The NHS is experiencing an unusual set of pressures at the moment, with waiting lists of 6.5 million, staff shortages, ambulance delays, long waits and much more. 

Meanwhile, public satisfaction with the NHS has nosedived, according to the recent British Social Attitudes survey. While politicians acknowledge the challenges and repeat their support for the NHS, outriders on the political right are flexing muscles and calling for more fundamental reform – despite the ink only just drying on the last set of NHS reforms with the Health and Care Bill receiving royal assent.  

Lord Norman Warner has been top civil servant, health minister from 2003 to 2007 and in the House of Lords for over 20 years, and has written about it all in his new book In Pursuit of Competence. He joins our Chief Executive Dr Jennifer Dixon to share his insights and reflect on what might be ahead. 

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Jennifer Dixon: Well it's clear the NHS is experiencing an unusual set of pressures at the moment. Waiting lists of 6.5 million and rising, staff shortages not least of GPs, ambulance delays, long waits in A&E and much more. Press and the public unsurprisingly have noticed. Shrill headlines like 'Our NHS is failing us all' and 'Feckless NHS is squandering Rishi's tax raid', are common in the comment pages of The Times, Telegraph and Spectator. Meantime, public satisfaction with the NHS has nosedived according to the recent British Social Attitude survey. Politicians of course acknowledge the challenges and repeat their support for the NHS. But as night follows day, outride is on the political right of flexing muscles and calling for more fundamental reform. This is despite the fact that the ink is only just drying on the last set of NHS reforms with the recent Health and Care Bill having only just received royal assent.

Norman Warner has been around this scene for some decades, and I'm delighted to say he's with us today to give us some insights to help us on what might be ahead. Norman has been top civil servant, local authority chief, health minister and in the Lords for 20 years. He's had a ringside seat on reform and seen it all. And he's written a new book on it called ‘In Pursuit of Competence’. I thought we'd start with a really general question. There's massive challenges around at the moment. It's an unusual amount of pressure in the NHS and other public services. There's also a sense of political drift, what's the agenda here? We know there's populism, the government seems in election mode. Given your history, has there ever been a time like this that you can remember?

Norman Warner: I don't remember a time like this in terms of what the situation is for both the health and care sectors. I think they're in a very bad place with some very serious risks. And the reason why I think they've got into this state is what has happened over the last 10 years is had a devastating effect, not just on the NHS, but public services more generally. And what you've seen over the last 10, 12 years is the impact of funding austerity, and in our case, health and care, serious neglect of the social care area. But people don't talk very much about it.

There's also been Brexit and the pandemic, and they've had a massive impact on the size and resilience of the workforce. And it's the workforce issues which bother me and are unusual as much as any funding issue. There is a naive political belief that if you just shove money at these highly labour intensive industries, you will solve the problem. Whereas what has happened is we haven't solved the problem because we haven't paid enough attention to the issues around the workforce, not just in health and care, but in the public services more generally.

Jennifer Dixon: So you were part of the Lords Commission, weren't you, in 2017 which looked at the long-term sustainability of health and social care? And one of the big features of that was a plea for longer term planning, both for investment and also the workforce. I mean do you see any signs that those messages, those basic messages were heeded as we came out of a period of austerity.

Norman Warner: Well I think there's no evidence that short-termism has been abandoned by the department of health and social care and the ministers in it. There's a hand to mouth existence and that's been fairly typical over the funding issue with the NHS over many years. There's been a feast and famine approach. You go for 5, 10 years where very little money is put in, certainly not keeping up with inflation. And then you have suddenly, as in the Blair years, a deluge of money being put in for 3 or 4 years. So it's very difficult to plan long-term if you don't have some degree of certainty and reliability about your funding situation.

Jennifer Dixon: And of course, all eyes then turn to the treasury. It's clear in your book that over all that time that you've been working around government that the message has still been the same, that short-termism, particularly in funding, rules. And yet, as we know, the NHS is Britain and indeed Western Europe's largest industry. Can you, to mix metaphors, run a railroad with such short-termism when it is not only the biggest industry in the country and the most complex, but also the one that's top of the pops with the public?

Norman Warner: Well the turnover of ministers, not just in the Department of Health, but the turnover of ministers with the exception of Jeremy Hunt is pretty considerable. And I think there's a cultural problem with the civil service. They see themselves as serving the ministers of the day. They don't see themselves as kind of responsible for the long-term safety and functioning of the services which come out of that government department. And it isn't just the Department of Health and Social Care, you see some of this in some of the other departments. Just go to the Ministry of Justice. I mean if you want to see another department in real trouble, it isn't just health and care that is being neglected over a long period of time.

Jennifer Dixon: Even if you got the funding right and consistent and predictable, and you got the staffing planning with a long-term view, there's still the kind of overarching guiding star for reform. It's hard to see what that is at the moment. What is the project? What is the agenda? It's interesting that obviously from when I started in this health policy world, 1990, we were just at the beginning of this big Thatcherite wave, weren't we, in working for patients which introduced market forces. That wave has gone. It seems to have crashed and gone out again, let's put it that way. And it's not really replaced by anything as strong other than I suppose collaboration and integrated care which the NHS long-term plan focuses on. Do you think that part of the issue is that there isn't a guiding consensus as to the shape of the system, even if you could get the basics like funding and staffing right?

Norman Warner: If you look through the history of the NHS, it's had a pretty good go at trying to make reorganisations improve its performance. It's had a pretty good go at saying, 'Well we need better management'. It's had a pretty good go at commissioning, which has never really worked very effectively. So if you look back all the things that have been tried, it's quite difficult to pick on some which could be said to have improved matters. There's a fundamental problem with simply accepting a public monopoly in all aspects of its activities. If you want to change something, you've got to find something which changes the way services are actually delivered to patients, not just changing the organisation or the managers. And certainly not the idea that somehow if you can put a bit of insulation between the managers and the politicians, everything will work because the ministers have powers of direction. They just can interfere. And that I think has been a problem.

Jennifer Dixon: Yeah. But it has produced the NHS's own long term plan, which is the first time in my memory that the NHS itself has got a long term plan together since. Well for 30 years. And now, that could be the fact that the NHS England existed as its own entity, or it could be that it had Simon Stevens as its chief to be able to do that. I don't know whether you have a particular view, whether it's the structural change or whether it's the characters involved that matter more.

Norman Warner: Well I think the characters of the individuals who are important. I mean Simon finally got across into the skulls of politicians you had to have some long-term picture of where you were trying to get to and how you were going to use the money that was being given to you. He also got, before COVID came along, a promise and practice of a substantial investment in the NHS. But I think the problem with the long-term plan is who is going to be the policemen overseeing the long-term plan? Secretaries of State come and go. They all have different views. And that is why in the Health and Care Bill I and a few other stewards tried to set up an office for health and care sustainability modelled on the Office of Budget Responsibility so that there was some entity independent of government that was sitting there trying to plan the funding and workforce issues on a sensible basis. It is that lack of seriously independent monitoring for the longer term that I think has bedevilled the NHS.

Jennifer Dixon: Yes, indeed. And actually for that reason, we at the foundation set up a small unit called REAL Centre, which Anita Charlesworth heads, to do long-term projections of the type you mentioned on workforce and funding. So monitoring, as you say, the progress of a long-term plan independently. And Norman, just going back to your time. So you were in the Lords, weren't you, and you became health minister under Tony Blair in 2003 to 2006, first under John Reid, a secretary of state, and then with Patricia Hewitt in the latter part of that time. And in a sense, that could be seen as the golden years because there was an enormous, what was it, 'Riches beyond anyone's belief,' I think you said in your book. You said you had double digit real terms growth at that time in the NHS. You also had a government with a healthy majority. And you also had a guiding star, which was still the use of market style incentives, not in red and tooth and claw, but definitely those that were nudging the NHS. And standing back from all of that, I wonder if you could just pull out some of your insights as to all the levers in your armoury at that point, but given the blend of things like performance management, choice, regulation, financial incentives, or old-fashioned targets, what do you think worked in the areas that you were working on?

Norman Warner: Well three things worked tolerably well. I think patient choice did drive some worthwhile change and it certainly made patients feel better about their NHS experiences. So patient choice, I think a tick, but it's not going to solve all the problems. Targets, certainly on access targets, they were a success. And at that time, they did push up public satisfaction with the NHS. And we did drive down health care acquired infection targets.

Jennifer Dixon: I remember.

Norman Warner: So there are some successes for targets. I think competition was always going to have a limited effect in something like the NHS. But we never really persisted with what the economists call segmented competition. That's the bits which competition can work in, elective surgery, diagnostics, pathology, these were the big three where you could make competition work. But you're never going to make competition work and you shouldn't even try with highly specialised services and indeed trauma and things like that. So competition is always going to be limited in what it can do. When we got to after the 2005 election, there was an interesting discussion we had which did lead to something which is in my view the really unexplored guiding star for reform. And that was when we produced after a massive public consultation the 2006 White Paper, ‘Your Health, Your Care, Your Say’.

Jennifer Dixon: Oh, yeah.

Norman Warner: Basically what frightened the life out of the top management of the Department of Health, that white paper suggested that we take many more services out of hospitals and deliver them in the community outside a conventional acute hospital. And the thing that I was trying to push for, which in the end never happened, was to control the amount of money going to acute hospitals so we could build up the services outside hospital. And I think the big issue now for the NHS is if you're going to put more money in, do you want to keep shovelling into acute hospitals? Or do you want to change the way we deliver services? And I don't just mean integration, I mean the places where people actually get their NHS services from. And that has never been tried on any scale.

Ara Darzi tried to run with that particular ball when he became a health minister. He was seen off by Gordon Brown with the 2010 election approaching and no one wanting to say, ‘We're not going to go on flooding money into our local hospitals.’ And the interesting thing for me was when we did this massive consultation with the public, their second to top by a long way priority was mental health, which in those days was simply not on the agenda of most health ministers.

Jennifer Dixon: Very interesting. We have been talking about shifting care for so long and well before 2006. In the REAL Centre, we analysed NHS spending by clump of service over the last I think it was 25 years and indeed found exactly what you said that the real increases are almost all gone to the hospitals, practically nothing going to primary care and community care. And Griffiths mentioned this, didn't he, way back in the eighties. So tell us about these forces that we'll have to overcome. It can't just be GB and in the election, there must be something more than that.

Norman Warner: I think it's endemic in the system. I mean the British population are in love with the idea of the local hospital. And it's a 1960s model of the local district general hospital being able to deal with virtually everything. You can have a bit of neurosurgery around the street corner, and it can't work. And we haven't got the resources in public expenditure terms to go on shovelling money into these bodies. There's a wonderful report on the work of the audit commission several decades ago, it was called ‘Follow the Money’. And ‘Follow the Money’, if you can't see the money going on what you want to be the delivery mechanism, you're not going to make that delivery mechanism work. And the forces of resistance are basically the barons in the big acute hospitals. They turned up to the select committee in the laws that you mentioned, and their starting point was, ‘We must have 4% real terms increase year on year.’ And we asked them, ‘Do you mean in perpetuity,’ to which they said, ‘Yes.’ Now, we have never had 4% growth economically in the UK in perpetuity and never will. So the idea that you could go on keeping these acute hospitals in the style to which they become accustomed was absolute financial nonsense.

 And I think until we have this out, and there's an absence of courage in the elected political class to do this, and I'm not making a party political point, I think it's across the spectrum, elected politicians are very nervous to say, ‘We're going to control the amount of money that goes into acute hospitals and we're going to put more money because we think that's the best way to deliver services in the 21st century into community-based services, where the overheads are lower and you get a bigger bang for your buck.’

Jennifer Dixon: Going back to what we said earlier about a guiding star and there doesn't seem to be one, well actually probably the obvious one which is writ all over the long-term plan is of course the shift into primary care, or the shift into community just as we're both describing in keeping people well. The question I guess is how to turbo charge this and also to make sure the narrative isn't just, ‘You have to stop funding high end, exciting new technology and hospital and treatments in order to fund needy basics in primary community and social care.’ There's a question there about where's the frontier of innovation that could really add spice to this move and help it? So you were minister of – you had R&D in your brief, didn't you? So you would've seen huge gravitational pull of science research towards stuff going on in hospitals, which will then excite clinicians to work in them and want to do more, etc. How could you swerve this hose pipe of cash into R&D into exciting things in the community, something that would really shift the dial here?

Norman Warner: We know what to do. We know quite a lot of what to do. And after the 2006 White Paper, there were a whole raft of clinicians supported pilot schemes on showing how services traditionally delivered in hospital could be delivered in the community. And if you actually look at what's happened to primary care, we got a massive shortfall of primary care. And I think I've missed a trick by going on calling it primary care. It understates what we want to do. We want it to be effective care for a whole class of conditions. And we have got to build better facilities to deliver that in. And here we are, we've got a government which is actually going to pile more money into expanding hospitals. My own view is that you need something radical. We don't need to keep contemplating new research, we need to actually take some action which puts the money into the development of community-based services. And if I was still a minister, I would actually be putting a proposition to the treasury which would say that we need to use capital money and treat the workforce issues in health and care as an infrastructure project. In which actually for 10 years, we're going to invest in developing that workforce and the buildings and equipment that those people will work with. Anything short of a 10 year transition program for community services I think is just doomed to failure. Somebody has to grasp that nettle, some elected politicians of the calibre that we used to have needs to be able to say to the public, ‘This is the better way to be delivering services with the challenges we've got in obesity, mental health and aging population and so forth.’ It needs to be explained to the public.

Jennifer Dixon: If you work in hospital, even with integrated care – right – it's still a fairly hermetically sealed environment. If you work in the community, it is separate from hospital. But I noticed you would've seen this policy exchange kite-flying document recently, which suggested that hospitals should be fused with primary care and that's the way to energise primary care. It's the way of skilling them up, it's the way of addressing the shortages and the haemorrhage of GPs out of primary care and the fact that no one wants to be a partner anymore, or fewer people, let's put it that way. Do you think there's something in that?

Norman Warner: Well we did think there was something in it when we were doing Foundation Trust. When we set up Foundation Trust 20 years ago nearly, we actually allowed them to generate a surplus. And we'd said that because of the system that we had for running Foundation Trust, there was a community basis in that management of those trusts. And they could actually use their surpluses to develop community-based services. Now, the trouble was the Foundation Trust were not allowed to keep their surpluses and redeploy them in the local community. Leaving aside the concern that you expressed about whether they would just control the flow of people into their hospitals, their surpluses were confiscated effectively during the periods of austerity. So the whole model of the Foundation Trust was destroyed. Now, if you want to go down that path of fusing, I don't object in principle myself to that. But you have got to leave bodies like Foundation Trust out of the hands of politicians. You've got to allow them to generate the surpluses and actually take more patients from failing services to develop services outside the hospital. We have never dealt in the NHS with clinical failure and service failure properly. No other business would go on pumping money into services that have historically failed in a hospital over a decade, not just a few years.

Jennifer Dixon: I must ask you here about regulation because obviously, it has been a feature of the last 15 years in particular. And I have to confess, I'm probably Miss quango here because I've been on the boards. I was the Audit Commission's longest serving audit commissioner, Audit Commission disbanded by Eric Pickles of course. Then I was on the Healthcare Commission, disbanded in 2009. Then I was on the board of the CQC, and I noticed now that Jacob Rees-Mogg is carrying out a review of ALBs with a view to culling the quangos. On the one hand, you have said in one of your Lords speeches that culling quangos is an act of, ‘Casual vandalism,’ is how you put it. But on the other hand, your book is very strong about culling the quangos because they take on a life of their own and start eating up cash and having mission creep. So can you just put me out of my misery having been on the receiving end of some of this stuff, firstly, what you think about the effectiveness of the regulations when it comes to failure, particularly CQC, I guess, and healthcare commission? And then secondly, what should our approach be to quango given the fact as soon as they're set up, give them five years, then they're cold again?

Norman Warner: Well I think there's two issues. The first is not that quangos are necessarily bad, but by George you do have to watch them, because they have built in growth and they are very good at actually selling their products for more money. So they do need culling from time to time and they tend to grow. But I think if you want some more decisions taken independent of political control, and party political control at that, you have got to have some arms' length bodies who are doing the job professionally on a year in year out basis. So you can be forgiven for being a quango-crat, Jen. I think the trouble is what job are you giving them to do?

Jennifer Dixon: Well yes. And actually, just to fight back for a second if I mind, being on the board of the CQC of the Healthcare Commission, what was common was that ministers would constantly want these regulators to do more, but not give them any more money. So the push was often from the political class, if I might say, to do a lot more, rather than the other way round, might I say. But your experience is clearly different.

Norman Warner: Well I think I inherited a set of quangos at a time when the government was trying to cut civil service and public sector staff. And every so often, governments do, do that and they do that with good reason. I mean they've been doing it since Harold Wilson started it. Even labour governments do actually cut public sector staff. So there is an issue about how you keep the lid on for growth of some of these bodies. Now, I wouldn't claim we did a very good job by quango culling in some respects, and the regulation was the bit where we made the greatest pig's ear of the changes, not just me, but my predecessors. But we did end up in a good place with the Care Quality Commission in my view.

Jennifer Dixon: Yes.

Norman Warner: Which was an integrated regulator. The problem is what do you do with the CQC's reports where they will show often year in, year out a particular set of hospitals, not only performing bad clinically, totally incapable of controlling their expenditure. The CQC has done a great public service in that it has actually demonstrated that being able to manage your money is a good indicator of whether you've actually got decent clinical services as well.

Jennifer Dixon: Yes. Yes, indeed.

Norman Warner: The problem has been I think largely political. Are you going to go on saying that failing institutions should go on having money invested in them in hope that they get better? Now, I would say there's a problem for the public services. There's a limited amount of management talent and you've got to make that management talent go round well. Now what that means is there's just going to be not enough good quality clinical and other managers to run too many institutions. And you see it in large parts of the public sector. You see it in schools, you see it in prisons, you see it in the police force.

So how do you grapple with that problem? Or how I would grapple with it, and I think how Ara Darzi wanted to grapple with it, was that you concentrate more of these highly specialized and expensive services on fewer hospital sites. And that's what he was proposing to do in London. And he did it and London did it with stroke services. So we've never really consistently tried to respond to failure in our hospitals by simply withdrawing services from one unit and making somebody else responsible for managing.

Jennifer Dixon: Okay, there's a lot to be said about that. So probably I think the question to ask last is a question about the future. So there's obviously a lot of gloom at the moment. Are you hopeful that the NHS is sustainable in future? There is a question mark in your book about this. And also, I guess if I can sneak in an addendum there, there's loose talk at the moment, as Simon Jenkins just recently this week said, a call for a commission, a royal commission or big review as the Merrison in the seventies and then the John Moore review in the eighties. Do you have any faith in that? So where is the hope, I guess, and is the commission any intelligent response or not?

Norman Warner: I don't think an establishment led royal commission is going to deliver the bacon. What could actually deliver the bacon is, and this does require some cross party political activity, if you set up a more expert commission with a clear brief about how you wanted the future to lookAnd got them to wrestle with the technical problems of getting from A to B, that is likely to be a more worthwhile exercise. So if you say, ‘I want to get more services out of hospital and I am prepared to curb the expenditure on the acute hospital sector which may also need reform,’ if you give that brief to a mix of outsiders and experts in the health and care sector, then you might start to get somewhere. If you don't do that, I think we're on a path of gradual decline. The NHS is not going to collapse overnight, but we're already seeing in social care providers handing back contracts to local authorities. We're seeing that sector wanting to walk away in many parts of the country from publicly funded social care. If that happens, the NHS will be in an even greater pickle than it's in now. And I cannot at the moment see that we've got the mechanisms to stop a process of decline and huge variations geographically in the services that are provided. Just look at dentistry, physiotherapy, maternity services, elective surgery...

Jennifer Dixon: Mental health.

Norman Warner: Mental health. I mean you name it. We can actually show now there are huge geographical variations in the quality and volume of some of those services.

Jennifer Dixon: Thank you. And perhaps I should end with the quote that you make at the end of your book, which is the quote by Lampedusa from his 1957 classic, The Leopard, where you said, 'If we want things to stay as they are, things will have to change.’ So I think that's a really great place to end, as well as Simon's quote on the dust jacket which says that he thought this was a brilliant, clear-sided explanation with, ‘Closely argued provocation.’ So I highly recommend everyone to read Norman's book. For those of you interested, listeners that is, we will put some references in the show notes, including of course reference to Norman's latest book. And given the challenges ahead, rest assured we will of course return to the subject of NHS and indeed social care reform in the year ahead. So next month, we'll be returning to health and looking at the question about why most of us think that we control our health far, far more than government or business does. And until then, I hope you enjoyed this one and stay well and bye for now.

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