After the COVID storm: where next for the NHS? Episode 3 of the Health Foundation podcast

Jennifer: We're clearly in the thick of it with the pandemic at the moment and it's very difficult to think about the long term, but this is exactly the right time to think about the long term. Where is the NHS going? Are we going to snap back to how we were before or is COVID an inflection point to set us onto a new path into the future? What are the deeper trends and opportunities and threats that we need to be aware of now? How might we chart a better course into the future? With me to discuss this today, we have Nick Timmins who's the seasoned former Public Policy Editor at the Financial Times, who's going to look at things from a political and economic perspective for us.

Nick Timmins: Your waiting times are stretching out really, quite badly and quite rapidly. If you look back to the 2000s, when they would tackle, it took five or six years to get them really right back down and it cost billions and billions and billions of pounds of money.

Jennifer: I'm also absolutely thrilled to have Jackie Daniel, who's Chief Executive of Newcastle NHS Foundation's Trust.

Dame Jackie Daniel: I now, as a chief executive in Newcastle, cannot distinguish between health, wealth, and economic prosperity and well-being.

Jennifer: Jackie has been a chief executive in the NHS for 16 whole years. She really has been right in front and centre in this pandemic.

Nick, in all your time, have you seen anything like this?

Nick: Well, no, we've not seen anything like this. I don't think anyone alive has seen anything quite like this. If you look at the broad economic situation, you use obviously budget responsibilities forecasts. We're going to be running a deficit this year of around £400 billion. That's the difference between the amount we're spending in the taxes coming in. £400 billion is roughly two and a half times the cost of the National Health Service, it's our highest peacetime deficit total. The total deck's going to hit more than 100% of GDP. That's more than £2 trillion if you can get your heads around that. Then there is Brexit on top, which in the view of most economists, including the OBR, is likely to cost somewhere between 5% and 8% of the lost growth in GDP over the years. Somewhere north of £90 billion. These are just stunning sums of money. Absolutely stunning.

Jennifer: Jackie, you've been in the thick of it up in the North East. How has it been for you?

Jackie: Well, it's been quite a year. Interesting is one word, terrifying at times, invigorating at other times. We've really had to step through it and work with our teams to know what to do sometimes for the days ahead, sometimes for the coming weeks ahead, and just respond to the pandemic as it's been rolling out.

Jennifer: Have you been given more freedom than normal to shape your own path in Newcastle?

Jackie: We'd been given a lot more freedom. I think we've had to take that. It's been very welcome, and I think we've demonstrated just what can be achieved with more local flexibility and freedom.

Jennifer: This is an emergency situation, but do you think when the emergency has subsided, that kind of balance between the national sort of strategy and performance managing and local autonomy will just snap back to what it was?

Jackie: Well, I certainly hope it doesn't just snap back. I must confess that during-- we've had peaks and troughs because we've had wave one followed by wave two, which was very different to the first wave. You could see in those moments, in those periods in between, the tendency to snap back. I think it's really essential that, that more localised autonomy is maintained I think we demonstrated. I think the recovery period is going to be tough, it's going to be long. I really hope there is room for local flexibility in the way that that's managed.

Jennifer: Given that we have this, we have Brexit going on, even if the government wanted to, does it really have the bandwidth to even think of possible solutions or reform for the public sector?

Nick: Well, I think it's going to have to at one level because obviously it's the old cliché about don't waste a good crisis. Clearly, it's going to have to address some areas of public sector reform. Jackie may have a view on this, but the bit that frightens me about the NHS in a sense, is your waiting times are stretching out really quite badly and quite rapidly. If you look back to the 2000s when they were tackled, they were effectively tackled, but it took five or six years to get them really right back down to the sorts of levels that we were enjoying at the end of the 2000s. It costs billions and billions and billions of pounds of money. I don't know whether the government has a grasp on that, but if it doesn't, that's a worry. There's the whole issue of social care, it would be repeated promises to fix social care including from the Prime Minister. Whether it has the bandwidth to do that, well, we'll wait and see.

Jennifer: Jackie, the bandwidth question is also relevant to NHS England, isn't it? Because there's only a fixed number of people. Given that you said a lot of solutions were found locally in this emergency, how do you think the localities within the NHS can somehow have more agency to try and address some of these huge problems?

Jackie: I think the backlog-- I was looking back at a timeline over 2020. I think this time last year, just before Christmas, we were feeling slightly more optimistic, that we got some manifesto commitments, some commitments to increase in real terms, spending, et cetera. On the 31st of January, we took the first UK COVID patient in Newcastle and kind of the rest is history as it were. There is no way that recovery of those now, very long waits, and that backlog will be done in a year. I think my best guess would be three years and that's with some significant infrastructure, building, and cash.

More worryingly I think for me is we've got a tired, a really tired, really fatigued workforce. We've had some funding more recently where we've been able to pop up facilities in areas like ophthalmology which can double the capacity but it is the same teams working even harder, working even longer hours, and I just don't think that's sustainable. I think we need a very different reset. We're at a very fragile point. Carrying on with the current trajectory just won't get us there.

Jennifer: Do you think something needs to happen in the way those messages get transmitted up to the policymakers wherever they are? Because surely, they cannot see the complexity of the types of things you're facing.

Jackie: Yes, almost certainly it does. I've been really worried. I was very worried between waves one and two. I don't think there's been enough conversation about this. I appreciate it's very difficult, as it we're in the middle of a pandemic and we keep talking about that, but we must find that bandwidth. We must face this reality. We haven't begun, in this conversation, to talk about the deepening inequalities and the deeper economic scenario. This is a ticking clock and we must start to face some of these challenges and work through what needs to be done to address them.

Jennifer: Nick, if you think about this government, it really was only just a month in, wasn't it, before the pandemic began to hit? If you were to sit back and look at the Johnson government if it were to have project for, let's say, the public services or indeed the NHS, what kind of project would that be? It's very difficult to see quite what they are about.

Nick: If you take the NHS there is a project underway in the NHS which is integrated care and has been for five, six years now. It needs to provide the conditions to help that move forward as fast as possible, so there is a project there. One of the odd things if you look back is that the Conservative Party's famous for loyalty and its interest in power, but over both Brexit and now over COVID, it's developing bunches of serial revels all the times so that even this 80-seat majority Johnson's got-- it hasn't fallen over yet but it keeps looking as though it's a bit under threat. if that continues that will make forms of reform very difficult. Very difficult because you need to be able to get your business through the house clearly and simply without too many compromises.

Jennifer: It almost seems like a technocratic agenda as opposed to an ideological agenda that seems to be pushing things forwards at the moment. Jackie, we've clearly just had the proposals come out, or at least the consultation document, on how to move the NHS forwards via a bill that's going to go in front of parliament. The main thrust of that bill, isn't it, is about clearing the barriers locally so that people can collaborate more effectively through what's called integrated care systems? Given the huge backlog and the challenges ahead that you see, do you think that this kind of integrated care agenda is going to be enough to deal with all of that?

Jackie: I think it really depends on the approach. I think it has all of the ingredients to be really transformational, but if I can try and elaborate just to colour in some of the reasons it might fail. I now, as a chief executive in Newcastle, cannot distinguish between health, wealth, and economic prosperity and well-being. Those three dimensions are in front of me all of the time when I'm thinking about everything I'm doing. Playing our part in the economic region generation in place with our other civic organisations, the local authority, gives us the best hope. We've got to get better at creating what I call sticky edges round-- Organisations, typically, is the largest NHS providers with a lot of research and innovation capability who can offer it at scale in the business and commercial sector, can contribute so much more than we doing. I think unless we get the join up with our local authority, with local business, the commercial sector and enterprise, we will not accelerate at the pace we need to do a U-turn on some of the impact of this last year of the pandemic.

Jennifer: A lot of the words in vogue at the moment, certainly, in meetings that I've been to nationally or internationally have included the following: sustainability, inclusivity, well-being, green. A lot of this is about how organisations can work together to try to push some of these longer-term and basic issues forwards. Nick, these seem like a whole lot of warm words. Do you see this kind of ball of words translating into any kind of tangible action at a national?

Nick: Well, I'm not sure whether it's national or local. It seems to be certainly in some parts of the country there's been much better cooperation between the NHS and local authorities through COVID, it's driven people together rather than apart. I think there will be people who want to hang on to some of the gains from that.

Jackie: Jennifer if I may?

Jennifer: Yes.

Jackie: Can I comment on the point that Nick's making about what's happened during the year of the pandemic because I think it's accelerated such a lot of quality and depth and breadth of collaboration. We've got complete join up in the city region around our care home provision, for example, as a result of creating support in all sorts of ways during the early stages of the pandemic. We're not going to go back to that. We've connected our data right across actually out into care homes. We've created such a lot of important new ways of working, but also infrastructure and committed to quite a lot over this last 12 months. I don't think that can be unpicked and nor should it be.

Jennifer: This raises the really interesting issue of devolution as a theme more generally, both in the country, in national to local government, but also in the NHS that we touched on earlier. Nick, going back to the government's manifesto, they did actually, way back in 2019, talk about English devo being on the cards. You have to wonder whether that still is on the cards, given what they've got ahead and also given their experience of COVID, particularly with some of the public the Metro Mayors, not necessarily playing ball in the way that the central government would like. Do you think, from what you see, that is going to be pursued or not?

Nick: I have no idea how that's going to play out because there are sort of counter forces aren't there? You might argue one of the lessons for central government, particularly around Test and Trace was it started off with this completely centralised and largely privatised approach. It took a long time to get to where it should have got to at the beginning, which is making use of local authorities. It's going to take a lot to change because the truth of the matter is that for at least 30 years, neither the Conservatives nor Labour have really trusted local government. The tendency has been to pull powers away from them. Labour had an interest in regional government which they put to a referendum in the North East and got a resounding no. They launched the mayor's agenda and the Conservatives carried on with the mayor's agenda. You see some of the tensions that has brought out over COVID, are these tensions a bad thing? Are they a good thing? I think there's an awful lot to play for there. I wouldn't like to guess what the outcome will be.

Jennifer: Yes. Jackie, it seems that that permission, if you like, for more autonomy, if central government could only do that with local government, could only help your agenda if really you're saying a lot of progress has to be made by using the public pound very innovatively locally through partnerships of the type that you're making both with across the public sector, but also with the commercial enterprises that you're doing up north.

Jackie: Yes, I continue to think it's really, really important. Even the North East is quite a broad geography, we've got our 12 local authorities playing in. Actually, they're not all equal in terms of the depth of the work that we're doing, but they are all very active. Interestingly, they've come together in response to the NHS EI document and said, "We're even more determined to work in some sort of a system footprint with health." I've not known it as strong as it feels at the moment and I think it's for all of the right reasons.

Jennifer: What more could you do as local entities to try to up this, bang the drum a bit more on this?

Jackie: It's interesting and Nick's right. We've seen the frisson, if you like, around political decisions, and junctures, just more recently. You can definitely see that playing out. You can feel it locally. I don't know that there's been, in my mind, enough of that over recent years, and I'd probably go-- I go beyond that pandemic, probably for the last few years. I chair the Shelford Group, and we've been having discussions recently about how do we-- It's all about impact, at the end of the day. We actually do need to be much more impactful in the way that we carry these things through. I think it's creating a cadence of that local, regional, with the national teams.

Jennifer: One of the signals that has [inaudible 00:16:40] of the office is about the NHS as an anchor institution. By an anchor, what this means for those of you who are not familiar with the term, it's about using the NHS, the NHS's purchasing power, its employing power, for example, its use of estates and other assets to try to further the health of the community so letting its buildings be used for other purposes. For example, procuring locally, or making special steps to soak up unemployment at periods like this, particularly for young people who aren't college-educated. I suspect you're very heavily busy with that up in Newcastle.

Jackie: Yes. We're very heavily into it. We are the largest NHS organisation in the North East with a provider of vast majority of the specialised services. We house all the research and innovation, architecture, infrastructure, et cetera. I think just by scale and asset, we're well placed. We spend well over £400 million in procurement each year, actually, making sure that some of that is supporting local businesses is really, really important. Joining a local COVID response centre has meant that we've employed over the last month 1,000 more people. We've been able to target some of those areas in our local economy which were the most deprived. There are some really practical examples there. I think we need to look across the country and look at where are those kinds of anchors.

Jennifer: One of the areas where of course businesses can help is in designing innovation and trying to get it used inside the NHS. That might be really helpful, mightn't it? For boosting productivity, which has got to be part of the picture ahead, particularly if your resources are squeezed. Of course, how the NHS spots productivity-enhancing innovation is not always as good as it should be.

Jackie: We're learning to do it, Jennifer. I think there are some organisations, we collaborate a lot with the likes of Oxford and Cambridge, and UCL. We're a public service. I'm always conscious about the taxpayer's pound. It's got to be done really well.

Jennifer: What do you think needs to happen if that agenda is going to be really boosted? That is, to try to get a lot more productivity ramped up in the NHS?

Jackie: Well, I think there are 10, 12, large UK health providers who could do this well. Not always in city environments, but quite often. I think, to work with their universities and their local authorities, just to have strength. Usually, the business networks are really aligned to local government. I think this is about those sorts of collaborations coming to the fore, agreeing where the priorities are locally and regionally and looking at all of their combined assets, and supporting the NHS. I've learnt a tremendous amount, particularly over the last two or three years through working more closely with local business and government.

Jennifer: Nick, outside of the NHS, do you see anything that the NHS can learn from in how technology is spotted, taken up, incentivised, used, spread?

Nick: Well, we've just seen a dose of it through COVID, haven't we? GPs doing telephone and online conversations, consultants doing the same. I don't know what Jackie would say. Whether her consultants feel this has been productive, unproductive, or has got in the way. I think general practice has actually found that it's quite productive. Clearly, it will not work for absolutely everyone, but there are loads of people for whom all you really need is a quick phone call. The patient does not need to go to the surgery. I think that we're seeing elements of productivity there. AI is coming into help one way or another with diagnosis, it has been for some years. There will be productivity gains from some of this.

Jennifer: I had a webinar recently, Chris Giles was talking about the financial squeeze ahead, but what he said was a bit of good news was he didn't think capital spending would be so constrained. In fact, he thought there might be quite a bit of capital around to make some significant investments that could set us on the right path. Jackie, if you had more capital investment, is it obvious where the good bets would be to try to up productivity?

Jackie: I think the kind of infrastructure that Nick was just outlining there, that definitely has been very well-received for us locally can only be really good news. For me, that should be pretty universally rolled out and available, but I think it is true. It's interesting what you say about capital, Jennifer. Obviously, we've just had a huge-- this government have spent a lot, 40 new hospitals and so on, but what we do know is that it's actually a drop in the ocean in terms of the requirements on capital, real estate, buildings and infrastructure, that is needed. We know that can be transformational. I'd want to be encouraging that kind of investment because I think the productivity gains are huge.

Nick: I would point out, one of the good things as Chris Giles pointed out, one of the good things at the moment is capital is cheap. Interest rates are very low, and the government can borrow very, very cheaply. There is a real chance to boost some capital spending.

Jennifer: Yes. I think my colleagues at the Health Foundation have calculated that we spend less than half of the OECD average per head on capital in healthcare compared to other countries. If you look at the work by some of the academics in the world that have done the most work on productivity, and I'm referring here to Nic Bloom and John Van Reenen, what they have found in a lot of their studies across different industries, including healthcare, is that the biggest active ingredient of productivity gains is actually not technology. Actually, it's good management. I wonder whether our blind spot to management and thinking about how to improve it is going to remain a blind spot in the next years coming ahead, both for the NHS and indeed for the wider public sector.

Jackie: I really hope that people can look back at the last year and think, "My goodness me, we've seen some first-rate leadership and management of services." I really hope that that is evident because I see it every day. I think the model of operation is the thing, how do we really create that environment, the climate within the NHS where great leaders and managers can flourish? We haven't seen a lot of that.

Nick: There's a really interesting challenging question here, isn't there? In the sense that if you look at clinicians, clinicians are very, very good at adopting the latest clinical technology, the latest advances in treatment. It percolates through very, very fast. Healthcare systems, this is not just the NHS, healthcare systems around the world, are much less good at learning from better ways of managing things that have been done elsewhere and adopting them. It's one of those paradoxes, I don't know quite how you crack it, but it clearly is the case. As Jackie says, getting that right is not about performance management, it's about a more open culture, so working out how you might better organise things.

Jennifer: Yes. Going back into the past, you remember Julian Le Grand with his knights and knaves analogy so that politicians can either view people working in the NHS as knaves; they will do bad things unless they're checked, which leads to a regulatory culture. Or they're knights; where they can do no wrong and you just give them a lot more freedom. It strikes me that the docs fall into the knight's section and managers traditionally have been in the knave section. How do you apply the knight methodology and zeitgeist to the managers is the question, and has COVID been an inflection point to try and flip that culture a bit?

Jackie: I think it's got the potential to provide that slight shift, if you like in behaviours, it's been a really truly bizarre year for all our managers, for example, in Newcastle where the usual things just haven't applied. We haven't had a budget like they would recognise for the whole of the year. Now, we're going to have to get them back into a cadence of good budgetary management. They've been managing their money well, but not in the usual way. I think there's something about harnessing the permissions that we've created, the more permissive climate and just what that's brought about, not stifling, it was completely suffocating that.

What I hope we don't do with integrated care document is lead to kind of structures. We've got to let some of this, I think, evolve and emerge because people are getting quite excited about working together in new ways across quite a wide geography, so it's been a much more vibrant discussion.

Jennifer: Do you see that these changes that are coming down, this roadway ahead, that we all agree is healthy, nevertheless, how is the patient voice going to be uppermost here?

Nick: Well, you need to try and ensure you retain some of the nominal rights that currently exist and some of these are around waiting times, access. Speed of access and access more generally. I don't see that people collaborating necessarily negates that at all.

Jennifer: What about choice though? Do you think that's there's enough choice in the system to really provide some kind of grit, some check on the system?

Nick: Well, the question is how much choice do you think? Let's start from first principles. The patients must, at some level, have some choice about where they are treated. That must be the case because otherwise, it's just a sort of state-run direction system. I'm trying to say there's two things. You can preserve choice within a collaborative system and that is rather different from saying you want to use choice as a weapon of driving efficiency.

Jennifer Yes. I suppose the question then for Jackie is how do you make sure that that choice signal is strong enough to change what could be quite cosy monopolies locally, which ended up being unresponsive to patients, but very responsive to provide a needs and desires and wishes?

Jackie: I think completely agree with Nick, that the kinds of collaboration we're engaged with here at the moment is uncomfortable sometimes, quite a lot of time, it's certainly not cosy. We're facing real issues. It feels much more mature than at any other time. We are going to have to work much harder than we currently are, I think. COVID, in a sense, we've just had to get on and do. We're going to have to really think about how we're-- the decisions we're making are done alongside our communities, alongside our patients, and in full view. That's not always as easy in a collaborative world. You've got to work harder at it in my experience. The lines are much more blurred. You've got multiple stakeholders but kind of creating a shareholding, I always say as the largest provider, I'm running that outfit as it were, I'm leading it, but actually, it's on behalf of the whole of the North East and North Cumbria and much further. It's about how we create a different dynamic with both patients and with stakeholders.

Jennifer: Where do you see the challenge in that system, Jackie? Even with the best will in the worlds, just imagine that things were not quite as good as somewhere else in the country. What would force you to change if you were all convinced you were doing the right thing and is the patient voice a strong enough signal? If it isn't, what other nudge would there be? Is that through the performance management route or is that through transparency as you say, or what?

Jackie: For me, it's about having the right dials in the cockpit. I'm sure we'll go through another iteration, through into next year and beyond on all the things that we really need to hold right in front of us. I think local government can offer something here. I do think devolution, actually working with local government and their communities, as we're planning service change, et cetera. I think it is really levelling up in terms of performance. Yes. I think it creates quite a collaborative, competitive conversation about wanting to be as good as it gets.

Jennifer: Yes, I suppose with more perspectives locally, other than the NHS perspective, that can only help, can't it?

Nick: Yes, and indeed. The more there is collaboration with the local government, local government, I would judge, is better at consulting the public about changes it's going to make, even when they are unpopular than the NHS has been in the past. I think there's some sort of joint learning there.

Jennifer: Unfortunately, there we have to leave it. A very, very big thank you to our expert guests, Nick Timmins and Dame Jackie Daniel. If you've enjoyed the discussion today then please subscribe to our podcast. If you'd like to give us a friendly rating, of course, that will be extremely welcome. This time we have something extra for you in the show notes, a powerful new short film produced for the Health Foundation that depicts the human stories behind the statistics of this pandemic.

Next time on our monthly podcast we'll be discussing inequalities in health, and in particular, the deaths of despair that have ravaged the United States. Join us again next month and thanks for listening.