It’s easy to forget the state the NHS was in 20 years ago – long waiting lists, heartrending delays in care, winter crises – and heated debate on whether the NHS model was obsolete.  

But the Wanless Review set the NHS on course to receive record catch up funding. So in this episode, we ask, given the pandemic and the mounting challenges facing the NHS to deal with a huge backlog of care, is it time for another Wanless?

Our Chief Executive Dr Jennifer Dixon discusses this with two expert guests and former Treasury officials, who were very close to the original Wanless Review:

  • Anita Charlesworth, Director of the Health Foundation’s REAL Centre and our Director of Research. Anita led the secretariat for the original Wanless Review within the Treasury, where she was Director of Public Spending from 1998 to 2007.
  • Nick Macpherson, Permanent Secretary to the Treasury from 2005 to 2016. Nick was Permanent Secretary to three chancellors, and managed the department through the financial and wider economic crisis which began in 2007. Nick joined the House of Lords in 2016 as Baron of Earls Court.

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Dr Jennifer Dixon: Hello and welcome to the Health Foundation podcast. I'm your host, Jennifer Dixon. In this podcast, we explore key issues affecting health and health care and always with terrific guests. Today, we're talking about that vexed issue funding the NHS.

Tony Blair quote: We realised that we were going to have to fund the National Health Service in a significantly bigger way, not just for a few years, but in the years to come when we received the Wanless report.

Jennifer: It's very easy to forget the state the service was in 20 years ago. Long waiting lists, heart-rending cases delayed, winter crises, and widespread debate on whether the NHS model was finally kaput, but an interview with Prime Minister Tony Blair on Prime Sunday Morning TV changed everything. He made a pledge to bring health care spending up to the European average in GDP terms by 2006.

The surprise announcement on BBC Breakfast with Frost by Blair in January 2000 set civil servants scrambling to work out what it meant. Bounced by the so-called pre-emptive strike by the Prime Minister, the Treasury commissioned a review of NHS funding the so-called Wanless Review. Now almost two decades old, it was the first serious attempt to assess the 20-year future funding needs of the National Health Service. It unlocks not only uniquely high levels of investment for the NHS, but crucially, help to justify the tax rises to pay for it.

There hasn't been anything similar since. As we come out of the pandemic, we face the twin challenge of a backlog in need for care, plus high pressure on the public purse given the hit from the pandemic. The question we're asking today is, is it time for another Wanless? To help us answer this, I'm delighted to welcome two guests who are very close to the original Wanless Review, and both seasoned former Treasury officials. Anita Charlesworth is Director of the REAL Centre here at the Health Foundation. Anita led the Secretariat for the original Wanless Review within the Treasury, where she was director of public spending between 1998 and 2007.

Anita Charlesworth: Health care is part of a critical national infrastructure. We need a system that's more resilient, and you just don't create resilience overnight.

Jennifer: And Nick MacPherson, or I should say Baron MacPherson of Earl's Court, served as the permanent secretary to the Treasury from 2005 to 2016 and was permanent secretary to three chancellors. He also managed the department through the financial and wider economic crisis beginning in 2007 and joined the House of Lords in 2016.

Nick MacPherson: Generally, when the politicians want to make a radical change, the last people they would consult is the Treasury. He would always tell you about 17 reasons why this is really a very bad idea and you should continue as you are at the moment.

Jennifer: Let's kick off. Looking back and reading around this issue for this podcast. I was really taken aback by the Federal environment that was early 2000s, about the state of the NHS. At that point, I was the policy adviser to the then chief executive of the NHS, Alan Langlands. I remember watching with him a very distressing BBC News in January, where the distressing case of Mavis Skeet was where this 74-year-old lady who had cancer, unfortunately, had her surgery cancelled by Leeds General Infirmary four times, and then told that the cancer was inoperable.

I was watching this with Alan, and we were just seared by this particular case, but it was one of many, wasn't it? I just wondered if I could ask you both where you were in 2000 and what you remember about that rather figural time?

Anita: I think one of the things that was interesting then was, up until the mid-1990s, people generally thought that the NHS, because he waited quite a long time for care, was a really efficient system. It provided a universal coverage; it was pretty good that we started to get data on outcomes. We started to get international comparative data on outcomes. It was pretty clear that the NHS wasn't really a crown jewel, it was more than tarnished. We were spending less than other countries. We might have been more efficient, because we didn't have high admin costs, but actually, we were getting worse outcomes.

In things like cancer, and all the big killers, heart disease, infant mortality as well. Things were pretty shocking when you compared this internationally. You couldn't argue that this was cheap, but that was because it was just more efficient. It was cheap, possibly efficient, but actually poor of quality all round. That, I think, was quite important in shifting a lot of medical debate and senior NHS leaders debate because it wasn't just individual stories. There was this clear data showing that we had a very, very significant problem.

Jennifer: I remember Robert Winston also, polling at that point about the care of his 87-year old mother funding in the elections was not as good as Poland, I think. I seem to remember him saying. Nick, Was this your recollection about that period?

Nick: Yes. The NHS have been a bane of political contention throughout the late '80s and most of the 1990s. The New Labour government was elected in 1997 with a mandate to improve public services as it happened, they inherited some pretty tough, public spending plans from Ken Clarke, which Ken never mean to implement himself, but Gordon Brown to show… to prove his credibility as a chancellor committed to those plans. Now, actually, the NHS did get more money in the late '90s, but it was becoming increasingly clear that it wasn't enough, and three years into that Labour government, I think Tony Blair, reflecting wider public opinion, took the views. He needed to make some bigger commitment.

Jennifer: You get the impression reading the headlines at the time. Not only did they have the winter flu crisis, but then they had this terrible story of Mavis Skeet. It was inevitable that something was going to happen, and then, to go on Breakfast with Frost and make a surprise announcement that even Tony Blair's advisor at the time, what the hell didn't know about this, it was quite interesting.

To inject at least 12 billion of extra money over the next six years, and to get the spending up to the European average by 2006, that's monumental. In a sense it was the pressure was building, wasn't it, politically and something needed to happen because the rack and the press was so huge, most papers weren't supporting the NHS at that point, it seems.

Nick: It didn't totally surprise me that Blair did make that commitment without telling anybody. Generally, when politicians want to make a radical change. The last people they would consult is the Treasury, who would always tell you about 17 reasons why this was really a very bad idea and you should continue as you are at the moment. It was a genuinely radical suggestion. My guess is that those of us in the Treasury, I can't quite remember my reaction to it, objected to it because it was basically an input target saying you've just got to spend a whole lot more, is only part of the solution, and if you're a Treasury official, you immediately start worrying about how you're going to pay for it.

I think that's really what then informed what happened next. Allegedly Gordon Brown got very angry, realised that this was the way the wind was blowing. Actually, the Treasury did need to react, but being Gordon Brown, he realised that the way to do this was to set up a review, which would be Treasury. I think it was against that background. I went along to see Anita who was minding her own business, working on welfare to work very effectively as I remember, to tell her, actually, her time had come and that it was time that she went and worked for Derek Wanless.

Jennifer: These are your thoughts, though it'd be quite interesting. There is the question if Blair had said, look, we're going to get up to the European average by 2006 you have to then say, well, why a Wanless. Nick's given some clues as to why what was your recollection?

Anita: There were two reasons why you then wanted to do this. One is that said this was an input target but actually, the politics of the day, I think, with New Labour was that Gordon Brown was a spender obviously, despite holding to cake pops because he's 97 but he had this very strong sense of doing some of these phrases prudence with a purpose, rights and responsibilities and that actually, there needed to be something for something and that people didn't like.

It was bad for Labour for there to be spending commitments that were very open ended, where it wasn't clear how they were going to be funded and it wasn't clear what you'd get for it. But a review by the Treasury is quite a bad way of doing that because the Treasury costs up the money and raises revenue but it then doesn't actually run the health service for the Department of Health and the NHS.

The big weakness of Wanless was that, although they were involved, it was very consultative process, it was never owned by them. Actually, once the money was forthcoming, the ambition and agenda that the Wanless review set out for the NHS was never really taken forward by anyone and that's the problem with independent reviews, their strength is that they can take a step back and look at things independently. The weaknesses, the people actually then have to do something with it don't feel any great attachment to anything other than the money.

Jennifer: Yes. We'll come back to that I think it's a very important point. Could you just for those who were less long in the tooth then we are, and we are charged the contours of the terms of reference, what did Wanless actually cover and what didn't it cover very importantly?

Anita: The original terms of reference, there are a couple of things, it was asked to look at the funding that was needed, recognising that in health care and it's like Lewis Carroll, it's the Red Queen, you have to run to stand still. Population grows, it ages, there's rising chronic disease, and most particularly medicine can do evermore. You have to try and work out, what does that… what does technological advance look like? What is the changing nature of our population? Like what does that mean, then for the funding that we'd need to deliver a comprehensive service?

That was its primary task, it wasn't actually tasked with looking at is a tax-funded NHS in itself a good idea initially. The other thing that wasn't in the terms of reference of wellness and what's his regret and we're definitely if you were doing this, again, is something you'd really pack with social care. It was very narrowly the NHS.

Jennifer: Yes, and Nick, Wanless came hard on the heels of the Sutherland review into social care and funding of Presumably, I think to remember that, that that was a very fraught report itself. Wasn't it? That was published in 1999.

Nick: It was and actually, even within the commission, there was the minority report and actually, the Sutherland commission is just one of many reviews of social care, the most recent one being the Dilnot one where it's always going to be the answer to life universe and everything, and then it arrives and then nothing happens. We won the state, make a recommendation that you really did need to look at social care, but this as Anita says, it didn't happen. I think we'd put the Sutherland commission to one side and from a narrow Treasury perspective, I think there was just a view.

Look, let's sort out the NHS first and then come back to social care. As we will, no doubt, come back to the problem by the down the line once the five years of money which Wanless effectively recommended, ran out, and indeed, he had proposed that there was a case of having another regular wellness type review. It happened to coincide with the worst banking crisis in the last a hundred years and suddenly the government had a huge shortage of money.

Jennifer: Just as you were becoming Permanent Secretary, I understand in 2007?

Nick: I became feminists actually 2005 so I'm one of the guilty men who failed to see the crisis coming and prepare for it. The one thing that you did achieve, which I think is the most important thing, is it actually helped build a consensus for more spending and also therefore enabled. I think the only discretionary tax increase I can remember in my working life, it allowed Gordon Brown to announce a 1% increase in national insurance by paid for by employers and employees.

We've brought in a serious amount of money, which did help what was a pretty extraordinary settlement of 7% real increase year by year by year, which at the start of the process, I thought we'll never get to spend that amount of money, but we did.

Jennifer: Then there was this national insurance hike, which I think you described, Nick, if I'm right, in Nick Timmins's reports as soft type of occasion, was it you, or was it Nick Timmins who described it as that?

Nick: I think I may have described it as that. He was basically lynching the increase in national insurance to the increase in spending. The reality is the money flows into Treasury. It's in some huge slush funds. Linking taxes to particular lines of spending isn't really a credible strategy for the long-term, but politics is all about selling an idea to sceptical electrodes, but the reaction was positive. Yes, people had to pay more tax, but they knew the NHS was getting more money and the cumulative effect of that spending, waiting time did come down. There was definite progress.

You can argue, come back to this point earlier that the Treasury didn't quite get all, its conditions for the extra funding fulfilled because Alan Milburn, I think at the time, wasn't particularly inclined to listen to what Gordon Brown had to say to him and as a result, and sadly in my view, a lot of the money just went on across the board pay rises when we were looking for serious step up in volumes of operations and so on, but it did make a difference. The NHS, I think by the end of that decade, was in a much more secure stage than it had been 10 years earlier.

Jennifer: Just while you're there, Nick, can you just remind us what the economy was doing at that point, because clearly, we're not necessarily in the same position now if we were to consider another Wanless. At the end of the 1990s, early 2000, were we awash with…

Nick: The important thing was in the late 90s, one of the, it is strange, but generally, getting revenue in is really difficult, but for various reasons, which I won't trouble you with, in the late 90s, suddenly, the government was awash with revenue. Revenues were coming in faster than expected. I can tell you that since that period, that simply hasn't been the case. The economy was growing, at that time, wages of people in work were rising quite rapidly compared to inflation and the Treasury was benefiting from that.

That began to change through the early part of the next decade. The economy was still growing, but wages weren't rising so rapidly, and revenues were tending to disappoint. Brian was running a budget surplus, which only happened twice in my lifetime, in roundabout at the turn of the century, but quite rapidly, this disappeared. People now look back on New Labour and think that actually they didn't spend very much on social programs. The reality is they did, they were intervening a lot in the labour market with transfer payments to the tax credits and the increase in spending on the NHS was unprecedented.

The problem from about 2003 onwards was the revenues weren't really coming in so quickly as to pay for all of these things. I don't subscribe to the view that we ended up with a big deficit because of spending. Actually, we end up with a big deficit because of a banking crisis. The banking crisis fundamentally changed the relationship between the basic economic relationships in the economy, in particular, that the economy stopped growing so quickly. Up until 2008 in a normal year, the economy grew by something like 2.5%, and there would be extra revenue to spend on priorities. After 2008, the economy simply didn't grow, productivity didn't grow, and wages didn't grow after taking into account inflation, and this made funding services far more challenging.

Jennifer: Thank you for that. Let's go back Anita. We'll talk in a minute about what the Department of Health ended with sudden largesse. In terms of the Wanless review itself, apart from the extra money and the tax hike justifying that, what did it specifically say about what needed to be done with the extra money? How far did it go?

Anita: Well, Wanless did, because it was part of the agreement with DH that it wouldn't look at the management of the NHS. We did not look at the management at the NHS, it didn't look at the organisation. What it did was develop and set out three scenarios, which were for different futures that health care could take. One, it recommended was this idea of a fully engaged scenario, which is a world in which you had a, what we would now call integrated care, a real focus on earlier diagnosis out of hospital treatment, prevention, and a big emphasis on public health.

It was called engaged as well because Derek Wanless is a banker so he came from a view that actually, they've been in the middle of actually a technology revolution in services, which meant that individuals were doing lots of things with the previously services did. Now, we all take online and mobile banking and all of those things for granted, and the NHS hadn't really embraced that, and it wasn't set up to, if you like, help people to help themselves. That's quite interesting now if you think.

We're 20 years old from that, but COVID, in essence, has supercharged some, in fact, with the use of digital services, but it's 2021 and we're still, on the back of a pandemic, still struggling with quite what the operating model is for a health care service. He was envisaging all of that unlocking, a lot of real productivity improvement with a lot of investment in capital.

His view was that you needed this period of very high increase in funding to put in place all the enablers. He'd argued for a lot of money into IT. A lot of the focus public health. Once you go through all of those foundations, you would still need to grow funding and grow funding at a higher rate probably than inflation and GDP but not in an unsustainable rate, because you'd have a different model of health care, which was funding mentally more efficient.

The result then was that, actually perversely, I think, if you like an acute hospital model, if you like old fashioned view of health care, probably the last 10 years aside from finally get to grips and had to get those productivity more so being, trying to work out how to make a reality of integrated care model, which it turns out is really quite hard, even if you've got a lot cash.

Jennifer: In fact, Wanless gave some controls about how he thought the money could be spent in broad terms as you described, but as Steven Nicholson, who was interviewed by Nick Timmins said, but the time you put it quite fruity, he said, the Department of Health was ‘a wholly-owned subsidiary of Number 10 at the time and one belong to the Treasury. The Department of Health simply said, thank you for the money and goodbye, and got on with its own plan,’ which is as you describe Anita actually took the form of the NHS plan, doesn't it? With more staff and pay and the things that you mentioned but with some good things.

From memory, if you think about the national service frameworks, you mentioned the other quality measures. As Nick said, the median waits went down dramatically. Who would have thought that was possible, but ‘never never lists’ could go down in that way – ‘never never lists’ being those people who were just permanently waiting as it seemed. Nick described hip weights going down from seven months to 78 days.

I'd also public opinion and satisfaction improved. It neutralized the politics for a bit because if you remember the 2005 election, the Conservatives went very quiet on funding at that point, having really been in full throttle in previous elections about the NHS as failures. That was a result, wasn't it? Going back to something that Nick said earlier, you said that Wanless recommended to repeat this modelling every five years, which would make sense to update it, but also because data improves. Why do you think clearly there wasn't one because of the financial crash? Why do you think we've not really? Why was this such a one-off?

Nick: I think because, governments have been very resource-constrained and the risk of initiating a review light versus it could come up with a recommendation rather similar to the last one. Certainly, governments since 2010, have been right of centre governments committed generally to reducing the size of the state until Mr. Johnson became prime minister. This was a question I didn't really want answered. I mean, from time to time, the independent office for budgetary responsibility does long-term projections and they've done some very good work actually on the pressures on health and social care and growing in demography and so on.

Governments have preferred a rather more drip-feed approach where you try and hold the line on a NHS spending for as long as you can and then inevitably you get small dams, which burst and whether it's Theresa May or David Cameron, someone announces more money. What you haven't had is a focus on the next five years, the OBR tend to look 20, 30 years out.

Well, most of public spending is really quite dull and actually relatively unimportant because compound growth has just meant that health is a very large chunk of it. I do think it would be good to have reviews, which set out the baseline pressures on the NHS and then in an ideal world, the political parties that general election time would set aside what their plans are and what that means for taxation. Maybe I'm being too optimistic about having a high-quality debate.

Jennifer: I suppose, as well there's one argument, which is having a published report where everyone kicked the tires on a model of supply and demand and looks 20 years out and you can then debate and I can see how that could be difficult politically. Generally, how does things work and forgive my ignorance here, these models occurring, but they're just not published in the Treasury or the Department of Health, or is the decision-making on the budget for the NHS, a more of an art with some arm wrestling involved?

Nick: Primarily the latter. I wish the Treasury had maintained the oneness model. I'm quite certain that I need to hand it is over, ready for us to use it well into the future. It's in the nature of these things that officials and politicians have short memories. My sense of NHS funding in recent years it's generally been fairly short focused on dealing with immediate crises. Now obviously, we have a crises which makes all previous crises look like the proverbial vicarage tea party.

If ever there was a time when we should have a debate as part of the reconstruction following COVID, I believe it is now. Because one thing we know we're all going to agree fully in this crisis is that all social care home sector is really very underfunded.

Jennifer: Yes and elsewhere in the forest for the integrated defence review, for the infrastructure, the plan for growth has 600 billion over six years, someone somewhere is doing these kinds of calculations, even if they are mainly for capital. Anita, what hope is there for firstly, more quantitative basis and objective basis to the modelling and secondly, more transparency to enable more people to kick the tires.

Anita: I think the OBR is an important development in that… a number of governments now I think over the last 15 years have realised that governments, especially when they leave a big, long-term decision to the political process alone, we often end up making sub-optimal decisions that it is in no one's interest, but it's a bit of a dilemma. Most politicians want to break out of that, but they can't see how to and the temptation of a bit of crude electioneering at the others expensive that moment is too great.

They have progressively tried to take some of these decisions, the independence of the Bank of England, the OBR recognising that trusting normal forecast is really important on climate change. We're doing that on infrastructure. We're trying to do that as well. What we saw with COVID is that it was over a 10-year period, we tried to, to borrow your phrase, run our system incredibly hot, at the edge, if not slightly beyond. We got away with that for a few years, but we had no buffer and no resilience in the system.

Then COVID hit and we built the Nightingales and discovered that it is possible, and if you prepare to pay, you can get oxygen and you can get PPE, difficult but you can. But what you can't do is magic up an anaesthetist or a theatre nurse for these people, actually prove to be a real problem and it was a problem for our health, but also actually it meant it was a problem economically because it meant then that our buffer for any COVID, if we're going to protect the NHS, we have to do more extreme measures, harsher lockdowns with the economic consequences.

I think the thing that hopefully this has taught us is that health care is part of a critical national infrastructure. Obviously, it's very unlikely that we get COVID again and one of the things we've discovered with our planning is we were perfectly prepared for flu and you don't want to be perfectly prepared for the previous crisis, but nevertheless, as I understand it but the science is saying that we are likely to get more incidents of extreme infectious disease. We need a system that's more resilient to that. You just don't create resilience overnight.

Jennifer: Oh, yes, because I guess if you don't have the money, you don't have a long-term settlement. You can't make some bold changes of the type that might be productivity-enhancing, for example, technologies. Not only do you not mitigate downside risk, but you don't take the opportunities for upside risk either. Nick, Anita just gave a very good case why you might want to invest in more resilient health service and health care infrastructure.

Of course, the other thing we saw in the pandemic was that the health fabric of the nation over the last 10 years had frayed as well for some of the reasons I think you outlined earlier, poverty and the fact that health was a grief and the life expectancy was stalling more in Britain than any other European nation. I think we were only supposed by the US.

You then think about investments in the wider determinants of health, like housing, education, early years support. Not because it's the right thing, but if only because it might be linked to economic prosperity in future. Do you think that argument is people are warmer to that argument because of the pandemic, or do you think that's just virtuous thinking, which is fiction?

Nick: Here's definitely a cycle in these things, just as public opinion was up for spending more on the health service back in 2001, 2002, I think it will be up for it now. A strategic politician in charge of the government would actually see this as an opportunity, the better to invest in the future. I'm not saying you can't borrow to fund these things, but there are limits to how much you can borrow. One of the problems, I think it's true in all democracies quite frankly, it's always tempting to think it's a particularly British problem, is the politicians do like to promise the earth whilst at the same time, claiming that they didn't have to raise taxes to pay for all of these things.

You can pay for it out of efficiency, you can pay for it out of all these bureaucrats so you can get rid of those usual and free up the front line while you’re at it. I think there will be opportunities. It's always easy to be dismissive about governments. Actually, sometimes governments can do really good things and can, to Anita's point, plan for the future.

It's little known fact that in the 1950s the government bought huge amounts of spare capacity in fire engines, Green Goddesses, they were called because of the threat of a nuclear war. As it happened, there wasn't a nuclear war and there's green goddesses. They knew became useful when the firefighters went on strike, but it was an example of the government actually doing sensible forward planning. Like Anita, I think in the future, the NHS will have to have more spare capacity. It's it is striking.

If you look at health care systems, say in Germany or Austria, how much capacity there is. Now that comes at a price. Austria spends probably 10% more of its national income on taxation and there is a consensus for doing that. Britain's always had this slight problem that we want to have a European welfare state paid for it, but with American type taxes, you cannot.

Jennifer: I guess, if we all agree that modelling can be useful and perhaps this now is the time there is a moment now, do you think the volume it would be to try to persuade the Treasury and possibly a central government to invest in that thing, or do you think it's more of an independent bodies role to do this? You advise the Lord's condition, didn't you on securing the future long-term funding of the NHS and care system.

Anita: I am a firm of some independence. I think the experience of bodies, like the Office of Budget Responsibility and the Bank of England and actually, the ONS has been made independent as well. I think all of that is very important, especially in an era where trust in politicians is pretty low. People want to know that analysis is robust, but you can't decide governments and funding on the NHS by an independent body. We are a democracy; it is ultimately for any government in a democracy to determine how much you spend and how it's paid for.

What an independent body would do is its two things. One, I think it would make it much harder to engage in Alice in Wonderland funding settlements that say here's a very modest rate of growth, but with that latest growth, we are going to do the following amazing things that are absolutely world-class and every government I can remember pretty much has fallen into that trap. I think a bit of transparency, accountability about just what's involved is quite important.

The other thing I think, which is quite important is the NHS faces a lot of, below the radar of these big political choices, quite important service planning decisions day in, day out, which have long-term consequences. The decisions about this home, just for, in the big set pieces that we're spending with you, we need to decide how much to put in primary care, which versus in hospital services, which parts of the country, all those sorts of things.

Actually, it's easy to miss that there are these underlying trends that accumulate that actually can have quite a big impact on what the right mix is, and at the moment that's done with no transparency of a lot of decisions that are take him by different bodies within the NHS family. Just being able to say to people then, ‘Well, actually, this is their decision, that's your decision. They don't obviously add up. Do we mean that? Are we sure about that?’ That's the value, I think, of this sort of body.

Jennifer: An ultimate question to Nick is, if there was such a Wanless or OBR type, better modelling, would that automatically, do you think leads to government wanting to have more control over the NHS than if it were just hand to mouth usual combat?

Nick: Very hard to tell. Sensible governments know what to delegate and what not. I'm not sure running the NHS sites of Whiteville is the answer to any problem. In fact, I would strongly advocate greater devolution and decentralisation, in particular, to enable budgets to be shared between social care and the NHS and the type of integrated approaches.

I travel hopefully, but I don't expect any great change in the coming period, perhaps I'm being a bit pessimistic though.

Jennifer: Well, let's see whether we have a new secretary of state to contend with. Maybe I can just ask you one very last question, which is a very simple one which is, is it now time for another Wanless? What would be your response?

Anita: I think it is to kick off a process and I think it is because, actually, COVID does raise really very fundamental questions about the sort of capacity and infrastructure that we need. How you manage that to be more resilient, I think that is a very specific question, but I hope coming out of that. Whereas Derek Wanless recommended that his review began a new way of thinking about this and that didn't happen that this time, the next review does begin a new way of thinking about this and seeding the architecture to do that.

Jennifer: We must leave it there. I'd like to thank our two guests, Anita Charlesworth and Nick MacPherson, for a really rich discussion of these issues and a possible way forward as we face recovery from the pandemic – and indeed, as we face the spending review in the Autumn.

For links to key reading on this subject, there is a rollicking good read of the Wanless Review, how it came about politics, and what were the impacts by Nick Timmins. The report is called The most expensive breakfast in history and can be found on our website and in our show notes, wherever you find this podcast. We'll be turning back to health and exploring the place in the UK where life expectancy is lowest and where one in four men will die before their 65th birthday. Glasgow. What is fraying health to this degree? Until then, that's all, folks. See you next time.

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The Q community

Q is an initiative connecting people with improvement expertise across the UK.

Find out more