commissioners are also thinking about that and therefore actually the way we work with commissioners in terms of what the service offer is, is changing. 

And that also includes how we're working with our partners across the system because this issue is not limited just to the NHS. Our partners in terms of local authority partners are also feeling the pinch and therefore we are being forced to think about, so collectively how are we going to do this differently?

Adam Brimelow

So in the face of these sorts of pressures, how do you safeguard quality? Is quality at risk because there's so much coming at you in terms of those pressures you have to contend with?

‘Foluke Ajayi

So I think if you think about the three elements of quality, then there are times when quality is at risk, particularly in terms of the patient experience element. Safety remains at the top of the list, if you like, as a priority. But patient experience is compromised because you are having to make some decisions around where can we have some compromise? Is it about the patient waiting slightly longer? Is it about where longer in terms of waiting list management? You don't want to do that all of the time. Delays in terms of when they might be seen on an urgent care pathway. 

Those sorts of things can affect the patient experience. But what we're very clear about is that we don't want to affect the safety of delivery, but we want to maintain quality as high as is possible.

Adam Brimelow

And when you're looking at these decisions, is it always a case of trying to find incremental gains here and there as and when, or are you being compelled to look at some bigger decisions around service design and letting go of some services because they're simply no longer viable?

‘Foluke Ajayi

It definitely is a combination of the two. Incremental improvements has its place and is valuable, but actually transformation in the long run is what's going to deliver the sort of efficiencies that we're talking about and really help us get a handle in terms of managing both the patient caseload that we have, but also delivering on the money in the way that we want to. 

And so that forces you to think in terms of are there collaborative approaches you can do with your partners, both in terms of looking at the patient pathway? Where can we collaborate and make a longer-term sustainable decision around how we're offering services? As well as actually what are the things we need to change within our organisations? And so you're having to balance both and the tension about what do we do today, but lean into what we need to plan for for the longer term. And so those are some of the issues that we need to balance.

And I think the other thing is about the impact on our teams. It means that our teams can sometimes feel that they're spread very thin because you're asking them to look at the hear and now as well as work with what the longer term can look like.

Adam Brimelow

So clearly you're being forced to think out of the box and look at things in different ways and collaborate in new ways. I mean, in some ways that sounds like a positive. Are there some positives that flow from these types of financial pressures in terms of forcing you to look at things differently?

‘Foluke Ajayi

Definitely, there are some positives. I think it forces you first of all to think about your benchmarking and where do you sit against the benchmark. And anything that improves the quality of service that you offer is a good thing. Anything that forces you to look at opportunities for improvement and transformation is a good thing. So that in itself, it's a good thing because it helps us to learn from each other and apply the learning. 

I think the other bit is about having much more joined-up services. And when you look at it from a patient perspective, joined-up services that means that I can get from A to B to C to D in a much more seamless way is also a positive, and so we have better links. And when we do things once rather than repetition, that is a good thing as well. And so there are some positives and I think it's about making sure that we stay focused on those positives rather than what can sometimes be a spiral downwards because of everything is too much. Actually, there are opportunities here that we need to really lean into and sweat the opportunities from.

Adam Brimelow

One of the things that came through in the survey was a sense that these immediate sort of front-of-mind pressures, the finances, relentless demand, having to deal with things like strikes as well, it's forcing people to focus on the here and now at the expense, potentially, of those big strategic shifts that were central to the 10 Year Health Plan.

Is that something you can relate to? Are you finding you're able to make headway on those strategic goals? Or are you being slightly pushed to the margins?

‘Foluke Ajayi

I can see why the survey might say that and I can understand why because, for example, the focus on delivering the money today for your organisation, delivering the waiting list ambition for your organisation, in a way diverts your attention from the opportunity you could do in collaboration with your partners. 

If we think about our approach in the probably 2020 onwards until about 2023/24, there was a lot of work on mutual aid. How do we help each other and really look at how we bring down waiting lists across systems, not just in individual organisations? I think where we are now, actually there will be a tendency to say, I just need to focus on making sure that my organisation can manage its waiting lists much more effectively. And therefore there is a risk that the approach to mutual aid takes second place. 

So I think the leadership challenge is how do we do both? Because we need to do both for the longer term. But it can mean that occasionally the focus will shift from the longer term to the here and now because you need to balance what's important to your organisation at a point in time.

Adam Brimelow

Yeah, obviously really important that area about mutual aid, but also in terms of thinking about things like the shift from analog to digital, hospital to community, treatment to prevention. Do you have any concerns for those goals being sort of eclipsed by dealing with immediate pressures?

‘Foluke Ajayi

I think particularly in the context of the shift in terms of hospital to community or really embracing the prevention agenda, I think the risk is much more about we can't spend the money twice. And so our ability to think about what do I stop doing, for example, in a hospital setting and having the confidence that there is capacity and capability to immediately shift it to the community setting is causing barriers for us. Because, you know, unless you get a significant change in the demands on the hospital, it's very difficult to see how you can immediately remove the resources from the hospital and put it in community when actually that is something that is developing. 

So we have to continue to be creative in our approach to doing that. And I think that that shift, in particular, is something that we have to work harder at to try and achieve some of those objectives in the timeframes that perhaps were initially thought. I think that's harder to do. It's not that it's not possible, but I think the financial constraints make it really difficult.

Adam Brimelow

Yeah. Now, ‘Foluke you're in the process of planning a new hospital at your trust, aren't you? Yes. That's because you've got very high levels of reinforced auto-claregarating concrete, the RAAQ problem, which has been obviously really prioritised in terms of renewing the NHS estate. What difference will that make as you go through with those plans in the immediate future and then when you've actually got that shiny, new hospital?

 ‘Foluke Ajayi

I think the difference in the current context is that it's an additional programme of work that requires our focus. So I talked earlier about the stretch that our teams are feeling and notwithstanding that we do have a dedicated programme team working on the new hospital, there is still an ask on our teams to help us develop what that approach will be in the longer term. So there is that capacity challenge that we experience in relation to that.

I think the other bit is about the work that we do today and the inconvenience, I think that's what people don't see, particularly in the context of Airedale, where building on the same site. And so the operational impact of building where you're working, it cannot be underestimated. And because of that, there are some consequences in the medium term around revenue consequences and how do we spend our money to mitigate some of those inconvenient issues.

When I say short term, it's short to medium term because I think over the next three, four years, we will live with significant inconvenience. But I think the longer term, there is hope because one of the things we are really keen to do is to build into the approach for the new hospital the vision for the longer term as the ten-year plan indicates. 

How do we build a hospital that's smarter technologically, that really provides us with the advances that we anticipate we will have? How do we collaborate with our immediate partners to look at the service offer and really think about what do we do once either in our hospital or in a neighbouring hospital and what things do we do in collaboration? And really think about the shift into community and into closer to home and therefore what are the services that we will retain in a hospital setting? 

And so it does provide us with the opportunity to deliver the vision of the ten-year plan. But the challenge is getting from here to there over the next period is what we have to continue to focus on on a day-to-day basis.

Adam Brimelow

Yeah, I can see that comes with some downsides, but obviously for the longer term, some really big plus sides for you. 

Fallukia, I'm going put you on the spot here a little bit, if you could offer one piece of practical advice to colleagues wrestling with the same sorts of problems that you've been describing, which have been highlighted in our survey report, what would be that one piece of cut-through advice?

‘Foluke Ajayi

That's very hard. A cut-through piece of advice. I think it's about how do we continue the conversation. It's very easy to put heads down and just think about my organisation where I am today. But I think continue the conversation with partners, with colleagues across the country to really harness the best ideas to help us push forward in terms of what we're here to do will give us hope and opportunity to achieve what we're trying to achieve.

Adam Brimelow

Brilliant, Faluke Ereje. Thank you and very best of luck to you and all your colleagues for the coming year. 

So I think that gives a real insight into the mindset of many leaders striving to maintain, improve and transform care in the face of multiple moving parts. And in that context, what's been achieved is remarkable, but it's equally clear that the hard-won gains of recent months may be at risk as financial pressures take their toll. 

So we'll be following progress closely on Health on the Line, offering NHS leaders perspectives as they navigate the difficult months ahead. 

Now, if you found this podcast useful or interesting, please do share it with colleagues across the NHS. Also, if you have an exciting or innovative programme of work that you would like to tell us about, please do, as we might cover it on a future episode. Just email us at healthcomsplus@thenhsalliance.org. 

Until next time, goodbye.