Health on the Line

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.  

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]

 

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.

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So until next time, goodbye.

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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.