The 18-week challenge: getting elective care waiting times into shape

Matthew Taylor

Welcome to Health on the Line. Later in this edition, we'll be discussing a major report that we wrote with Carnall Farrar around the government's waiting list target and the challenges of meeting that. But first of all, we're going to talk about what's really been the big story of the last few days, and that's the Darzi report. 

There were no surprises, I guess, that when the report was published, the headlines were all really about the problems that the NHS faces. It was an evidence base to go with Wes Streeting's phrase that the NHS is broken, broken but not beaten, as he now says. 

But actually, we've had time now to read the whole report and it's maybe a more nuanced, a more mixed story than those headlines might have suggested. 

So to explore a bit more of the nuance of the Darzi report, a few days having passed since it's been published, well there's no one better to do that with me than Siva Anandaciva, who's interim co-director of policy events and partnerships at the King's Fund and their chief analyst and has already written a really fascinating blog about the Darzi review. 

Welcome Siva. 

Siva Anandaciva

Thanks for having me, Matthew. 

Matthew Taylor

So as I've said, in many ways the headlines that accompanied the Darzi review were the ones we could have written the day that he was commissioned to do the review, but what was there in the report, having read it in detail, that surprised you, that maybe wasn't something that you would have predicted a few weeks ago? 

Siva Anandaciva

Great question. I suppose, yeah, first of all I completely agree with your analysis, which is I was quite cynical when the report was announced. I thought this is going to be a thorough piece of work, but a thorough piece of work with the aim of saying, look at what a mess we've inherited, that's it, give us some more time to get on with the job as the government of fixing the NHS. 

But I also agree that your assertion there's more nuance than this is valid. And one of the things that really struck me is, first of all, Lord Darzi is by his history and practice, clearly a surgeon, a very hospital-focused clinician, but that's not what comes through the report at all. I think one of the things Lord Darzi is exposing is a stark choice over what kind of health and care system do we want to have over the next ten to 15 years. 

So that choice of a very hospital-dominated, hospital-focused system based on access and waiting and treating times versus a more preventative model, I think is case throughout the report. 

The second thing that really surprised me is I think this really is an independent report because Lord Isley has also exposed some very difficult choices for the government that are going to be made in the Autumn Budget. 

So just take a few examples. His remit was very narrow, diagnosis not treatment and look at the NHS not adult social care or public health. But he absolutely has things to say about public health and adult social care and need to fix them. At a time when the government has said, look, we're not doing nothing on social care, but you'll have to wait for more concrete plans. 

So that's one tension that the Darzi report creates, the need to do more urgent work on fixing social care. 

And the second one is capital, which I know the Confed has done a lot of work on. 

And again, with all Darzi's work, I was just looking at the charts in the technical appendix. My goodness, how many charts are there on just how bad capital investment in the NHS is at the moment and the consequences of that for staff and patients? 

Again, what is the message from the government? It's that there are tough choices to be made, including re-profiling the plan to build up to 40, 48 new hospitals. 

So again, that's another strategic tension where all Darzi's saying basically, you need to fix capital if you want a better healthcare service when the government's saying there's not that much money to go around. 

So I think one of the points of nuance is this is an independent report that has some tough messages for the government and really does lead to some very difficult, tough choices ahead. 

Matthew Taylor

I absolutely agree. And I think, you know, as a long in the tooth public policy analyst and commentator, one of the things that happens in public policy discourse is an idea can be around for a very, very long time and experts like you and me can talk about it, but it somehow doesn't get to the point at which it becomes common sense, a universally accepted thing. And I think what Darzi's been, people talk about the Overton window, it's not quite the Overton window. It's not that he's said anything that no one has said before, but it's shifting the kind of sense of the common sense, is what I would say. 

So I think the argument we have to move resources upstream, that in a sense the domination of spending in the acute sector is a problem we have to solve. I think that's an argument which is finished now. I can't see can anyone really argue with it? The question is, is how you do it? 

I think the argument that when we think about health policy, we can't just think about the NHS. We have to think about all the other things that contribute to our health. It feels to me that that argument is kind of over now and there's a recognition of it and hopefully we just accept that now. 

There was one other argument which was a newer one. I mean, one that I've made, we've made in the past, but was slightly more novel and that was that the NHS is under managed. I think if I could pick out one of the things in the report that I particularly welcomed was the attempt to knock the kind of ‘there's too much bureaucracy in the health service’ on the head. 

What did you think about that? What do you said about management? 

Siva Anandaciva

I think there were two bits of management that, again, back to surprises, I really wasn't expecting it to be in the report and certainly not to be in the report with the prominence it had. 

The first was about how many times we restructured the NHS, and that beautiful chart of bodies being created and abolished. 

And the other one was about the importance of managers. 

And both, again, you know, people like you and me would talk about this and internalise it all the time and then we go into the real world. And of course people would say, the NHS has got too many managers, too many bureaucrats. 

I think what Lord Darcy is trying to say is, first of all, basic statistics about, the NHS isn't over-managed, if anything, it's over-administered but under-managed. But also now we have to move past this debate. 

Some organisations, some of your members, have revenue of over £2 billion, if not over 20,000 people. Now, what argument would you make that you need to take management out of that? 

I was in the Department of Health around the time Lord Lansley came in and we started cutting managers. And what did you see? You started to see five, six years later, I'd go to big hospital trusts and they'd say, guess what we're trying to do? We're trying to put in managing directors, we're trying to get a grip again on how we run this operation because the idea that you can run an organisation of a billion pounds or a community trust that's based in about a hundred different sites without some management capacity is just a fallacy and that's what I would say normal steady state, let alone a time when we're trying to flip our health and care service on its head. 

Rewiring how we pay for services, rewiring how we regulate services rewiring the culture and leadership and the tone we're trying to set. All of that is management. All of that requires capacity and capability. And I think you're right, Darzi is putting that as one of the pillars if the government's going to pull off what it wants to pull off. 

Matthew Taylor

And I had a fascinating conversation the other day with an official who, who said to me that there are secretaries of state who kind of care about the model of change in health service and others who don't at all. It doesn't interest them.

He said that Wes Streeting is one of those health secretaries who is thoughtful about how it is we make change happen in the health service, thoughtful about how we have a centre that is empowering and get away from the kind of over-hierarchical short-termism that the NHS has suffered. So I found that very heartening. 

Now, two final questions, Siva. 

The first is the one thing that I found slightly grating about all the commentary about Darzi was that it was treated like it was a historical novel in the sense that well, this is all things that happened in the past. But of course, the uplift in spending in the health service this year is worse than most of the years of austerity. And we're going into a difficult winter where Streeting's position is it's going to be tough; there's no choice and people will blame the Conservatives. 

I have to say, I think that slightly confuses blame and responsibility. They might blame the Conservatives, but if, you know, ambulances are taking far too long to get out to people and A&E departments are under immense strain, they will hold the current government responsible. 

What's your sense of what we're going into in winter and the kind of risks? And I guess a bit of advice - we are at the Confed, more in sorrow than anger, are saying that even at this late stage, some funding to be able particularly to enhance social care and community capacity and help with hospital discharge would make a difference. 

Do you think we're kind of barking at the moon? 

Siva Anandaciva

I fear you are, to be honest, but I mean, like you, I think people have just got to keep barking. 

You use the word ‘responsibility’, which I think is absolutely right. This government is going to be the government that is leading the NHS through winter. I mean, not directly. I know there's we've got NHS England, but they will be politically accountable for the health and care service this winter. 

I look for signs and symptoms that the government gets the reality of what services are facing and gets that it's got some levers in this toolbox that it can use. And what are some of the levers? Well, one of them would have been getting money, if you're going to give money to the system to support overwinter, for goodness sake, get it out as quickly as possible so people have time to build the teams they need to build, put the services in place, rather than try to rush the money out the door. 

And the second thing would be, try not to put too many constraints over how that money is spent. Set a broad outcome first. Don't micromanage that it needs to be used for this particular type of discharge pot or that particular type of discharge pot. 

Unfortunately, the weather's already getting colder, and I fear that yes, we're getting some messages and letters about how to manage in winter. What I don't get is a change of tone and narrative that we want this winter to be different and part of that difference is we are going to give you, if we're going to give you resources, we give you them early. 

Or we have a really honest reality check, which is there isn't any more money on the table. So we are accepting that the balance will get worse. We are accepting it is going to be a brutal winter. What I want to get out of is the old debate of the NHS and wider health and care systems can do more with less. I think we've rid that horse for far too long. 

If there's not more money on the table to support health and care services, the proposition to the public has to be you're going to wait longer. Some people will face poorer healthcare outcomes. That's reality of where we are. 

So what I don't want to do is for the health service to go into winter in a more fragile state than I've seen it, I can remember since covid, except in covid, in my career. And the message to leaders is buck up and just keep going. 

Matthew Taylor

My final question, Siva, we've nearly run out of time. Obviously, we're all going to be making the case for capital. The Confed are doing lots of work on how we can get more capital into the health service, how we can have a more flexible system that encourages health and local government to work more entrepreneurially about capital investment. Again, that's for another conversation. 

But the big other financial question is surely this double-running issue. Chris Ham directed me to a great King's Fund report written a few years ago about what happened in mental health, how we moved people from asylums into care in the community and which was, despite some things going wrong, a largely successful transformation. Importantly, that report said it was made possible in part by willingness to pay for double running. 

How do we transform the health service? Is it possible to do it without some element of double running? And if not, the government is going to have to pay for that, isn't it?

Siva Anandaciva

Yeah, I think that's right. 

I think you've got a first order decision, know, macroeconomic decision of on the money. Are you willing to invest more in public services to the extent that you could double run? For the moment, the government's holding the line that the decision's made and the answer is no, you've got to reform without money. 

So you're into your second order decisions. And I think it is possible. But, you know, I'm going back to some work you did with Carnall Farrar about tackling waiting lists. And I took two messages from that. 

One is there is lots of good stuff that the NHS and wider health and care services are doing out there to improve services for patients. 

The second thing is, despite all that good work, it's going to take far longer and cost far more to tackle waiting lists if the government really wants to meet all constitutional standards in five years. 

So if double running, if parallel funding is not on the table, I think the proposition to the public goes along the lines of, this is what we're trying to do. We want to move to a more prevention-focused health care system. What that means in the interim is the tough choices like you're going to have to wait longer than you would need to for hospital care because we're going to invest more in primary and community services and they get a bigger share of the pie rather than growing the pie.

Now the question for the government is do you believe that and if you believe that how honest are you willing to be with the public? 

I think then we go back to this ten-year plan that the government's working on for spring next year. One of my tests for that is honesty because you can't have everything. I think we do want that preventative focused healthcare service that is the direction we're heading in. 

The tough choices are, the long waiting times that might be part of the steps on that path. 

Matthew Taylor

Well, Siva, as always, it's fascinating to talk with you and it sets up fascinatingly, doesn't it? What Wes Streeting is going to say next week at Labour Party Conference, because one thing that Darzi has done and your work has done and we try to do is to get that realism into the debate. And I think people are becoming increasingly aware of the kinds of choices this new Labour government faces. Sue, thanks so much for joining us on Health on the Line.

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In that conversation with Siva, he mentioned the work that we've done with Carnell Farrar around a waiting list. So that's a great prompt. The next part of our conversation, which is with Hannah Farrar about that report.

During the recent general election campaign, one of the most concrete pledges from the new government relating to health was to introduce 40,000 extra appointments a week, or 2 million a year. This was obviously to help with the waiting list challenge. 

Now it's a pledge that sounds very positive, boosting capacity through a mixture of staff overtime on evenings and weekends, use of the independent sector and sharing resources between trusts.

But we all know that waiting lists are at record levels and they're currently rising - 7.5 million plus unresolved open care pathways, impacting an estimated six and a half million individuals. So what will it take to clear the backlog and get us back to a position where people needing care can access it in a timely manner or more specifically where the vast majority of people will get seen to within 18 weeks?

So for this discussion, I'm delighted to be joined by Hannah Farrar, who's chief executive and co-founder of Carnall Farrar. CF are a health and data consultancy and have been leading on a major research project to examine this pledge and the methods that are supposed to achieve this pledge and how they match up with the reality and scale of waiting lists as they stand.

Hannah, welcome to Health on the Line. 

Hannah Farrar

Thank you, Matthew. It's great to be here.

Matthew Taylor

So, we at the Confed have worked closely with you for a number of years. Anyone in the health service will know about you and the great work that you do. 

Just to start us off with a kind of a soft launch, as it were, let's just talk a bit about you and about your background in the health service and what led you to co-found the company and what essentially you see CF being all about. 

Hannah Farrar

My career has been dedicated to working in the health sector. 

So colleagues, many colleagues will know that I actually started in the Department of Health. I was a civil servant and part of the headquarters of the NHS when it was integrated together with the Department of Health and Social Care. 

And then over time I ended up as an NHS manager, worked in a number of different roles and my final role in the service was as part of the board of NHS London, where I held the strategy transformation and development brief, which meant that I got to do some very exciting innovation and transformation change programmes. 

And it also meant that I dealt with some of the toughest challenges. And as we all know, the 2013 reforms were a bit of a seminal moment in terms of the NHS and how it operated. And that was the moment that change programme restructured the role that I was in and I guess maybe devalued some of the functions that I performed in terms of strategic leadership and strategic transformation. 

And I decided that I would, with Ruth Carnell, found CF. And our offer was to provide consulting services to the health sector with many of the consulting skills and talents that that profession brings, but with a knowledge base that's deeply focused on the health sector and its needs and blending those two things together. 

And that's what I've spent the last decade trying to build. 

Matthew Taylor

You've done some fantastic work. 

What I find fascinating about that, of course, is that you exemplify part of Lord Darzi's analysis, because of course, part of his argument is that the reason the health service is in such a poor state is a combination of austerity and the Lansley reforms, which led to an exodus of very effective leaders and managers, which then meant we went into covid in a fragile state. 

And of course that meant covid impacted us more than most other health systems. And that's why we are where we are. 

So it must be slightly poignant for you reading the Darzi analysis to realise that you're part of what he describes as the problem. 

Hannah Farrar

Oh I don't know that I'm part of the problem, but rather the change programs that ended my career in the health service might have been part of the problem. 

I worked with Lord Darzi when we did Healthcare for London together, which was just the strategic strategy for London that the health authority led. And he was a key figure who helped us to do that work and I very much enjoyed doing it with him. 

He then got promoted to become a minister and I was left trying to implement it and he made sure that that was my duty to make some of what we'd set out in Healthcare for London happen. 

And definitely at the tail end of my time in the health authority when the government changed and we got the coalition government come in, it was clear that the kind of orchestration of strategic transformation in the way that had been my role in London wasn't part of the kind of regime and the Secretary of State at the time, Andrew Lansley, didn't think that some of our approaches, eg to the London Stroke Programme, which happens to be one of things that I'm proudest of in my career, he didn't think that we'd gone about doing that in the right way because it had been organised for the whole of the capital, as opposed to the strongest organisations becoming the hyper acute stroke units for London. 

But we had to organise the capital investment, we had to organise the education and training. And I would say that hyper-acute stroke units wouldn't have been able to be created if that level of organisation hadn't happened. 

And perhaps what Lord Darzi is pointing to in his report is like, that was a gap, it was needed. It is needed if you're going to run a health system at the edge of its efficiency, that you haven't got room for more capacity than you need, but equally, therefore you've got to optimise the capacity that you've got on plan it really carefully.

Matthew Taylor

And that's something we'll come back to later in our conversation. That's actually a fascinating story, Hannah. Thank you for that. 

So let's go to the report that we published together a few days ago, a report that got lots of coverage and indeed was welcomed by none other than Wes Streeting himself. 

Why did you decide you wanted to work on this question of the kind of credibility of Labour's 18-week pledge and the means it was suggesting for tackling that? 

Hannah Farrar

We have worked with organisations up and down the country on elective recovery for many years as a management consultant supporting colleagues to deliver improvements. And what we are all too often finding ourselves doing is helping people to do more within some really challenging constraints. And the narrative around the recovery of elective care, I find is very focused on just doing more work. 

And rather than a kind of critique of what the government have said it was more taking them at their pledge that is: by the end of this term, we want to deliver on this 18-week standard commitment that is in the NHS constitution and is a core part of the offer for the public that you can rely on the NHS being there from referral to treatment within 18 weeks when you need it. 

And what I wanted to do and together with yourselves, Matthew, was stand back from incremental asks for more activity. From the knowledge that we have, from the work that I've done throughout my career, actually it needs more of a strategic transformation here if we're going to recover back to 18 weeks. We do need the NHS to be doing more activity, but more activity alone isn't the thing that's going to secure the 18-week target. 

And so as they work on their NHS plan, it felt like an opportune moment to stand back and give people kind of a holistic picture of what's needed to get there. 

Matthew Taylor

So there are two distinctive parts to the paper. Obviously, they go together, but actually they're independently important, I think. So I want to focus on each in turn. 

The first is the way in which you help us understand the nature of the problem and I know from speaking to journalists as I did when the report was published a few days ago, they were really kind of struck by the points you were making about the demand profile, the demand curve; it's this kind of recognition that you're talking here not just about this stock of 7.6 plus million people but it's the flow onto that list as well that you've got to address.

So, just take us briefly through that, the kind of point you're making there about the scale of the challenge. 

Hannah Farrar

Yes, and we very deliberately split the challenge in two. 

There is what you need to do to year-in, year-out, deliver 18 weeks, which is balancing capacity and demand and I guess caring and treating 3.6 million people at any one moment in time. That's what the NHS needs to pull off. And then over and above that, we've got roughly 4 million people, which I like to describe as a one-off challenge. 

So over a decade, we've built up, because the waiting list hasn't been kept in balance, an excess number of people who are now waiting for care. And as a one-off, we need to work harder, faster, whatever, however you would like to put it. But as a one-off challenge, we need to treat an additional 4 million people over the next five years. 

So we split the problem in two, and then we say in the first, what we need to do year-in, year-out to balance. If all we do is think we have to stand still, we will miss 18 weeks next year because we have a growth rate. 

And we say in the report it's 3.8 per cent. However, we're also at pains to say it isn't 3.8 per cent actually for anything practically. 

And so we set out both the different growth rates by healthcare specialty and also we chose region. Practically you want to do it at a system level, but it would make the report kind of unwieldy. So we set it out by region and when you see that actually no healthcare specialty has a growth rate of 3.8 per cent, one of them has 10 per cent, something else has minus 10 per cent. So dermatology has got a 10 per cent growth rate on it. 

And then what you see is huge variation by region and we need that to be planned for, else target will be missed. 

Matthew Taylor

So that's the first part of the report and very important for people to understand. And I think one of the reasons it's so important to understand this is because the case that we have to win with the treasury, those of us who feel that we're going to need more investment in order to transform the system, is we have to win an argument about that long-term demand curve. 

I think we have to win an argument that says, look, if you do nothing, this is the demand curve, and this demand curve will mean the health service consuming more and more money, a higher and higher proportion of public spending, a higher and higher proportion of national wealth. And therefore, what you have to do is to take actions that will reduce that demand curve over the medium term, over the kind five- to ten- year timeframe. 

And you have to invest money with that in mind. 

Now, when we talk about transforming the health service, we talk about activity levels, that's all fine, it's all important. But actually, I think economically, it's that demand curve argument that is the most critical one to win the treasury. 

So I found that analysis really useful, enabled me in some of the interviews I did to kind of raise that longer-term issue and to try to get through to people that it's not about pouring endless money into the health service, it's about transformation in order that we have got a greater chance of medium-term sustainability. 

Now, the second part of your argument was really about the credibility. I mean, I don't want to be mean to Wes Streeting. I don't suppose he ever really thought that the things that he's promised were going to do the job on their own. 

But when Wes Streeting talks about how he's going to solve this problem, he talks about staff working overtime, evenings and weekends, the independent sector, sharing waiting lists between trusts; all commendable things to do. 

But the second part of your report said, given the scale of the challenge, that's fine, but there's some other things that we are going to need to do as well.

What I want you to do Hannah is just maybe pick out three of the other things that you think need to be part of a national strategy to be able to hit that target over the next five years. 

Hannah Farrar

Yes. If you don't mind if I directly answer your question. It is partly why we split this into two points, because if all you think you have to do is recover the excess number of people waiting, you can simply do these targeted initiatives that are one-off and you don't have to sustain them. Whereas what we're saying is at an underlying level, we aren't doing enough activity every year simply to maintain the waiting list. It is still growing. And so we've got to raise the minds to that as well. 

And so I guess if I have to be choosy, because we were trying to be holistic end to end, but if I was to be choosy, the management of the waiting list, so digitalising it. And then the way that we engage, I'm going to use the word booking/scheduling. 

So administrative staff and their value and criticality to this process with data or digital tools to enable them to do it better will make the whole pathway more efficient, use clinical time more efficiently and improve the experience for patients.

Giving that the care and attention that it needs and the capital investment in the digital systems is pretty critical. 

My second one would then be the environment in which we're asking people to work is not optimal. And so the creation of elective hubs, well-trodden national policy, but we need to have enough of them and have enough capacity such that every operation that can be delivered in an elective hub because it's a day case or because it's high-volume, low-acuity care like hips, knees, cataracts are done in these facilities. 

And that will make it more efficient, make it less likely to have the kind of unpredictable impact of the emergency care. That also requires capital investment. 

And then allied to that is remodelling the hospital estates where we do have major centres which do have emergency departments because the most complex cases do need to take place there interlocked with other services in order to get optimum outcomes for people. But again, the environment in which people need to work in has got to be optimised to enable it to be efficient. 

So they'd be my three.

Matthew Taylor

Thanks Hannah. And when I was reading the report, talking to people about it, I was reminded of that well-worn phrase, the future is out there. It's just unevenly distributed, because almost everything that you recommend can be seen somewhere. 

I've been to elective hubs in Newcastle, Ascot, London and they're fantastic places. The Health Foundation finds that they're 20 per cent more efficient than undertaking the same procedures in a district general hospital, but we need more of them. 

I guess that takes me to the question, which is in terms of the balance of investment and as it were good practice, where do you think this kind of lies? How much of this problem is just fundamentally an investment - capital investment, revenue investment problem? And how much of it is the some places are doing great stuff, for example, in the way in which they manage their waiting lists and others are a long way behind. 

Hannah Farrar

I think if we can create better operating environments for people, by which I mean working environments as opposed to simply operating procedures in this context, where we can create better working environments in terms of elective hubs, but also the digital tools and systems that staff are being asked to work with, actually it unlocks quite a lot of efficiency improvements.

And where people have done that, I don't know if you've been to Trafford, but the Trafford Elective Hub, actually it is inordinately more efficient just simply because that space has been unlocked for people and it's kind of freed up staff to work in optimum ways. So I think that as a constraint on people, it can't be underestimated. 

I would say having said that, we do know that many of the elective hubs that already exist don't meet the gold standards set by GIRFT and in the report in terms of saying what's needed we assume those standards can be met and more aren't meeting them than are meeting them, through the kind of intelligence and data that we have available to us. 

So there is improvement opportunity and I think it'd be remis of me to understate it. 

Matthew Taylor

Yeah, it's really interesting.

I was chatting with Rory who runs our Acute Network a few weeks ago about how might be interested to try to bring together the people running elective hubs as a kind of group to start to think about improvement and peer and supporting each other in change. 

Because I find it interesting going to those hubs that there are differences, you can see those differences, they're new facilities, most of them. And there's a real opportunity, I think, to create a really kind of dynamic improvement collaborative between all of these hubs. 

What I did find all of them was a keenness to learn because they're all in some ways feel, you know, quite experimental. 

I want to kind of end by asking you to speculate on perhaps the most difficult issue of all for the government, which is the government is committed, Wes Streeting is committed to transformation. 

He talks about his three big shifts from acute into primary and community-based care; prevention; and kind of digital and technological transformation. But the problem, and this isn't a kind of abstract problem, I spoke to a hospital leader just this morning who articulated exactly these terms, is this double running problem, which is how is it you create a different health service, one which working with our partners in local government and the third sector, is able to bend that medium-term demand curve. 

How you do that at the same time of sustaining the services in the current form they have, or to put it even more pithily, speaking to an acute leader a couple of months ago, who said to me, look, if I could give 5 per cent of my budget to primary, it would be utterly transformative in terms of what primary could do and utterly transformative for the system. But I haven't got 5 per cent to give them, even though I know it would be so. 

What's your answer to this conundrum of a government that wants to transform health care but has no money to undertake this kind of double running? 

How do you, what's your theory of change of how you get from where we are now to where we need to be?

Hannah Farrar

It's a fiendishly difficult problem and it's one reason why we wanted to do this report on elective care is because compared to the question you're asking, Matthew, it's more straightforward and actually we need to solve some of the more straightforward things so that the brain power and the effort can go on to the more complex challenges of shifting the pattern demand of how, I mean, people use different phrases for it, but like the left shift, the anticipatory demand, but the theory is and the practice that capital is a huge enabler for change. 

Capital enables you to use labour in a different way, or people, in a different way. And it has been artificially constrained in the way the health service has operated over the last decade. And actually, if there was more flexibility for organisations within the health system to kind of self-determine what's capital versus what's revenue. Actually, you can achieve a lot if you can invest in your infrastructure and your digital systems and advances. 

So, partly we need to stop the artificial divide on that and recognise its role in pump priming, if I can put it that way, or double running. 

Matthew Taylor

Yes, well, I'm sure that's right. And of course the denuding of capital for the NHS was another theme of the Darzi report and something that we've talked about a great deal. I think one other element of that is we need to try to join up more effectively in understanding the impact of NHS investment beyond the NHS. 

So in a couple of examples, there's a new town where, currently held up in the new hospital programme, which has been, of course, suspended where the old hospital, the building of a new hospital is vital for the health service, but actually the old hospital site is going to be used for housing, which is critical to the regeneration of that town centre. 

Or another example I heard was of a local authority which offered the health service an abandoned department store, which could have been used for a community diagnostic centre, I don't know, maybe an elective hope, who knows. But capital rules meant that health system was not able to take advantage of this enormous opportunity. 

So we need more capital, we need more flexible use of capital, and we also need a more entrepreneurial approach to capital, I think, because NHS capital investment, has externalities which go beyond the health system. 

Maybe that's a subject for a future piece of work. I just want to say, Hannah, we at the Confed really enjoyed working with you on this report. We're really proud of having produced it with you, and I hope it's the first of many bits of work we'll do together. 

Hannah, thank you for joining me on Health on the Line. 

Hannah Farrar

Thank you, Matthew. It's great to be talking to you.