Paul Corrigan CBE and Isabel Hardman: Avoiding short-termism in the NHS

Matthew Taylor

Hello and welcome to Health on the Line. Later in this edition of the podcast, we'll be talking to Paul Corrigan. That interview we recorded the day before his role as a Department of Health advisor on Labour's ten-year strategy was confirmed. Fascinating conversation with Paul. So stay tuned in to listen to that. 

But before that, and I'm sure it's going to be equally fascinating, I'm talking to a bit of a hero of mine, Isabel Hardman, journalist and author of many books, but I'm particularly talking to Isabel today because of her book, Fighting for Life. 

So Isabel, welcome to Health on the Line. 

Isabel Hardman

Thank you for having me. 

Matthew Taylor

The reason I really wanted to talk to you was because of your book, Fighting for Life. And we talked about that on this podcast a few months ago. And it's a kind of analysis of the history of the health service, things that have gone wrong. But one of the key themes in it is the impact of political short-termism on the health service. 

So my first question is about is given that part of your kind of diagnosis of the NHS's problems is this problem of political short-termism, how do you think Labour is doing so far in terms of the way in which it's talking about the health service? 

Isabel Hardman

Well, I think Labour has landed better than it did in 1997 in that it's coming to government with a health policy, which it didn't in ’97. That was something that Tony Blair said very clearly to Alan Milburn when he made him a health minister under Frank Dobson, he said, we don't have a health policy. Whereas I think this time around they have spent a long time thinking about it. John Ashworth, when he was shadow health secretary and then obviously Wes Streeting have put a huge amount of opposition time into coming up with a philosophy for the long term of the NHS.

Having said that, they're stuck in, I would say it's a short-term crisis in terms of waiting lists, but it's going to take them a long time to fix it. So it does sort of stretch into the long term, but could distract them from their longer-term aims that you and I have both talked about and are very keen on, of rebalancing the health service so it's not all loaded towards the acute end of a patient's journey, but actually at the stage at which it's easier and cheaper and better for them to be treated in the community or indeed prevent it. 

And this is one of the issues with the NHS is that I wouldn't say it's been in perma-crisis, but a crisis is never that far away. Indeed, the Department of Health starts planning, so tends to start doing the planning for the next winter in January because it knows there's going to be another crisis in a few months

And because it's going from one crisis to another, it never really has the opportunity to take that step back and say, where do we actually want to be spending the money? And Wes Streeting has come in with a very clear view about that, but he's also got a massive task on his hands just dealing with the here and now and the industrial action, which you've obviously spoken about a lot, Matthew.

Matthew Taylor

Yeah, so I think we knew, didn't we, Isabella, elements of what was going to happen before the election. I briefed our members about the fact that there was probably going to be some kind of audit of the health service that was announced last week. Ara Dazi is going to undertake a kind of audit of performance. 

And then there was going to be this kind of ten-year plan. And we've heard about Paul Corrigan, Sanny Warren being part of that. It feels quite, as you say, quite a kind of strong, credible of model of change. Do you agree? 

Isabel Hardman

Yeah, I do agree. And the fact that the audit, I think, is going to report in September is something I find quite cheering because normally whenever a government announces a review, I sort of groan because I think, you already know what the problems are. You're actually just delaying having to make the decisions. But I think probably to get that detailed information over the summer is probably fair enough as long as they then act on it as soon as they receive it in the autumn.

I think one of the really interesting things about the past week has been the language. So we were both anticipating Labour to come in and say public services are broken. But I don't know about you, but I was really struck by how far Wes Streeting in particular has pushed that line. So on entering the Department of Health, he said the policy of this department is that the NHS is broken. He's since described it as wrecked and it's been very, very striking that that is official government policy now. 

And I think it's one thing to have that as a line, as a retort in the House of Commons when you're at departmental questions and you've got Tories complaining about something. And just as David Cameron and George Osborne would do back in the early days of their time in government, they'd say, but know, Labour broke it. I was expecting that from Labour. I don't think I was quite expecting the language to be that as strong from Streeting as it has been. 

But I suppose he has also really strikingly, announced that the Department of Health is an economic growth department. And that's something that a lot of people have been very, very keen for the health department to have as its aim, which is to contribute to the health of the nation so that the nation grows and flourishes rather than, as I said, be dealing with a permacrisis. So it's not all sort of doom and gloom from Streeting, but I was really struck by how strong his description of the NHS was. And I think it's the kind of thing you can only really say if you're a Labour secretary of state. 

I think if you had a Tory saying that, people would immediately be saying, you're about to privatise us. Now people are saying that about Wes Streeting as well, but I think that's more of sort of subset of those who are further on the left, who I think based on my kind of Wes watching over the years, I think he quite enjoys winding that lot up.

Matthew Taylor

I'm sure that's right. indeed, we've done loads of work on that kind of health as an investable proposition argument, you whether it's around getting people back to work, around health on the high street. 

I visited last week a community diagnostic centre and a shopping centre in Wood Green. It's got a fantastic example of how you can use health facilities in ways which can contribute to the local economy. So it is great to hear him saying that. 

Now, last question, Isabel. I really hope that the ministerial team and their officials have read your book because it is important to understand how things have gone wrong in the past.

I was reflecting the other day on how when we look back on new governments and we can see the mistakes that they made, look back on ’97 and we can see that Blair didn't really use his political capital to grasp the most difficult issues. He left it two, three, four years and some of that political capital had been used up before he really grappled with things. 

When you look Labour - I know it's a hard question as well - but if I had to say to you, do you think, know, what might be, either it's the whole government or just health in two or three years, if we look back, what do you think is the thing you're most worried about them getting wrong? 

Isabel Hardman

What a big question. I am really interested in how far Keir Starmer wants to push the Labour party on health because it's all very well saying in the abstract, we want to move resources from acute to primary preventive but you have a Rachel Reeves-shaped problem in that you're not, you know, resourcing both, you’re moving money. 

And I remember actually it was interesting that Sally Warren's gone in because she's obviously made this case, but said that you can do this without moving money. But I think that's probably not something that's going to wash with the treasury because there's not going to be a massive overall boost to the NHS spending envelope.

And at that point you get debates about whether certain acute services should close and so on. What do you do first? Do you close hospital beds? Do you close wards? That kind of thing is always really unpopular with MPs of any stripe. I think that the use of the private sector is something that the left tends to get very upset about if - and I don't think Streeting is going to sort of push for a kind of red in tooth and claw competition element to the NHS - but if you're starting to move to anything that looks like a move away from collaboration, then you are going to get a lot of soft left MPs getting quite uncomfortable. 

And I'm just interested in how much Keir Starmer has on this because I don't think from the sort of blurted out answers that he's given from time to time on the health service that he has the same ideological flexibility as Streeting. He's not a Blairite and that's fine. But I think one of the really revealing answers in the TV debates during the election campaign came when he was asked whether he would ever use private health care for a loved one. And he immediately said, no, not at all. Now I was really struck by that because I know that Wes Streeting, because he said this in interviews, would say, yes, of course, but I want the NHS to be good enough for people not to resort to private health care. And I think that kind of ideological commitment to the NHS that goes above and beyond the emotional response that I think most Brits have where, you know, of course if your loved one is sick, you will do anything to try and get them timely treatment. And people love the NHS, but if it's not working for them at the time of, you know, somebody waiting in pain for a hip replacement, then they'll just say, we're just going to go private. And that's the interesting thing I think is where is Keir Starmer's emotional response and what does that mean for Labour rebellions on the health service? 

Now think it's really interesting that Paul Corrigan has come in. It feels a bit like one of those sort of TV series where they do a series about ten years after the original one and the gang come back together and they're all a bit older and wiser and Corrigan's back in. And I had a wonderful time. I think I interviewed him for about four hours for my book actually because he's such a fascinating guy. But he had to work so hard with Alan Milburn and then John Reed to get foundation hospitals through the Labour Party and it cut Blair's majority massively. 

I remember him telling me that they had 400 meetings. Some of them with the same Labour MP over and over again to try to get that over the line. A source of great angst for Paul Corrigan's wife who was the chief whip at the time, that basically he was the one causing her the most strife in terms of whipping MPs. 

But it is really, really difficult sometimes to get things that might academically make total sense, but that emotionally for Labour people can be very, very hard to contemplate.

Matthew Taylor

Yes. And do you know, Isabel, who was the person in Number 10 leading the kind of operation to try and get the foundation trust initiative through? 

Isabel Hardman

Who was that? [Asked humorously]

Matthew Taylor

It was me, Isabel. [Isabel laughs]

So, yes, the old gang is getting together, but not me, apparently, which is fine because I love running the Confed. 

Isabel, it's been really brilliant to talk to you. We're going to get you back on every few months to tell us how you think it's going. And thank you also - very professional of you for mentioning Paul Corrigan in your last answer because it's him that we're going to be talking to now. 

Isabel Hardman, thank you very much.

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Matthew Taylor

Well, these are truly momentous times, a change of government after 14 years, a new secretary of state with big plans for health. 

Now, who better for me to be discussing this new world with than Paul Corrigan, an old friend of mine, Paul Corrigan, CBE. Paul has held all sorts of roles around the health service. I could spend ages describing, but I'd pick out two or three key things. Paul was special advisor to Secretary of State for Health, Alan Milburn. Paul has held senior roles the health service himself. He was director of strategy and commissioning for NHS London between 2007 and 2009. Paul's written extensively about the health service, about leadership, about politics and his recently discontinued blog was really a must-read for managers and leaders and other people interested in health policy. 

So Paul, welcome to Health on the Line. 

Paul Corrigan 

Hi Matthew. 

Matthew Taylor

So Paul, let's just start because you're a seasoned political commentator as well as an expert on health. Tell me what you made of that election result. 

Paul Corrigan

Well, elections are something very special for me. I mean, other people will measure their lives from their children's birthdays, and for me, it's elections because I was brought up in a family that from the age of 11, my family used to run its own little committee room. And that meant in the 1959 election, I remember being part of running numbers backwards and forwards. So elections really matter and have an impact on me because I think I get a bit dewy-eyed about democracy even when I lose and this is my eighteenth election and ten losses and eight gains. 

So I think the thing about it is I still feel it's all a bit remarkable that on Wednesday last week there was a government and on Monday this week there's a different government and things are just very different. So that's my general feeling about elections which is they're big events for me and big events for the country where a change happens in a very dramatic way. I mean, one of the things in 2001, when I went to work for Alan Milburn, one of the things I said to Mike Barber, there's a very odd thing about elections because the political party does the second most difficult thing in the world, which is winning the election, and then does the most difficult thing in the world the next day, which is running the country. 

And so it's a big deal. And this one, because I've always been a Labour party supporter, it's an even bigger deal for me because it's about a big change in the direction of the Labour party. 

And so I celebrate elections even when I lose and I celebrate this one because I think it's a very significant one for the country. 

Matthew Taylor

Let's stick with reminiscing for a while because I'm interested in your reflections on the difference between now and 1970. Now some of that is pretty obvious, but let's pick out a couple of things. 

So this, I think, is the first time there's been a change of party in government without the new party having a commitment or pretty soon reorganising the health service. I was going say that, of course, the Conservatives in 2010 said they weren't going to reorganise the health service and then did it. So do you think there's something significant about the fact that Labour has committed to know they want to reform the health service, but it said it's not going to reorganise the health service? Of course, Frank Dobson did reorganise things in 1997.

Now, I think that is significant. And I think in a sense, it demonstrates that in the sense learning theory works, which is if you look at most of the reorganisations that I was involved in and Lansley was involved in, they didn't achieve very much and they destabilize a lot of people who really shouldn't be destabilized. So I think what's interesting about it, very easy to say there'll be no reorganisation. But what that means is that everybody in the current system needs to make it work. And at the moment, I'm not sure it does work. So governments usually come in and say, this current system doesn't work and we're going to abolish and create another system. Whereas actually, I think what needs to be done is people's behaviour needs to change to make the current system work. And I think that is quite as much more difficult as a change than pretending you're changing the world by passing an act of parliament. So there are tens of thousands of people in this what we've now got quite a complex system trying to do things which come into conflict with other people and how that is resolved, as I say, is going to need the behaviour change of almost everybody. absolutely. 

Matthew Taylor

And that reminds me a bit of what Patricia Hewitt said, of course, in her report last year when she talked about having created integrated care systems, but not creating the environment in which they can succeed. We'll perhaps come on to that in a moment. I'm going to go straight into what seems to me to be the kind of hardest question actually, or the one that I'm finding most difficult to get my head around. You know, I'm not going to mess around Paul, let's go through the really tough stuff. Keir Starmer is, I think this week, by the time people hear this broadcast, he already have had the meeting, meeting with the metro mayors - combined authority mayors. Now, Labour has a big commitment to devolution and it's really interesting that Keir Starmer emphasised that point at his very first press conference. Now I know because I work for Tony Blair that getting Tony Blair interested in local government was not easy at all, to be honest. He was not a great enthusiast. So that's a really big shift that Keir Starmer says, no, these mayors are major stakeholders from whatever party they come. 

So you've got that kind of idea. But then you've also got another big change from way back when, which is the existence of integrated care systems, which are bodies that bring together very often local government and the health service try to take a kind of system view. 

But then the third element in all of this is you've got a secretary of state, Wes Streeting, who, like all secretaries of state, is quite impatient to drive change, has got some key targets, particularly around waiting lists, wants to go back to all the constitutional targets that the health service has got. And that can often suggest a kind of rather dirigiste approach, a kind we in the department are going to fix the targets and we're going to directly input; often people think that means directly inputting into acute hospitals, bypassing systems, let alone working with local government. 

So Paul, how would you kind of pull together these various strands of how Labour is going to govern in relation to the health service? 

Paul Corrigan

Well, I think there needs to be sort of a short, medium term and longer term approach to these changes.

You commented on Patricia Hewitt's report on ICBs. Undoubtedly, I believe, and along with I think most people, that integrated care and integrated care systems are the future of any health service and ours in particular. However, we created these organisations, gave people jobs to do, and didn't do any development about how they might do these incredibly difficult jobs.

And so the four main things that ICBs are meant to do are incredibly hard about efficiency, about using the health service to create economies, about value of money, about prevention. And the assumption that these can do these tomorrow, well, it's not happening and it needs to happen. So there needs to be a medium- to longer-term issue about developing ICBs. There needs to be a short- to medium-term issue about getting waiting times down.

The reality about the election is that most people saw the NHS as the first, second or third issue in their lives and in their politics because many people know someone that's waiting for a very long period of time. And if the government doesn't fix that, it doesn't fix the NHS as far as the public are concerned. 

So we actually have to do that. That has to be done alongside the beginning of a longer-term process to create integrated care. And the two things need to start happening at the same time. One is medium to longer term, the other one is shorter to medium term. 

Matthew Taylor

I see that. I guess to push the point though, Paul, our experience often in politics and policy is that the long term never arrives, that everything feels short term. And also, as I've written, the danger of looking as though you're bypassing systems in order to directly work with, for example, acute hospitals on waiting lists is that that sends a powerful message into the health service, which sounds like, well, when it comes to the things the secretary of state really cares about, he doesn't really believe that ICBs, ICSs can deliver. 

Paul Corrigan

Well, when I talk to acute trust team executives, nearly all of them know that they can't deliver on their own. They recognise that flow in their hospital totally depends upon flow into their hospital and flow outside of their hospital. And so the crucial thing for an acute chief executive is flow of patients through rather than flow of patients in. And the flow of patients through depends upon other organisations.

And so as much as acute chief executives might say, I'm in charge of my organisation, actually they're not in charge of organisation. And they know that because they need external organisations to work with them to create those partnerships. 

So I don't think there are many that believe the answer to acute waiting times is only to be found in acute hospitals. So I think there's an appreciation of a set of partnerships that are necessary. It's how you get those partnerships working together. I don't think they work very often and very well at the moment. 

Matthew Taylor

And that's something, and this is one of the reasons why, Paul, I've always valued your insights so much as because you've got your hands dirty by going into places, working with leaders on these kinds of issues. Like how do you get people to collaborate effectively, to integrate effectively? Now these are conversations you've been having for decades. 

So when you say it's not happening at the moment, why do you think it's not happening at the moment? And if Wes Streeting was to say to you, look, well, how do I get these trusts? I'm getting phone calls from trusts who tell me it's the system's fault. I'm getting phone calls from systems who are telling me it's the trust's fault. How do I get these people to work more effectively together? What would you say to him? 

Paul Corrigan

Well, I would say, and this is a small pass on the back to the Confed, that he needs to read the Confederation’s report that came out in March this year on developing new forms of financial flows. The reason the integration doesn't work very well is that the financial system in the NHS fragments the system rather than integrates the system.

So there we are trying to create a relationship between, for example, primary care or domiciliary care and stopping elderly from going into a hospital. And there are just in those three areas, there are three entirely different funding streams that don't relate to each other. And so we can come up with a really clever scheme to relate these three things together. But actually, because the financial flows don't work like that, our clever scheme is split up by the way in which the finances work. 

So we need to have some innovation about how we work the money through the system so that, for example, the extra money that goes into either primary care or domiciliary care to keep far older people out of hospital is in some way paid back by the savings that are made in that entirely different stream in emergency care and the hospital. 

And when you suggest this to people at the moment, they find it very, very difficult to imagine a different form of funding flow. But without that form of funding flow, I don't think we're going to get the integration. And without the integration, I don't think the acute care system will work. 

Matthew Taylor

So you think it's doable, Paul, because I completely agree with you. I guess the scepticism people have is that that sounds like a pretty significant bit of engineering. And when governments have tried to do that kind of thing in the past, it often goes wrong because it's so hard to predict what's going to happen. And when you do it, almost inevitably things don't happen quite as you want them to. 

This is one of the reasons, Paul, why, you know, in all my kind of work around change, I came up with this little rather trite phrase, but the phrase for how you need to go about change is you need to think like a system and act like an entrepreneur. You need to think systemically as you've just described but you've got to be very agile in the way you do this because grand plans to do things differently in the centre rarely survive contact with the reality. 

Paul Corrigan

And that's why we need entrepreneurs in the health service. And what you and I mean by entrepreneurs, I mean, as it used to be said, I had the French, I'd have done much better, right? So entrepreneur means between two things, right? Doesn't mean making money because you're between two things.

It is actually demonstrating if you're between two things, you can make the thing work better. And that's generally done by people who are quite innovative and stand between two things and see something different from what other people have seen. 

We've always linked that with making money, but actually there are public sector managers who are brilliant entrepreneurs because they do that sort of thing. So what you're quite rightly saying is if there is a top-down reorganisation, which doesn't allow people in every system to be entrepreneurial, then it generally doesn't work. 

So you and I could construct a new financial flow which dots every T and crosses every I and looks as if it's going to be completely perfect. But because there's no room for human beings to make it work, it wouldn't work. So the answer to that is not to do that. The answer that is to construct a system which actually has the ability of human beings, in this case, primary care, hospital doctors and others, to make the system work. You need in your work in the system and think like an entrepreneur, you need some room for human beings to make these things work. 

So again, patting the Confed on the back, what's happening in this year is that a number of ICBs are looking concretely at how to construct new financial flows in order to make better care for the elderly. And they're doing it as real people. They're not doing it as an abstract set of sentiments. 

So I think it really is possible for people to grab hold of these things and to make them happen. 

Matthew Taylor

Thanks, Paul. 

And let's turn to another element of this new Labour government statecraft, which is the notion of the mission. 

Now, we've been really keen on this because we think it's very important. One of the peculiarities of the debate about health in the UK is that when we talk about health, we almost immediately start talking about the NHS, when actually health policy is much, much broader.

And also, you we agree with all sorts of people from kind of Chris Witty beyond who would argue that it's really hard to see how the NHS is going to be sustainable unless we can help people live healthier longer. And the NHS is only part of the solution to that. 

Are you excited by this notion of a health mission? Again, Keir Starmer talked about this on Saturday. He'll chair that programme board. What's your kind of view on how do we get mission government to make a difference? 

Paul Corrigan

First of all, I think it's both - actually essential and it's essential not just for the future of the health service. I mean, because the statistics of illness coming down the road towards us into the next ten years is just enormous and will overwhelm a reactive health service. But it's not just that, it's just people have rotten lives if they get ill in their early 50s and they lose 15 years of their life when they're ill, when they could be playing with their grandchildren. 

So this is a social good in its own right, as well as saving the National Health Service. And I think it exactly is a mission rather than a policy. It's something which then I think we need to say, what can the country as a whole do and not just Keir Starmer? And Keir Starmer's job will be to bring together aspects of every ministry that can do something about health. And that's all of them. And that generally, that's not seen as culture. A whole range of ministries don't see health in their area, but it is absolutely crucial in their area.

So I think we will need people in all of those departments. One of the things about modern departments of state in the Whitehall is they all have non-executive directors. It'd be quite interesting for every department to have a non-executive director interested in health. And so they just simply said, and what about health?

And this was tried in New Zealand around budgets where you could say, what would it look like if rather than having an office of budget responsibility, you said, what does it mean for the economy? If you had an office of health responsibility that said, what does this mean for health? And if year after year, you don't put up fuel tax because you want to maintain petrol prices, that has an impact on health. 

So I think we can see the architectural government that would raise health in all policies. It's then making that happen is actually something which hasn't happened in a very departmentally-focused Whitehall up till now. The reason I think mission is the right word is we are planning to change a lot of the ways in which government works. 

Matthew Taylor 

That's right Paul. For me, it's three elements. So it's one that you've described, which is a recognisable approach that we've seen in relation to equalities.

I remember way back in a local government being required to explore what it meant for equality. That was government policy as well, I think. But we've also seen that same approach in relation to climate change, that we have to consider the implications of policy. So that approach, which is, let's make sure every policy is looked at through that lens. Now, the problem with that approach is it can be a bit woke, a bit bureaucratic, a bit box ticking. So I think you need two other things. 

The first is you need to identify areas where joining up between health and other departments and other priorities could really be a game changer. And I think the obvious area here is health and work, where the past, the previous government did some stuff around work well, and we've supported ICBs in that programme. But there's so much more that we could do if we thought about work and health together, getting people back into work, keeping people in work, the quality of work. 

But then the third element that I think is important is having a clearing house, where if there is a policy that doesn't quite work, if you just look at it through one department, but actually if you look at it through two or three departments, it would work, you can get on with it. Because this is the other real frustration. So if you take something like homelessness, if we had a joined up approach to homelessness, recognising the number of people who are homeless who end up in A&E departments, how people who are homeless can get stuck in hospitals or worse, can be just discharged onto the street. We think about the criminal justice elements of this, the housing elements of this.

We're trying to do a piece of work around how do we get more refugees to take up work in health and care. So again, you need various departments to look at making that happen. So that would be my third element is policies that may not be huge, but which will never get over the line if they're just looked at from one department or one department's budget. But if you can get the other departments and you can be reasonably agile, you can make more progress. 

Do you think that's credible, Paul? 

Paul Corrigan 

I think it is. Coming back to a phrase you used just now, I think what you're describing is classic entrepreneurial work, which is where somebody sits between two departments and says, yeah, if we did these things together, then something different would happen. And again, if you think about your description of, again, the human cost, but the amount of economic resource wasted in homelessness is because nobody is constructing the right financial flow around the costs of all of this and simply saying, it'll cost us more to house these people.

It would cost a lot less if everyone joined up that amount of money being spent. But to do that, we need people who are passionate about the joining up, rather than passionate about their, in a sense, the policy in departmental aid. 

And that's not going to be easy because departments have run things before. So these mission boards are going to have to have missionaries. They're going to have people that go out and sell and produce different ideas and different ways of making the world work because the people who are interested in department X are just interested in X. 

So I think there are tens of examples that we could come up with about how a small cost can save lots of money if we work across departments. 

Matthew Taylor 

And Paul, you've spoken to Labour folk, you've advised them. One thing that's really important here is understanding that these kinds of changes do require investment in things like organisational development and training.

You know, and we've seen over and again in the health service, haven't we, changes which have been undermined by a failure to recognise the need to invest in leadership or normalised organisational development. I think of the establishment of primary care networks, you know, which is broadly a positive story, but yet what they've achieved, they've had to achieve with almost no recognition of the fact that you're asking GPs to play a very different kind of role. 

So do you sense that folk in and around the Labour, I was going to say Labour party, but now Labour government hierarchy, that they do understand that if you want to do things as differently as this, you do have to invest in organisational stuff. 

Paul Corrigan 

Yes, and I think, do people understand as much as they need to? I think perhaps not, but I think more and more of the things we're talking about, there are pretty good examples on the ground, and are very small, and that ministers come and look at that and say, that's great and so what we need is that going on in 50 per cent of the country. But developing people in the other 50 per cent of the country to do these things is a process of development. And to do that, people, need to believe that human beings can change and can grow and do different things if they're given the leadership to do it and they have the space and time to be developed. 

One of the things that happened to me when I was working with Alan Milburn, is there was a famous Irish doctor called Aidan Halligan. And Aidan set up a meeting between the Department of Health and the Ministry of Defence, looking at how we trained our top leaders. And nobody in the Ministry of Defence could believe that we didn't do it, that we didn't train them. Because in the Ministry of Defence, if you want to be a brigadier - you don't have to be a brigadier, you can go on doing all sorts of things you're doing - but if you want to be a big idea, you've got to spend six months doing IT, six months doing HR. And you develop people through practical activity. And you have a spreadsheet of the top 3,000 people and you work out the things they need to learn to do. 

And I don't think we have, well, we've not had the same approach in other aspects of public service and the forces. And I think we're going to need to develop that and that will take time and effort. But the return on that investment is enormous. 

Matthew Taylor 

Which brings me to my final topic, Paul. You've been very, very good at giving us so much time, but it is the money question. 

So, I found myself over the last few days quite conflicted in sense that we're working on a document. We've sent it in now to the secretary of state. And it's largely about how we can help this new government deliver the things that it wants to deliver. But it's also our job, I guess, to flag up things which we haven't, perhaps we don't feel have been fully addressed in the election campaign or the manifestos. And money is one of those things. 

Now, I don't want to seem like one of those predictable trade association people who come along and go, well, you we can't do anything unless we're given, you know, ladles of money. And I don't want to kind of be seen as predictable. 

But yet on the other hand, I feel like I kind of need to say to the government, there is quite a big gap right now today between what systems and trusts have been told to deliver and the money that they have got to deliver that. And that that means that plans are at risk and the preparation for winter looks quite shaky, there is quite a lot of risk built in. 

How do we talk about money in a way that is realistic, reflecting the reality, but doesn't, in a sense, confirm a view which new ministers may have and that many of the public have, many journalists have, which is that the health service just is simply always, always, always asking for more.

Paul Corrigan

Well, I suppose one way to change the impression that we're always asking for more money is to stop asking for more money. But that may be a bit simple. And it seems to me there is a lot of evidence that CIPFA and others, IFG, know, uncovered a 20 per cent increase in doctors and nurses in four years in acute trust and not an increase in productivity. And I think that is a problem. I think it also is a problem that there is an enormous variability in productivity between different parts of the health service. 

So I can understand people saying there needs to be more money, but the money that's there, and I'm talking very specifically about two trusts there because the same amount of increased money has not got into primary care. But the money that's there, when people say we've had a 20 per cent increase in doctors and nurses and we need more money, I just think it's not feasible. 

So I think coming back to my idea of periodisation, that in doing the medium to the short to medium term and talking about decreasing the long wait, one of the things that the medium to long term has to do in constructing a new model of care is to find different experiences for people have at the moment of waiting. It is truly awful for people who are said, I think you need to go and see a specialist and then no one hears anything for a long period of time. And then they might hear something and they might not.

So one of the things that I think the medium term with a different model of care can look at is how do we change that experience of waiting so that something happens to people? And I think technology can do that. I think technology can make sure that people are not just left on their own to wait, but are part of a national system that makes them feel they're part of something. 

So I think there's a different way of dealing with the whole process of waiting as well as increasing productivity. In five years’ time, will there need to be more money? Probably almost certainly yes. But hopefully by that time there might be some more money to use. 

Matthew Taylor

Yeah, it is a conundrum, Paul. I feel that we do need to say that we think there are real vulnerabilities in the current financial settlement. But I think we have to make a deep commitment to recognising that the NHS, once it is more consistent, not just about how much money, but it's the consistency of funding. 

We've seen NHS annual spending move around from the six or seven per cent of the labour years to one and a half per cent in the austerity years, then back to over three per cent for a few years, and then back down to less than a percent this year. And that is pretty awful. 

So I think somehow the message we have to give at a the Confed is things are very, very tough right now and there are real dangers and there is a gap. But there is a real desire for leaders to get into a situation where we can balance the books every year and that is what is expected of us. So that's going to require bit of trust as well. 

But look, Paul, I'm really grateful to you for joining us today and we at the Confed, we've been working with you in the past. We look forward to working with you again in the future. 

Paul Corrigan

Very good. Nice to talk to you, Matthew.