Isabel Hardman: The NHS is being failed by not reforming social care

Matthew Taylor

Hello and welcome to Health on the Line. The cost-of-living crisis and the economic impact of the government's recent mini budget continue to make headlines with conversations at the moment about the impact on benefits. For so many people, these discussions have huge practical implications, not just for their financial situation, but for their very health and wellbeing, including their mental health.

It's an issue that a lot of the leaders I speak to talk to me about - the impact of cost of living on their populations and of course, on their staff. This week, the Confed has been marking World Mental Health Day and I'm going to be discussing mental health with the guest of this latest episode of Health on the Line, journalist and author Isabel Hardman.

It's good to be hearing that the government's planning to invest in mental health support to help get more people to find, to stay in work or to return to work. Having a job can be very important for people's mental health. But I also know, because I've done a lot of work on work and good work, that employment can also be a source of stress and worry for people.

So, alongside the government using money to help people stay in work or get work, it's also important that employers across the country do everything they can to support the wellbeing of their staff. So, we hope that all across the country, people are reflecting on the meaning of World Mental Health Day.

In terms of the wider context on mental health, it's important to say that there are well over a million people on waiting lists for specialist mental health care and that these services are struggling with huge staffing vacancies of their own. Linked to the debate around the government's economic strategy is the suggestion that further savings might have to be found from public service budgets, including health. But that just isn't realistic.

We have a waiting list topping 7 million, huge problems with the flow into and out of hospitals, and 132,000 vacancies. It's also short sighted as research the Confed is about to publish shows that when health and care services are overstretched, it has an impact not just on patients and staff, but the wider economy. For example, it's one of the biggest factors leading to people of working age not being in work.

Conversely, as the research we're publishing will show, investing in health and care has a significant economic multiplier effect. On another topic, in the past few days, we've also fed our members views directly to senior decision makers who've been working on a refresh of the NHS Long Term Plan. That original plan was popular and impactful. It looks now as though the refresh has been put on hold perhaps for the long term, but we talk to a lot of members as the work on that refresh was taking place, roundtables and interviews.

So, we still thought it was important to say what we felt needed to be included in that plan. We've published all this on the website, but two or three key points we made is, first of all, we've called for fewer more focused targets. We got some publicity for that last week. Politicians really do have to resist the temptation, politicians of all parties to announce targets, to get publicity, but not to take responsibility for thinking about how you have the capacity to deliver on those targets.

Secondly, more specifically, we said that we need proper investment in dentistry before we can expect ICSs to make progress when that responsibility is handed to them. And then again with a broader lens, we repeated our view that the new NHSE has to be one in which local leaders working in collaboration with their partners have more freedom to innovate and be responsive to local needs.

So that's a few highlights of the work we've been doing over the last couple of weeks. Speaking personally, I continue to gain enormous insight from talking with leaders and making visits like a recent trip I made to Yorkshire Ambulance Service. So please do stay in touch and keep the invites coming.

So, I'm delighted to be joined by Isabel Hardman, who I've known for many years. I think you first spoke at an RSA event I did; it must be getting on for ten years ago now Isabel, and I have followed your career closely ever since. Isabel is as everyone knows, a journalist and author, someone who has this rare ability to talk about the big events of the day, but also from a very kind of personal and engaging perspective.

So, Isabel, welcome to Health on the Line.

Isabel Hardman

Thank you for having me and for that lovely introduction as well.

Matthew Taylor

Well, this podcast is going to be going out a few days after this conversation we're having now. So, I suppose to talk to you about what's going on in politics runs the risk that it's all outdated. But I guess in a way that's kind of interesting, isn't it? For the record, if things have moved on enormously in a week's time, the way we saw things today might be of interest to our listeners.

So, just before we kind of get into the health-related elements of this, it is remarkable what's going on politically at the moment isn't it, Isabel?

Isabel Hardman

It really is because I think the thing that's really struck me is the level of surprise from Conservative MPs, ministers, those in the Tory ecosystem, who knew that this autumn was going to be tough and had accepted that they weren't going to have a few months of people saying Liz Truss is showing us how to do it, but they hadn't expected it to be tough like this.

And the sort of level of fear that I think a lot of their constituents have and are communicating to them about, well, a whole range of things, really, their energy bills, whether they're going to be able to actually stay in their home and pay their mortgage, their pensions, if they're on benefits, whether their benefits are going to rise in line with inflation and actually also alongside all of these money worries are a lot of people who are parked on NHS waiting lists.

And weirdly the NHS crisis has momentarily disappeared from the forefront of politician's mind as the worse thing that's happening to the government. Because everything is gone into a meltdown that they didn't expect. They expected to be unpopular but not like this. Not terrifying, they expected people to be cross with them, not frightened by them.

Matthew Taylor

So, I read a brilliant book a few weeks ago by a guy called Phil Tinline called The Death of Consensus, which is around kind of big shifts in in British politics. And it's based on the thesis that one of the things that holds the establishment together is what it's frightened of. And in the thirties, the establishment was frightened of the collapse of the pound and a kind of German hyperinflation.

And then in the post-war period, what we were frightened of was mass unemployment. And so, as it were, as things change, the fears that we have change. Now, he sees 2008 as another kind of critical turning point. But what's interesting is that although after 2008, in many ways the public fall out of love with a kind of free market philosophy, you get conservative governments.

But each conservative government we've had wanted to have a big project, which is to say, in a sense we’re not just economically liberal. So, David Cameron has the Big Society, Theresa May has compassionate conservativism and just about managing and Boris Johnson, of course, has levelling up. And one of the things that's kind of fascinating about this, the Truss administration, is that it's in a way, it's the first time we've had a Conservative government that isn't saying we're doing something other than kind of right of centre policy. And it's kind of Thatcherism but with funny money. And I find that fascinating as well.

So, I guess what you're saying is that the Conservative Party knew that they were doing that, they knew they were going for something full blooded, but they didn't know they were going for something quite so kind of high risk.

Isabel Hardman

Yeah, absolutely. I mean, that's a much more astute description of how things are going than I could ever muster. But I think that what they hadn't expected was for the consequences of being unpopular, to be people being frightened about being able to keep or stay vaguely warm in their own homes. And I think that's the difference, is that if you're Tories, you have over the past decade got a bit used to people being cross with you.

You know, you look back at austerity under Cameron and Osborne, and Brexit even, the fights over Brexit have toughened up, probably to an unhelpful extent, a lot of Tories, because they've just been used to not just people being cross with them, but actually people screaming at them in the street and following them and all the things that we really don't want to be happening in politics.

But that sort of, in the politically engaged world, where it’s sort of it's okay for those people to be cross because they're always going to be cross because they're actually members of the Labour Party or whatever. These are just people who thought they'd actually ticked the boxes that they'd been working towards in their life. They’ve got a nice but not flashy house. They've got a car parked outside the front. They'd got a bit of money aside each year to go on holiday. And now they're thinking, I mean, is that all going up in smoke? That's the kind of level of anger and fear. It’s got out of the political world and into the housing estate where I live at the moment where no one is very interested in politics, but they jolly well are now.

Matthew Taylor

I think one of the things that I find interesting is that the big story over the last 20 years is really the decline in Britain. And I guess in a way Liz Truss is speaking to this when she talks about being bold and about growth. But you know, I think it's the case that we're now poorer per head than Slovenians and that in five years’ time we're going to be poorer per head than the Poles, and we are kind of becoming a middle-income country with middle-income public services to match.

And I often think that part of the problem of politics and why politics is so incredibly difficult right now is that we don't seem as a as a country to be able to talk honestly about ourselves and the position we’re in. It reminds me a bit of, you know when you're in a playground and there's a child on a slide and they're trying to climb to the top of the slide by climbing up the slidey bit. And the more frenetically they try to push themselves up, the more they slide down. And eventually they realise they're going to have to slide down and walk around and start methodically walking up the steps and that’s the only way. But it feels as though in Britain we are the child that keeps trying to scramble up the slide when we probably need to recognise that we need to adopt a pretty different strategy about what our expectations are or what's possible.

Do you do you think that’s right? Part of the problem is that we, the public, can't quite face the truth about the way our country and its prospects have changed.

Isabel Hardman

Well, I mean, that's certainly true in the NHS, isn't it? And it wasn't that long ago that I was interviewing you on the radio where you started to talk about how the public may have to manage, lower their expectations of what the NHS could do for them as well. And one of the things I found really interesting about writing the latest book is that actually when you say a comprehensive health service, I mean it’s never going to be comprehensive because comprehensive is limitless. But for how far does comprehensive go? Does it include IVF, for instance? And the arguments have been going on ever since the first test tube baby have been, is this something that the health service should be providing? Is infertility something that should be treated through IVF on the NHS and so on? And is that now something that trusts can really afford or less sort of attention grabbing for the people with the particular conditions themselves, extremely emotive, highly personalised drugs, which can make a huge difference to one person, but also cost so much that whatever configuration of commissioning authority you have within the NHS, whether it's PCTs or whatever, warn very quickly that this is going to be unaffordable.

And that kind of clash between patients who were told this was a comprehensive service and the reality of what that can mean as technology in particular advances, is fascinating. And that's the case across all of western health care systems. But you're right that because we have a special view of ourselves as Britain and as the NHS is often a sort of a good way of understanding what we think about ourselves in Britain, because we have I think it's fair to say, an elevated view of the NHS, thinking it's the best in the world when you know, there are lots of ways in which the world might envy it, but it's not necessarily the envy of the world in the way we think and that sort of level of, I don't want to say delusion, but misunderstanding, is something that you can extend far beyond the NHS.

Matthew Taylor

So, I want to get into that in a minute. But just before we move away entirely from what's going on at the moment. I've been in this job for 14 months, Isabel, and I’m on my fourth secretary of state. What do you expect we're going to see from Thérèse Coffey over the next couple of years, assuming that she stays in the job?

And, you know, as you and I both know, the capacity gap in the health service, particularly in relation to workforce but also estates, the level of demand which is unprecedented, means that we are going to be somewhere between crisis and near crisis for the next couple of years, almost whatever happens. What do you think is going to be the conceptual approach? Is it going to be to try to mitigate it, to distract from it, or even more radically to start to talk about the fact that the health service as I read most days in the Telegraph, isn't working.

Isabel Hardman

I think that latter point is very hard for conservative politicians to make. And, you know, far better than I do Matthew, how much more leg room Labour has to come out and say that. It doesn't necessarily mean that Labour politicians have the will to seize that opportunity and to do the reforms that are necessary. But the problem for the Tories, which is again embedded within the health service, is that they never really seemed fully signed up to it in the eyes of the public and certainly within political discourse.

And so they have to work a lot harder to make any big reform arguments and they accept, and Thatcher certainly accepted this, that any attempt to start again and build a health service that they think would actually serve the needs of this population, not the population in 1948, that they would not be forgiven for that, even if it were the right thing to do, that they politically would not recover from that.

And that's why Thatcher was very tempted by the idea of an insurance-based system, freaked out when she saw how the public responded to that sort of thing. And I think that's a sort of a lesson for Liz Truss.

Matthew Taylor

So often, you know, commentators like yourself, writers, are able to say things which politicians aren't able to say. You're completing your book about the National Health Service. What are the kinds of conclusions you're coming to in terms of… do you reach conclusions about how you think we should talk differently about the health service, how we should have a different conversation with the public about it?

Isabel Hardman

One of the things I've decided not to do is to talk about whether it's worth tearing things up and starting again. I mean, sort of to have a lengthy discussion about that, for the basic reason that whether this is the right thing or not, it's not something that Brits are going to go for. And there's actually still a lot you can do within the health service as you know, your organisation is frequently pointing out, that would help it a great deal and that would make it much more efficient. So, for instance, one of the, you could say the flaws, or the kind of biases that was built in very early when the health service was being created, was the focus on acute care. And that was partly because Bevan obviously nationalised the hospitals, couldn't nationalise the GPs. It was also because community services, community care didn't really come into the NHS orbit until the 1970s reorganisation under Keith Joseph.

And that means that the kind of the first level of care, not just primary care but health visiting, sort of the preventive agenda which I know lots of people in the NHS sort of groan about and say that's not our issue. But those things have always been at the periphery, at best of the health service, and so it means that you've got all the funding loaded towards acute and my God acute needs at the moment, but it's always going to need it if you're not funding and prioritising the services that get to someone earlier on.

And obviously you have to have a discussion about social care within that because I find it frustrating, laughable, infuriating that Conservative politicians talk about how the NHS needs to be more efficient and apparently there's all these middle managers sort of, I don't know, painting their nails and going on away days or something or whatever they imagine to be happening.

But they never acknowledge that they, as a political class, have failed the NHS and are causing it severe strain every day by dodging proper reform of social care. And I sort of laughed bitterly when Boris Johnson said, we have reformed social care as he left Downing Street. And if politicians want to challenge the public about the NHS, I think a good starting point would actually be to talk about social care and to, as the Truss government claimed in its first few days, have balls of steel and jolly well get on with, you know, being unpopular for very good reason, not just sort of blowing things up, and do the reforms that people are going to get cross about whenever you do them.

I mean I think if there's one thing to learn from the last 30 years or whatever of failed social care reforms is that people already think it's free unless they're in the system and then they are in a nightmare, which is probably making them ill, as well as the relative they're trying to advocate for.

And so, whenever a politician, whether it's Theresa May in the 2017 campaign with a half-baked plan or, you know, Labour with its death tax back in 2009 or whatever, whatever you come up with is going to annoy people because it's going to involve them paying more money in some way, even though they already do that. And so, I sort of glance from those calls for an honest conversation with the public about the NHS, because I kind of think, well sure, I mean, yeah, we can have that. But as part of that we need to have an honest conversation about the things you know they're going to get cross about, like social care to stop a situation where you've got people who are being branded bed blockers costing £700 a night, stuck in an acute bed because there's no care package for them. That's pretty unforgivable.

Matthew Taylor

Yeah. And what's worse is they are, and I hate this word, but they're becoming deconditioned in hospital, they're getting sicker. And I completely agree with you. And we at the NHS Confederation have been consistently saying for several months now that the absolute priority is to raise the pay of the lowest paid social care workers.

In fact, just yesterday I was talking to the head of our Wales Confederation, talking about how there’s an Amazon warehouse across the road from the hospital. There’s literally people crossing the road to get another £50 an hour, a pound an hour, but also actually feeling that, and this is a pretty terrible thing to say, but that being in an Amazon warehouse, it's a better quality of work than it is doing social care, given that you're in teams that are under-staffed and the kinds of pressures that you're under.

So just today, we're seeing that the pace of nurses leaving the health service is accelerating. So, this workforce crisis is the number one problem. And I completely agree with you that the politicians’ strategy on the NHS is kind of “look there’s an eagle.” It's just to try to distract us from facing up to the fundamentals.

But I also think the challenge - this is my day-to-day challenges, Isabel. So, I absolutely believe in two things that we do need over time to shift resources upstream or leftwards, however you want to describe it, from acute into community, primary prevention. Not necessarily prevention in the sense of doing things today that pay off in 25 years, but I mean more humdrum prevention, stopping people having medical interventions they don't need, stopping people who have one long-term condition from getting a second or third or fourth. So targeted kind of preventative work with a reasonably fast feedback loop. So, we need to do that. And we also need to innovate, and we have to innovate faster.

The problem is when I talk to leaders and say to them, how are you trying to shift resources upstream or how are you trying to innovate? They say we have no headspace at all to do that. And people often talk about covid and the level of innovation in covid. But of course, in covid, the health service was allowed not to do a lot of things that it would normally do, and the public understood that it couldn't do a lot of things. But now what it's trying to do is, on the one hand, cope with unprecedented level of demand, with inadequate resources, but also try to provide the full range of health services to a public who understandably wants that full range of health services.

So, it feels so hard at the moment to give our leaders the headspace to think about doing things differently because they are understandably in crisis management mode.

Isabel Hardman

Yeah. And what also really doesn't help that is the greatest train set in Europe situation where you've got politicians and you pointed to one of the factors in this, which is getting new Secretaries of State, all of whom want to make their mark on the health service, all of whom think, oh, I can just move this track this way and play with that and make my mark on the health service. And you get these reorganisations every like 18 months basically.

And some of the people I talked to for the book had re-applied for the same job 11 times. So, it's just the amount of headspace that takes up, that reconfiguring your commissioning organisations, your chief executive, your local relationships, all that kind of stuff. And even if it's the right thing to do, it takes a long time for organisations to embed and recover and then woosh here comes another Secretary of State and Prime Minister.

I mean, it sounds like I've sort of spent the Conservative leadership contest in the weeks after rocking backwards and forwards laughing bitterly at the various things that are being said, which is probably not that far from the truth actually, because I mean, Liz Truss, during the leadership contest, whenever she was asked about the NHS, she kept saying what the NHS needs is fewer middle managers, which I appreciate that is sort of catnip for Tory audience, but really? You've just enacted the latest health and social care reforms this year and what you're going to just like blow up NHS management, which again suggests to me that her sort of Thatcher obsession is only skin deep because Thatcher introduced middle managers to the NHS. So come on read your Griffiths report, love!

I don't think she was being serious that she wanted some kind of big stripping out an entire tier of NHS management. But then again, she was auditioning to be Prime Minister and a sort of level of seriousness about public services the size of the country would presumably be an important part of that.

Matthew Taylor

Yeah. I mean just to say on the management issue, the evidence - we published a lot of this, is that the NHS is almost certainly under managed, number one. Number two, a huge number of managers are actually clinicians - they combine being clinicians and managers. And thirdly, the evidence is where you have more managers, you actually get more efficiency. So it is, as you say, kind of pretty galling when you hear this attempt to suggest that the problem is to do with management.

I want to make a point that might feel slightly kind of policy wonky, but it does then fringe into something that you've written a lot about as well. I'm really interested in your perspective on that, given you're now thinking about the NHS.

So, I think part of what we have to do is about is we have to reframe the conversation about health and we need to do that in two ways. First of all, we need to talk about health as an investment proposition. I mean, it's interesting to me that, you know, we have an economy suffering from labour shortages. And what are the biggest reason why people of working age are not working is because they are unwell or because they've got caring responsibilities.

So those are the problems of our health and care system feed directly into the tightness of our labour market and create a kind of vicious cycle. Because then you've got a tight labour market and makes it even harder to recruit people into social care. For example, the NHS is often the biggest employer, one of the biggest investors. So, on the one hand we need to understand the role the NHS and care system has in our having a dynamic economy and a good society.

It's not just about health. And on the other hand, we've got to think about what is sometimes termed as health in every policy that what the NHS does only determines what 20 per cent of our health outcomes. And we need to think about much more deeply about the impact on health of our employment policies, our housing policies, our planning policies, etc., etc.

Now, you know, this might sound like an abstract point, but I actually think it's vital as long as we go on talking about health as only being a way of spending money and only about what happens in the health service. We're not going to get this debate into a better place. We're all just going to go round in circles.

And you've written a lot, of course, about the importance of things and nothing to do with the health service in terms of health and wellbeing - nature, physical activity, the kind of attitudes you have to life. Are you bringing some of that stuff into your analysis of, of the NHS? This need to rethink what we talk about when we talk about health and wellbeing.

Isabel Hardman

I am obviously interested in mental health within the NHS and I have to say that one of the conclusions I've reached is that if you define success of the NHS as being an organisation that exists in place of fear for people, I'm not sure you could ever really say that it's done that for mental health.

I don't think having looked through the attempts to reform mental health and sort of Enoch Powell onwards all the way through to care in the community in the present day, I'm not sure that many people, any stage would say, I don't have to worry if I get mentally ill. If I get seriously mentally ill, I don't have to worry. Because I think the recent scandals, the BBC Panorama and the most recent allegations show that still actually we have people who are really, really, really vulnerable in really appalling settings.

And in a sense, those vulnerable people in inpatient sort of medium secure settings being abused by the people supposed to be caring for them. They're often regarded as the lucky ones because they got a bed. I'm not sure the NHS is really sort of fully existed for mental health.

So, I've looked at that. I have, as with social care, not done an exhaustive history of health policy outside of the NHS. In the same way as I haven't done an analysis in the covid chapter of the decision to lock down and borders policy and so on, because I would be stretching the reader’s patience over five volumes at one chapter.

And so I've decided to be very narrow and actually focus on the health service. And perhaps that's one of the problems actually more generally is that we talk about health - oh yes the NHS hospital wards - and we don't, as you mentioned in your question, think about the way in which we design our towns and say that people aren't habitually inactive.

Listeners fortunately can't see this, but Matthew and I both wearing fluorescent clothing having done our morning exercise before this podcast and mine was actually cycling with my son to his nursery, which our area of Scotland is designed in the way that that's quite safe. But there's no way I would have cycled with him to nursery in London because that would be quite frightening with him on his bike, me on mine.

So you know, things like active travel, keeping people active as part of their days rather than requiring them to take this phrase personal responsibility and somehow squeeze into that day a trip to the gym or something like that to sort of, you know, separating out exercise is another thing they have to add to their to do list as opposed to the thing that gets them to school, the thing that gets into work.

We've been very clever at designing activity out of our lives of all towns and so on. And I'm not saying we should go back to the Mangle, and I've actually got a robot Hoover, so I don't even do manual housework now. It just I've just got this little robot that goes round it does it for me. And so I'm not a great example, but that kind of labour-saving device is a great idea. But we have got to a point where activity is, you know, is a hobby as opposed to the way we live. And that's not great. When it comes to the second book I wrote, we've also become extremely good at designing nature out of our lives to the extent that an astonishing number of people I know are terrified of moths and even though we don't actually have any moths anymore, they're all dead.

And you know, when I was growing up, I'm 36, so when I was growing up, I can remember moths dancing in the headlights of my dad's car as we drove through country lanes. But he can remember something called a moth snowstorm, which is completely outside of my experience, which is sort of blizzards of moths. And now I'm quite happy if I see a moth in a day, because we not only have we sprayed them out of existence, we've also designed access to nature out of our lives to extent that, again, if you say, oh, I'm going to go and experience a nature, you assume that you're going to get in your car and drive to like a nature reserve half an hour away. And when you get home, you'll actually probably vacuum clean your fake lawn and shut the door and hope that there's no bugs anywhere.

I don't think that's particularly good for our mental health. There's lots of evidence suggests that's not very good for our mental health. Not being active is obviously not good for our mental health. It is also very bad for our physical health and not just in terms of obesity, but in terms of all sorts of other things. So before anyone even reaches hospital, there are a range of sort of public policy decisions that have been made that have affected them. And that may be actually quite big factors in the fact that they now need acute care.

That's very easy, I think, to get lost because you kind of silo off the NHS and say this is health which is actually this is illness requiring hospital treatment as opposed to this is someone's wellbeing. And I think just to finish, another problem with this is that as soon as you say wellbeing, even people like me sort of who love being in nature all go out and they think about Gwyneth Paltrow. And again, that's become another sort of like an industry that seems to just involve endless candles and herbal teas, most of which are disgusting and have nothing to do with the health of the general population and keeping them outside of needing regular medical attention.

Matthew Taylor

Well, first of all, you've talked about moths in the context of mental health, which forces me to tell you one of my favourite jokes, which is about a man who goes to the doctor and says: “Doctor, doctor, I think I'm a moth.” And the doctor says: “I can't help you. You need to see a psychiatrist. Why did you come to my office?” And he said: “Well, your light was on.” So sorry. I've got that terrible joke out of the way. There's an irony here. Well, and the irony is this arguably the biggest reason we are where we are in terms of the problems of not just the health service in Britain, but I was talking to a senior NHS leader the other day who'd gone back to America to practice in his hospital.

And he said for the first time, and this is a high-level American hospital and there's no capacity shortages in America, given how much they spend, for the first time, there were ambulances queuing up outside the hospital. And why were there ambulances queuing up outside the hospital? Because they were old, frail people they couldn't get out of the hospital.

And he was pointing out that in America, they've taken 200,000 beds out. We took 20,000 beds out. We took all the beds out. And we didn't recognise what we were going to have to deal with in terms of older, frail people. So, we've got this kind of irony, which is the problem for the health service, on the one hand, is that we are the success actually of the fact that we are living longer. But the problem, on the other hand, is the failure to attend to the broader kind of public health of the nation.

So, we have the worst of both worlds in the sense it is of course a good thing, and I’m over 60, so I think it's a really good thing that life expectancy has increased. But if you increase life expectancy, you don't improve general public health at the pace that you need to you end up where we are.

And I guess that leads me to a final question which is this: you're writing this history and of course we can exaggerate how big a break the NHS was, but nevertheless it is a revolutionary idea and it involves politicians taking a big leap and also saying to the country we are going as a country to have to demonstrate commitment to each other, we'll have to fund this system, but we commit to this radical principle.

What is the equivalent now? And in the end, I think the equivalent now is that we have to commit to becoming a healthy society in the broadest of terms, into attending to the things which make us which make us not just unhappy in the day-to-day sense, but which make us vulnerable to mental illness. And until we can have that broader and deeper conversation about how we create a healthier society, that the health service is going to be there having to pick up that broader failure.

And I know, as you say, that when you talk about things like wellbeing and public health, it can feel amorphous. But it seems to me that unless we address this and also health inequalities, which of course is a really big part of this, because what we talk about the social determinants of health, we immediately see those huge inequalities in how easy it is for people to live healthy lives.

Somehow we have to reframe the debate in these terms. What do you think?

Isabel Hardman

Yeah, I mean, I agree with that. But sadly, it seems that the current iteration of the Department of Health doesn’t because they've just scrapped the health inequalities paper, which is so depressing and you might have a sort of quibble about anti-obesity policies or whatever. But the idea to my mind that Conservatives shouldn't be worried about health inequalities, I don't think financially adds up because even if you have that kind of bare financial focus, you end up spending a lot more money on populations who actually just have poor health and would not need the medical attention, the higher-level medical attention that they end up getting because, as you know, as we discussed out this podcast, there should have been an intervention earlier or there should have been a change in the planning system or something like that.

But the planning system is a whole different book that I am not going to write because I would need to write another book on mental health afterwards just to recover.

But how much is the debate in the Conservative Party at the moment focused on building healthy neighbourhoods and how much of it is actually focused on not building neighbourhoods in constituencies in the south east that will get cross with the Tories? Again, there's this just all these competing political parties and healthy lives tends to come quite low down in that, unfortunately, even though actually it's what all of us want for ourselves.

Matthew Taylor

Absolutely. You know what we ask people, what is the most important determinant of your own wellbeing health comes out pretty much at the top. So somehow we've got to connect the political debate to how we or most of us actually think about health and wellbeing in our day to day lives.

Well Isabel, it's been fantastic to talk with you. As I say, we'd love to have you back on next year after the books are published. Thank you.

Isabel Hardman

Thank you. I really enjoyed that.