In The Loop: the BIG Questions

In their latest In The Loop podcast Niall and Roy lock horns with Dr Charlotte Refsum Director of Health Policy at the Tony Blair Institute. In a frank discussion Chalotte a former GP  reveals how the former Prime Minister is still closely involved in policy development and she lays out the stark choices facing the NHS if it is to survive in the face of the enormous challenges it currently faces.   Charlotte is a former GP who has specialised in health policy. She worked for the consultancy firm KMPG and has been involved in supporting change in 25 countries.  She contributed to the government’s NHS plan and has worked with Sir Patrick Vallance and Sir John Bell on technology and how the arrival of the AI era will transform health and care.In the podcast Charlotte defends the Institute’s links with big tech companies and non- democratic governments and insists she and her colleagues have editorial independence and have never felt under any pressure to write anything or hold a view because of those relationships or funding. What follows is a frank assessment of the current government’s strategy but hard questions about what will be needed to implement the changes needed and whether the absolute priority, which concentrates so much of its resources on older people with long term conditions, is justified. Charlotte suggests the current budget may be all we can afford, and in her view the NHS needs to find ways of living within its means. That will involve thinking like an insurer, assessing future risks and taking prevention much more seriously. And there is also  talk of copayments for some new treatments for those who can afford it and the need for the NHS to start decommissioning some services if it is to embrace the technological revolution that is underway.  And she suggests we need a revolution in primary care. As for the professions, she suggests the impact on doctors and others is uncertain but will be profound.  One of the changes she identifies is how new technology will continue to undermine the asymmetry of information that underpins the professions and how it will become easier and cheaper for people to seek advice from elsewhere. But she adds, that does not mean a dystopian future where we send out someone with an NVQ and an iPad to get and manage complex cases! 

In the Loop – the BIG Questions Niall Dickson CBE and Roy Lilley with their latest guest Rob Webster CBE  For this next edition of In The Loop podcast Niall and Roy come together with Rob Webster one of the most prominent NHS managers and a huge advocate of integration. Rob heads up the West Yorkshire and Harrogate Health and Care Partnership an integrated care system.  And like every other system in the country he is grappling with a huge financial challenge, a big reorganisation, redundancies and staff threatening industrial action. So how is he managing as he faces a 45% reduction is his workforce and key staff in an angry mood? Rob reveals this is the most frustrating period in his 36 year career with enormous pressure on everyone and he admits it is causing harm to his staff.  But he insists it will not distract from the work. While he acknowledges the difficult financial position, he says the transition is incredibly difficult, supports the aims of the reorganisation and believes that close working relationships between health, local authorities and the third sector can and will deliver meaningful change.  He says the NHS must put its people first and argues that staff have quite rightly become dissatisfied and that the job of NHS leaders is to do something about this. He notes how painful it has been to see the attrition of standards over the past fifteen years but suggests this can be a period where the NHS has to recover and transform services.Niall and Roy remain concerned about what can be achieved given all the headwinds but here again is a leader who says they can make progress.   N.B. This podcast was recorded before the government announced the go-ahead for widespread redundancies in ICBs and NHSE.  Speaking at a Providers conference on 12th November the Secretary of State said; ‘...Funding arrangements [for voluntary redundancies] have been agreed with HM Treasury and will be from within the existing funding settlement. We will not be cutting any investment to the NHS frontline. Further detail will come forward in the coming weeks.’ It is widely anticipated that NHS organisations will be permitted to overspend budgets in the current year and the amounts reclaimed over subsequent years through efficiency savings. 

In their latest In The Loop podcast Niall and Roy have a revealing exchange with NHS England Chief Executive Sir Jim Mackey. In a wide ranging discussion  Jim admits just how challenging it will be to meet the government’s ambitions for the NHS. If they deliver, he thinks books will be written about it and that it could be the greatest public sector turnaround of all time. “We are trying to do a lot in one go, we are trying to do major change on pretty much every front,  very quickly and what feels like in a rush, and at times it feels a bit overwhelming.”  But he remains optimistic and argues that they have no alternative but to address a whole series of fundamental challenges.   Sir Jim makes clear he did not know NHS England was going to be abolished when he took on the role. He supports the plan but says it would have been reasonable to assume that when the announcement of job losses was announced everything about the redundancy programme would have been ‘boxed off’ and ‘lined up’. But it  wasn’t. And he says that matters have  become more complicated as the year’s gone on and as other things have changed politically and  economically.  He insists that redundancies at NHS England and for staff at Integrated Care Boards (ICBs) should be achieved through voluntary deals, but admits they are still negotiating with the Treasury and that it has taken too long, with lots of argument and this issue becoming tied to other negotiations. According to Sir Jim “The delays on the redundancy costs have added complexity and drift and we do feel we are trying to do too many things at once. The big problem we’ve got is we do not have the time because the public aren’t as patient with us as we’d like them to be, because of the mess we had go into.”“I am as irritated and annoyed as anyone else is about how long it has dragged. It’s no way to be treating people but it is complex and it is not about compulsory redundancies.  We are going hammer and tongs to get things resolved as quickly as we can. It has gone on too long.”On ICBs he says he always thought 42 was too many with too much difference in their sizes, and that they were given too much to do and had to  work with a very expensive and incredibly  complicated operating model   In future ICBs will concentrate on commissioning rather than performance management – Sir Jim admits he did not love commissioning but feels the absence of it in recent years has been a problem and that they need to restore its value,  with performance management largely sitting  with regions On resident doctors “We are in bad way, where there is significant dislocation between them and what they need and what they want, versus what we as employers want and need, versus what the population want.”  Sir Jim says they need to fix some of the stuff that is causing irritation but also take a fundamental look at how the training and rotation works ‘as they clearly don’t like it’ 

In their latest venture In the Loop, Niall and Roy turn to mental health and conduct the first interview with Claire Murdoch,  NHS England’s outgoing mental health director since she dramatically resigned earlier this month after nearly ten years on the job.   In the podcast, Claire says she quit because she felt she no longer had political support and reveals her dismay at the failure of the new government to maintain the share of NHS spend on mental health. In a strong defence of what has been achieved on her watch, including more than doubling the number of professional staff working in child and adolescent services, much improved access for young people, despite a huge increase in demand, and great progress on a nationwide roll out of mental health support in schools. Looking forward, she says the share of NHS spend has been phenomenally helpful and must be protected and that as far as she is concerned it was ‘job begun not job done’. But this discussion also reflects the reality of mental health care in England today with services desperately struggling to meet the explosion in demand and with patients of all ages unable to access the support and treatment they need.