Insights 5 minute read

Sir Ciaran Devane's keynote address

10 June 2026

Our chief executive's inaugural keynote address at NHS ConfedExpo 2026.

Leadership
Improvement
Health inequalities
NHS architecture
Mental health
Neighbourhood health
Workforce

(Check against delivery)

Thank you, and good afternoon.

I am honoured to be here with you as the two-month-old chief executive of the NHS Alliance, it feels like a real privilege.

The first thing I want to say is thank you to everyone who has welcomed me back to the NHS world after ten years away. The second is that I am looking forward to meeting many more of you over the next two days and beyond.

Today I want to talk about the future of the NHS. Not the next budget. Not the next target. Not the next reorganisation.

I want to set out where I believe the NHS is on the journey to becoming the sustainable and high-performing system that we all want and need it to be.

As we said in the early days of NHS England, when I was on the commissioning board: how do we deliver high-quality care, for all, now and for future generations?

Because I believe the next few years will determine whether the NHS remains not just great, not just sustainable, but true to its founding principles.

A story if I may. When I started at Macmillan Cancer Support we had a great mission statement about improving the lives of everyone living with cancer. My geek’s question was ‘how many people is everyone?’

The answer, after a lot of work, was around two million people in 2010. About three million by 2020. And four million by 2030. Twice the number of people alive but with a cancer diagnosis in 20 years.

And that is a fantastic success story. It reflects extraordinary advances in treatment and care. The same story can be told in cardiac care, stroke care and many other specialties. The NHS is remarkably good at helping ever more people survive serious illness.

But that creates challenges of course. More people are living longer with complex conditions and not necessarily well. More people needing ongoing support. More people needing care closer to home.

But there is another factor in this as well as collective health. We are not dying of acute conditions as we were, but healthy life expectancy has reduced since 2010 for both men and women – by about a year.

This is largely due to erosion of the wider social determinants of health and lifestyle choices leading to chronic illness of working-age adults.

So if we’ve life expectancy going up; healthy life expectancy going down, that’s a much larger cohort of people living for longer but not well.

The success of the current acute model, in many cases hospital-led, means we need to shift to also supporting people at home with a neighbourhood model - while maintaining and enhancing the excellence of our hospitals.

It’s not really from hospital to community or to neighbourhood but from episodes of care to planned care. We are getting better at helping people live longer. But we are not getting it right yet at helping people stay healthy.

A truth, therefore, is that the future NHS cannot simply be a bigger version of today’s NHS. The maths makes that unsustainable. We must become a different NHS.

And there is something for me even more important at stake. For generations, support for the NHS could largely be assumed. I do not believe that is true any longer. For the first time, I think we have to earn the right for the NHS to remain free at the point of use and based on need rather than ability to pay.

If access deteriorates, if inequalities persist, if services fail to adapt to changing needs, or to how people are today, then support for those principles will weaken.

There’s also a generational shift as those who remember the fear of impoverishment disappear, and attitude shift as access becomes harder to deliver in a consumer world where we expect access more quickly, these are both upon us.

Not being overwhelmed matters because we cannot ever take our universal healthcare service for granted.

But connections are fading with the time when to be ill was to fear destitution.

And new social and political forces mean the place of the NHS in the nation’s heart is not assured.

If we do not adapt to this new world, if access becomes harder, if care for today’s or tomorrow’s populations is not available, then it is not inconceivable that emerging forces could advocate for the NHS to shift to an insurance-based model, offering a basic safety net to the public at large, while incentivising more people to pay for private medical insurance from the market.

While there is nothing intrinsically wrong about doing healthcare through insurance, if the rules are right, but it does risk increasing not diminishing the disparity in health outcomes and does nothing to address the inverse care law Victor mentioned this morning.

For the first time we have to collectively defend the right to care ‘free at the point of use, based on need not ability to pay’.

The most guaranteed way to undermine those principles will be a failure to improve care, a failure to reduce health inequalities, a failure to resource and lead services effectively.

So, our task collectively is not simply to run the NHS or rform the NHS. The task is to renew it. And renew it before the maths overwhelms us.
That is the collective challenge I think we face and must take on. And it’s where I and the NHS Alliance - working across England, Wales, Northern Ireland - will support you to respond to these challenges.

There is a second truth about the NHS, which is that we are indeed seeing some green shoots after a number of turbulent years.

There are some great things happening in Northern Ireland and in Wales, which you can hear about in some of the sessions.

For example, it is good that in Northern Ireland, Mike Farrar, formally of this job, with his colleagues are making headway on major and much needed reconfigurations.

It was lovely to hear in Wales there is a Cabinet Member for Prevention and Population Health - a clear signal of intent to embed prevention at the heart of policy and delivery across the whole system.

In England, we’ve heard Jim talk about the hard-won gains, including cutting waiting times for scheduled care, cutting ambulance call-out times, meeting rapidly increasing mental health demand, improving access to primary care and delivering more care in the community.
The service has also met some of its toughest ever efficiency targets.

All of this during a turbulent year of strike action, constrained finances, rising demand and a major reorganisation.

We’ve talked a bit about the public is now starting to recognise that. The latest British Social Attitudes survey reported a 6 per cent increase in satisfaction, alongside the biggest drop in dissatisfaction in 25 years.

This is something that should be celebrated. And congratulations to everyone in the room who has played a part in what we all hope is the start of a long-term trend. It was not easy but we got there one year and we need to do the same again this year.

One of the first things we did as the NHS Alliance, was to undertake a major survey of NHS leader opinion on what the financial and operational challenge looks like for 2026.

It told us, you told us, that the challenge for 2026/27 is looking even tougher, with local NHS leaders pointing to likely service closures and job cuts this year.

Many of the gains made in 2025 were reliant on one off measures that cannot be repeated. It is not always realistic to squeeze more out of an already squeezed service.

The remaining options will lead to difficult trade-offs. Some will require choices between patient care, staff numbers and financial balance.
Others will need sites to give up their beds to neighbours and to focus on community services which may be locally contentious.

Otherwise, we face a race to the bottom where we increasingly salami-slice services and fail to undertake the real reforms that are needed.

One example of the risk is that for many of our primary care members, the focus on access (which is front and centre of the what the public wants) could come at the expense of routine and proactive care, which will impact longer-term health outcomes and result in potentially more expensive care further down the line. This is directionally wrong.

So is cutting the available time for GP leadership of reform. As I was told last week, ‘we are doing this as charitable activity’.

That is not sustainable, we can’t reform the NHS based on goodwill alone. Bandwidth and stress are an issue for leaders across the system.

We must ensure there is protected time for leadersto make those tangible improvements.

So, I think there are six major changes needed in how we do things and perhaps a self-interested seventh:

Firstly, we must move into the reform world.

It’s understandable that the first two years of this government have primarily focused in the English NHS on recovering services.
This has led to those notable improvements.

But members told us of the risks to the shift of more care into the community if we get consumed by only being able to focus on the performance metrics.

This is an ambition our members and government are aligned on but almost three quarters of local leaders said they are concerned about delivering it.

To quote: “The overriding focus on finance at the expense of patients and particularly staff, that will have repercussions.”

The frustration is that we have an alignment of policy between the government, the centre and local leaders, but an absence of some of the conditions required to deliver consistently and at pace.

A big part of the answer is moving more funding to collective programmes, which include acute providers, as well as those in mental health, primary and community care.

At the Princess Alexandra, where I was last week, they know that improving productivity will only be achieved by working collaboratively with primary care and community services.

They built a new community diagnostic centre based in St Margaret’s Hospital and in-reach into A&E to reduce admissions by seven per cent.

This kind of innovation is exactly what we need to do and is exactly what we need to be spending more money on.

If you will forgive me another Macmillan anecdote – as I was leaving I oversaw Macmillan’s first social investment fund: £10 million in 2014.

After a decade of testing, learning, improving, Macmillan is investing £250 million in neighbourhood health programmes for people living with cancer, frailty and co-morbidities over the next three to five years.

So, harnessing the local voluntary organisations, local government and private sector partners who can help lubricate the change.
But the big thing is that we need to harness the financial flows.
We must empower the services that most of the public and the electorate interact with to take a leading role in the neighbourhood agenda we keep talking about, backed by the right contracts, funding mechanisms and protected leadership time to deliver the change required at the speed we need to change it.

The second of my key changes is something our members feel deeply – the need to have a supportive centre enabling local autonomy and delivery.

I’ve spoken to many members in my first couple of months and it’s clear we don’t yet have the right culture in place.

The centre has, in some places in some times, exerted too much control, micromanaged local leaders, second guessed decisions, set over-punishing efficiency targets, and has not been seen to listen to the reality that’s in place.

Some places have a punitive culture that has caused a lot of damage to local leaders – often to those CEOs who took on difficult jobs in challenging systems when it would have been easier not to.
Jim and his team have made inroads into stopping all this and have made welcome changes. That is to their credit and should be applauded but there is much further to go.

But with a new target operating model in development, we need to take this opportunity to deliver a more fundamental shift in autonomy and trust and behaviour are displayed across the system and make use of the merger between the Department and NHS England to make use of this debate.

This is felt across all parts of the system. Take our ICB members. Without re-litigating the last year, it’s been extremely challenging for ICBs. They’ve been pushed around and we’ve lost a lot of good colleagues.

ICBs need to be backed as strategic commissioners. Lessons should also be learned when it comes to how change programmes should be run, or maybe not run.

There is an opportunity for us to create a new and better relationship between the department, the regions and our members. Reform will only happen if local leaders are motivated, enthused and supported. We can’t make the changes we hope to make if they’re not. Let’s use this opportunity and have less parent-child, and more peer to peer.

What would good look like? It deserves its own talk but our view, but we need to create a rules-based system with a clear set of roles and responsibilities, no duplication, with the right national and local balance as part of that – all backed up with good governance and a good culture.

That will require clarity as to how the NHS will be managed and led within the department.

I understand that, for example, one comms function rather than two is an efficiency and might well result in more seamless strategic communication.

But operationally, the NHS will still need managing. So how that is done is important. There will need to be some form of clear visible leadership for the NHS which is on the case 24/7, 365 days a year.
How that is established, and how it interacts with departmental policy setting, is a truly critical success factor. It is easy to get wrong and it needs to be very well thought through.

What room, with whom in it, will lead the day-to-day drive for performance, reform and improvement? Who will manage the fires and combine what we used to call ‘grip’ with the empowerment of the wider leadership? Is there going to be a David Nicholson lookalike or a Hugh Taylor lookalike?

If one of our asks is for political support locally and nationally, another ask is that we help the political team get the new bill right.
Health will always be political and it’s unrealistic and undesirable to keep politics totally out of the NHS.

But one of the consequences of abolishing NHS England and putting powers of regulation, appointments and oversight directly in the hands of the Secretary of State is a big shift.

The Alliance is working closely with our members, parliamentarians and with the bill team to ensure there are the right safeguards and checks and balances in place to curb any potential future interventionist Secretary of State who wants to meddle too much in operational issues, and more mundanely to identify how the NHS would be protected from policy shifts every time a Secretary of State changes.

This latest reorganisation of the NHS will only be worthwhile if the result is a much more empowered front line. This will require close attention to detail in the legislation (I will be in front of the Public Bill Committee on Tuesday if you want to tune in for an even more exciting watch).

But I am optimistic for one big reason which is, at least for now, the will is there at the top.

The third of my key changes is taking mental health services more seriously.

There is growing recognition of mental health’s key role in supporting economic activity, education and public wellbeing as well as health status.

But despite being an important element in the 10 Year Health Plan, mental health has less visibility up to now than other NHS pressures. At least on the ground in the day to day.

And this a problem, as we are seeing rapidly rising demand in mental health.

94 per cent of mental health leaders who responded to our survey said they were concerned about meeting increasing demand.

Perhaps mental health lacks the kind of totemic political targets that tend to lead the NHS sections of party manifestoes – the 18-week elective care target being this government’s version.

But our mental health members are all up for a clarity around their direction of travel, meaningful targets, and will again need the freedom and political support to innovate.

Our number one ask of government on mental health is that it helps to bring clarity and coherence to a complex and often misrepresented or poorly understood area.

The route through this is the development of the new cross-governmental mental health strategy. It offers the prospect of a more joined-up approach to policy-making across the NHS and wider public services.

The approach we are seeing is exactly the kind of strategic direction we need from the centre – a clear direction of travel, connecting across public services, clarity about what local leaders need to do to drive population health, economic growth. It’s something to applaud.

I know from having visited the new mental health neighbourhood centre in Birmingham and the Mental Health Crisis and Assessment Service in North London that innovation is alive and well. What we have to guard against is losing sight of the goal due to understandable concerns over tragic, but fortunately rare (though not rare enough), events, or due to confusion over where mental and social distress begins and ends and where mental illness begins and ends. We will work closely with the Department to help ensure that does not happen.

The fourth of my changes is an obvious one for the chief executive of a membership body: we need the right funding levels in the right places.
I get the state of public finances are not good but at least release more capital. Let me talk hospitals. Whether acute, psychiatric, or indeed community, hospitals need a lot more capital to sort out deteriorating estates, to enable new models of care, and to avail of new technology.
Hospitals have great people. They just need to be given the tools and environment to allow them to thrive. And thrive they must if we are to get to this brave new world.

The reason we have such demand for community services is that hospitals have done such a good job. Equally they are the source of research, trials, audits, innovations, which will be the next set of improvements in outcomes.

As long as I am in this job, (which I hope will be a while!) I will champion the cause of hospitals, and champion the idea that it is not a game of hospital bad and neighbourhood good. Hospitals are part of the neighbourhood.

I don’t think any Secretary of State could have foreseen the global conflicts and the resulting inflation eroding the value of every NHS pound.

But it does mean that the NHS is facing unplanned costs – alongside prolonged industrial action and the expected impact of the US-UK drugs deal.

While we don’t expect much if any movement from the Treasury on the revenue front, there is clearly unfinished business when it comes to both covering the unforeseen costs and addressing the dearth of capital funding.

This remains one of the most significant barriers to further productivity gains. I don’t see how we can get it without capital funding. And to state the obvious, productivity is about time. Get more out of staff time by giving them the environment and tools to do more in the same time. Not by asking them to run around the hamster wheel ever quicker, that won’t work.

On the optimistic side we are facing incredible possibilities when it comes to AI, biomedicine and med tech, genetic profiling, smart diagnostics and wearable tech, an almost infinite potential for identifying and responding to diseases sooner. Go around the exhibition stands and you will see.

And while I don’t entirely share Tony Blair’s enthusiasm on AI, it undoubtedly offers huge potential when it comes to analysing X-rays, MRIs and CT scans to detect tumors; for predicting a patient’s risk or population risk of disease through machine learning; or more basically by saving time for clinicians through automating administrative workflows.

But we need to work out what does work and how to implement it.
Hold that optimistic vision in your minds, while also thinking about the capital-starved environment that, with all the outdated systems and stifling regulation that means it is much harder to get business cases approved and much harder for innovation to be spread across the NHS.

You can see why it’s a source of major frustration to local clinicians and local leaders when they can see the art of the possible, but where they are stifled by not even having an electronic patient record in their organisation…

…or where it takes years to get approval for capital investment to make even the most basic improvements to their buildings and facilities.

Much of what I have talked about so far is about reforming services, financial incentives and accountability.

But at the heart of our health service and the local communities we serve are people – both in terms of the people we care for and the people who work for the service. This is the fifth of my changes.
This is a service delivered by people for people and I think it’s fair to say that we are not in the place we want to be when it comes to providing the best possible care and the right conditions for our staff to do their best work in.

Victor is right when he says that we cannot continue to accept stark inequalities in the outcomes that different local communities receive.
How can it still be in 2026 that people with learning disabilities die 20 years earlier from preventable causes? What are the barriers and what are we doing about them?

Or that black women are more than three times more likely to die in childbirth? What are we doing about that?
At the NHS Alliance we will play our part in supporting you as well as our own organisation to be better at understanding how this difficult area of differential outcomes works.
This is one reason I am proud that we host the NHS Race and Health Observatory and a reason we are doing a review of our own performance in this space.
That leads me to my next and final change which is, how do we care for our staff?
Lord Mann’s review last week was a stark warning about Jewish colleagues in the NHS being harassed, bullied and abused. And if there is antisemitism, there is Islamophobia and racism.
As the country’s largest employer, we know that our staff from diverse backgrounds feel particularly under threat at the moment.
They are having the same experience in the NHS as in society more broadly.
Victor said at the NHS Alliance’s anti-racism conference in April, good leadership is anti-racist by definition because our job as leaders is to lead all our people, everywhere, all the time.

Again as the Alliance I want us to support you to tackle this at a local level.

There is also the wider issue of how we treat all our people. Our survey of NHS leaders showed widespread concerns about morale within the NHS.

If there is one stat in the survey it was that 93 per cent of leaders said they were worried about staff morale.

It’s not hard to see why, but there are multiple factors at play and we need responses for all of them.

Some of it is about fearing service closures and freezing posts, will lead to a worsening of staff morale this year.

But a bigger issue is the need to create hope. Staff need to be both treated well and see that the change we all want is happening. You can put up with some hardship if you know that things will change.

We have to put hope into the system. Tangible progress now is better than the promise of a new hospital in 2040. Capital investment for the kit which saves the time so more people can be treated more quickly.

Communication which respects our clinical colleagues and service managers and reminds them of what a great job they’re doing. Flexibility which allows staff to have a life outside the job.

One of my surprises on arrival is that I have lots of conversations about money, restructuring, neighbourhood, performance.

Not so much about people. About how you, the leaders, are supported and treated, but also everyone else.

One of the things I hope you will see from me is a push to improve what it feels like to work in the NHS, to help develop our staff to be the workforce of the future and to make it easy for our amazing, skilled, resilient staff to provide the great and improving care they joined the service to provide.

A promise from me is that I will work closely with NHS Employers and colleagues in the Department to to help try and create that. The Messenger Review is a good place to start.