Daniel Elkeles: The biggest barrier we have is thinking in silos

Matthew

Hello and welcome to the latest Health on the line. I'm speaking to you from our Primary Care Conference, the first face-to-face primary care conference in London. It's a fantastic event which just had a really good session with Amanda Doyle, Claire Fuller, Philip Johns from Coventry and Warwickshire, talking about the future of primary care really engaged audience. Things are very tough for primary care, but the group we've got here, it's really wanting to focus on solutions and particularly how we can work effectively at place and system level. So, it's fantastic to be here and I'm really proud of the work we do in the Confed on primary care and linking that to our other networks and particularly to our ICS Network.

I'm also talking to you on the day when we hope we'll be seeing meaningful negotiations between the RCN and the government. We welcomed yesterday the news that these negotiations are going to take place. Last Friday, we wrote to the Prime Minister and said he had to choose either to continue to refuse to negotiate or to jeopardise his commitment to reduce waiting lists. So, we're glad that the Prime Minister seems to have made the right choice. We hope these negotiations are fruitful and we hope that we can also see the beginning of conversations with the other trade unions, with the junior doctors.

Although I have to say reading today, the government is also determined only to have a 3.5 per cent pay rise for the NHS next year. I do wonder how these sums are going to add up. We're either going to have to find a lot more money that we haven't got to pay for salaries that the government centrally is not paying for or else we're going to have to see our staff suffering a real-terms pay cut at a time when it's already tough to recruit and retain and motivate the staff we want.

So really big challenges. But today, let's at least celebrate the glimmer of hope in terms of that industrial action that was worsening and putting an enormous strain on our leaders and having a real impact on the public.

Final couple of things before I encourage you to listen to a really interesting conversation I had with Daniel Elkeles, chief executive of the London Ambulance Service. One is if you've got time, check out the blog I've written about the role of social care in prevention. I'm trying to suggest we need to change the conversation with local government and social care. So, it's not just about social care helping get people out of hospitals, but it's also about the really important role that social care can play in preventing ill health by supporting the resilience of some of our most vulnerable members of our community.

And then finally, another thing that I'll be writing about and I'm really excited about is the work we're doing around the health service and regeneration and the ICSs fourth objective around social, economic, sustainable development. This is a really big agenda. It's not one that is widely known, but actually I think absolutely central to a different kind of way of thinking about the health service. On the one hand, understanding that health policy is about everything we do planning, housing, welfare, education, but also that the health service has got a really big role to play in local economy, local society and sustainability. So, changing the terms of the debate. So do check out the work we're doing in that space.

So that's enough from me. I hope you'll enjoy the conversation with Daniel.

Matthew

I'm delighted to be joined by Daniel Elkeles, who's chief executive of London Ambulance Service. Welcome, Daniel. How are you?

Daniel

I'm well, thank you, Matthew.

Matthew

Thanks so much for giving us the time, particularly because I think today, the day we're recording this, is quite a challenging day for you. There is industrial action.

Daniel

So today will be the fourth day of industrial action that staff in London Ambulance Service have taken. Yes.

Matthew

And how are you coping with that? I know that you're making a public statement about that today. I think the thing you want to kind of emphasise is that, generally speaking, we're managing to cope on these strike days, partly because the public is using services less intensively, but it's having a kind of underlying effect which we shouldn't underestimate.

Daniel

I think that's very true. So, a minimum service level is not the same as a high-quality service. Normally we'd put out 400 ambulances and 50 solo paramedic cars in a day, and today we'll just about manage to put out 200 ambulances. But of those, half will be staffed not by people from London Ambulance Service. In reality, 90 per cent of our staff will be taking industrial action today. And the time and energy that that takes to plan for is huge. And it means we can't be focusing on the things we'd love to focus on, like implementing the great stuff in the recovery urgent and emergency care plan.

The other thing that is really hard about this is that the debate seems to feel like it's between cost of living and inflation. But we keep missing out on, actually, there's a big patient care impact here because on a strike day, we get to almost 1,000 less people face to face. So those people, those patients are getting a less good service.

Matthew

I found that this aspect of it really interesting that what we've seen. and I think it's actually become less significant as the strikes have unfolded, but at the beginning, certainly the public's response to strikes, particularly ambulance strikes, was simply to be calling 999 a lot less. Actually, over the years, we often said to the public, only call 999 when you truly need to. And of course, one of the things that the ambulance service has said for years is that quite often ambulances get called out for things which really didn't need a call out.

So, when you look at the public's holding back, is that is that something that it has got positive elements to it or do you think that rather like covid it’s simply storing up more problems for the future?

Daniel

A lot of the public have listened to the message and made a very intelligent call as to whether they think they're having an emergency or not. And so, less people have phoned.

But we also run the 111 service for most of London. And what we have noticed is that most people make a choice as to whether to phone 999 or phone 111. Very few people phone both. And some people's perception of what is an emergency is very different to others. And so you can get people who phone 111 with a heart attack and a stroke as well as you get people who phone 999 with a nosebleed.

I think the really important thing is our job is to get people the right care, whichever access route they choose to use to come into the NHS when they have an urgent and emergency care episode. And in not being able to offer a full 999 service, I think we are likely to be causing harm to some people who are not sure what the right route into the NHS is during a strike.

Matthew

Just before we leave the strikes, I'm reading a fascinating book, The Paramedic at Work by Leo McCann, which I'm enjoying, partly because he's a sociologist and so am I. And one of the things in that book is that the last major industrial action by ambulance workers in 1990 was actually a kind of turning point because that was the point at which as part of the pay deal that was won in 1990, for those people who have a long memory, Roger Poole was the chief negotiator, and he rose to some notoriety at the time.

Part of that deal was about the upskilling of the ambulance workforce. That was really the point at which the idea of ambulance workers being paramedics rather than simply being people who were caricatured up to that point as people with first aid skills and who drove vehicles. So, given the importance of industrial action in the kind of evolution of the ambulance service and nobody wants this industrial action, do you think there are learnings that are taking place during this one as well?

Daniel

I think that book that that you refer to that Leo McCann wrote is totally brilliant. And I've read it too, and recommended my whole leadership team read it because it explains so much about the culture of paramedicine. But I think the parallel is different this time. Since the industrial action began, we already had the largest Unison membership of any NHS trust, but it's gone up by 1,200 people in the last three months. We now almost have 80 something percent of our staff are union members and that includes nearly all of the newbies, the newly qualified paramedics who are the future of paramedicine.

The issues that are people feel about this industrial action are very deeply felt. And it's not just about pay. It's as much about the state that the NHS is in and people feeling that they can't do the job that they would love to be able to do and feeling they need to voice their frustration about that.

Matthew

I want to turn to the kind of core issue of how does the NHS get out of this apparent state of what we might caricature as perma crisis. But before we do, because we talked about Leo McCann's fantastic book, I just want to delve a little bit into your past and the insights that's given you, because the interesting thing about you, Daniel, even though you're still, you know, relatively young, is that you have been a commissioner, you have run an acute hospital and now you're running the ambulance service.

So I'm interested, as you've taken each step in the health service, has that kind of helped you to see the system in a different way because, I guess if I was, I’ll lose my job for saying this, but nevertheless, if I was a bit critical of the kind of narrative in the NHS, I'd say there's quite a lot of blaming goes on, quite a lot of nobody carries risks like we do, nobody has the challenges that we do in our part of the health service.

Given that you've worked in three different bits of it. Tell me about what you've learnt as you've moved around and how that's given you a kind of, has that given you, do you think, a more rounded view of how the whole service works?

Daniel

Well, I hope so because I've been doing it for 27 years now.

I think the thing that I learnt the most in running Epsom and St Helier hospitals was if you want to make change happen and for staff to feel that they've got a better place to work, it is actually all about what is their interaction with their line manager. And can you provide the support and development that people on the frontline need to feel able that when they're dealing with very difficult situations, that they feel supported and can develop themselves?

And so, the point in the Messenger review all about culture feels to me absolutely crucial. And the thing that I then identified when I came into the ambulance trust, everyone says it's very different. And the ambulance sector really is very different and it's different for lots of reasons.

So, there's the obvious bit about it's a uniform service, it's very unionised, it generally works on command and control.

But the bit that is so different is the bit that we all take for granted in the rest of the NHS, which is people work in teams in the rest of the NHS and in general multidisciplinary teams and the ambulance service is both almost uni-disciplinary, it is nearly all paramedic, but it's very hard to get teamwork to happen because we operate from so many different locations. In some sense it's a bit like a community service or a mental health service. But in community and mental health, the shifts all align. So, you have team time at the beginning, at the end of the shift. In ambulance land, the crews start at a staggered time all throughout the day so that you get an even distribution of activity. But what that means is there's very little contact between your frontline staff and their managers. And that is very bad for culture because it means people feel very isolated and also they practice very autonomously.

So that is the big cultural paradigm, the ambulance sector needs to change to make it feel much more like the rest of the NHS. We've got to get multidisciplinary teamwork into the way we work.

Matthew

That's fascinating. Let's just get into that a little bit more, Daniel, because we have seen, haven't we, some pretty damning reports about some of the other kind of emergency services recently. You're in London, the Met Police has been seemingly embroiled almost continuously in kind of scandals, going to the heart of the culture of the organisation. For some time, we've had some pretty terrible reports about aspects of behaviour in the fire service. As Leo McCann points out in his book. You know, there are elements of that kind of that kind of slightly macho kind of culture within the ambulance service as well.

Across your career, Daniel, you've achieved a great deal and one of the things that you've often achieved is really improving kind of staff morale, staff engagement wherever you've gone. So, you've described one element of that cultural change, which is the kind of multidisciplinary element, but is there also something around, as it were, those kind of issues around a more inclusive, more open kind of culture?

Daniel

Absolutely. One of the first things I did when I came here was start a set of conversations about what are our values and behaviours, because it was very clear that the number of incidents of staff behaving very badly to other members of staff was very high.

It was also clear that you could almost say that sexism, racism, all the bad character traits were all quite visible and people didn't know what to do about it.

So, we had a conversation which involved 2,000 members of staff about what makes a good day here and what makes a bad day. And the thing that leapt out was that what makes both a good day and a bad day were people not feeling cared for, people not feeling respected and people not working in teams.

And so, we have a new set of values and behaviours which say together we put caring, respect and teamwork at the heart of everything we do for Londoners. And we wrote a book about what did that mean? And that included things like a sexual safety charter. And then we took 650 of our frontline leaders through a one-day masterclass in what it is to lead with caring, respect and teamwork. And, you know, culture takes a long time to change, but in the staff survey results we've just had back, I'm really pleased to see that in every one of the people-promised domains, we have shown people are more happy to be here, better performers than they were the year before, with the exception of pay.

In all of the things that were in my control to influence and my leadership's team control to influence, we've made an improvement and I'm feeling that we're on the right track. But boy, is there a long way to go.

Matthew

You have every right to be proud of that, and proud of your team as well, because the thing is, you've done that at a time when the service has been under immense pressure, because I sometimes find when I talk to leaders in the health service and I talk to them about change, that there's a kind of sense of we haven't got time for change, we can't change because all we're doing is dealing with the crisis.

So, any kind of attempt to be positive or to talk about solutions can feel almost like disrespectful in the face of what people are dealing with day to day. So, to achieve all that apparent progress in terms of culture against the backdrop of your teams having to work incredibly hard and have very, very difficult days of work, that's what seems to be remarkable about it.

Daniel

I think there's an adage that says you should always find the good things when things are very hard and focus on the things that you can use as levers for improvement.

So, if you take the current industrial action, what we have seen is that if we bring the most senior clinicians into our control rooms, we can increase the amount of hear and treat that we do. So, we're doing much more telephone assessment of patients to find out what exactly is their health care need rather than dispatching an ambulance in adversity because we don't have an ambulance to dispatch. And what you discover is that when you have the capital's most senior GPs and lots of hospital consultants coming to help you get very different responses.

In response to being the really welcome news of the ambulance sector getting more money for next financial year, one of the things we would like to propose is a different operating model for the 999 service. So, we would like to make routine that patients who phone us where we don't think they have a life and limb threatening emergency rather than dispatching an ambulance, we invest in some senior clinicians to actually do detailed clinical assessments first, because we think that way will get more patients the care they actually need quicker.

Matthew

Well, that's fascinating, fascinating and takes us into the kind of question that I wanted to get to, which is how do we get out of this kind of sense of crisis after crisis?

I remember when I started at the Confed, which is, you know, about kind of 20 months ago, I talked to Danny Mortimer, who’d held the fort been a brilliant interim chief executive before I was appointed. And he talked about the fact he said, well, you know, I've been on the Today programme a lot, doing lots of media because of covid. But, you know, he said that won't last. You know, the NHS will, will, will fall back into kind of a more routine world and there won't be so much media demand. Well of course, although Danny is right about most things, he was totally wrong about that because ever since I started, every week, every two weeks, there has been some element of a kind of story about the NHS in crisis.

Now you've been involved in particularly the urgent emergency care strategy. You just described one really interesting innovation. But tell me, Daniel, what are the things that we need to do so that even by next winter we can go in with much greater confidence that we won't find ourselves facing some of the pretty appalling scenes that we saw just a few weeks ago.

Daniel

So I'm quite hopeful and upbeat because I think the UEC recovery plan and the extra money that is specifically allocated to improve the UEC pathway could make a real difference if we seize the opportunity that we now have to spend the next few months thinking about what are improvements we could make in the here and now with the constraint that we know that we don't have the workforce we would like to have.

And yes, we need to massively expand our clinical workforce, but that is going to take quite a lot of years. But I am pretty certain there are a lot of very good ideas out there from the chief executive community, from senior clinicians about things we can do.

So, could I give you, can I paint you a vision about how to access the urgent and emergency care?

Matthew

Daniel, I love visions. There isn't enough visioning in the NHS in my view.

Daniel

Okay, so I think you could postulate that the biggest issue that we have in the urgent and emergency care pathway is people's feeling that if they phoned their GP practice to ask for an on-the-day appointment, they won't get one because either no one will answer the phone or the or GPs are just so overwhelmed with demand they can't do it.

Then what happens is that people choose to access the urgent emergency care system and all sorts of places that we didn't really want them to access it. So, they either phoned 999 or they turn up at urgent treatment centres or they turn up at A&E. And we get demand in ways that we can't control.

So how about a vision which says: people really want the care to be provided by their GP and nearly everybody knows the telephone number of their GP practice. So, what happens if we networked all the GP telephones together and used something like the 111-telephony infrastructure so that we knew that we could answer the phone. And then, Matthew, so suppose you phone your GP, except that it's Daniel's 111 service that answers the phone and we say: Hello, Matthew, we know you phoned your GP practice. How can we help you? And you'd say: Well, I'm feeling a bit grotty. I'd like an appointment. And we'd say: Okay. We can see that your GP practice has separated its list of patients into those people who it's really essential they have an appointment with their GP because they're very complex and there are those patients who actually just need episodic on-the-day care. So, we'll say: Matthew (you don't explain it quite like this to the patient, but you get the drift). Matthew, so we think we can offer you a clinical assessment on the phone now. So, then you get put into the 111 pathways process and we do a clinical assessment. And at the end of that it says, okay, so you do need a face-to-face appointment. Your choices are we can book you into an urgent treatment centre, we can book you into a GP practice that's close to you but might not be your GP practice, but we can give you the face-to-face care. But we've also been able to sort out your prescription on the phone, send it to your pharmacist.

But the gist is if you could take away a huge amount of the on-the-day demand from primary care for people who didn't need to see their own GP and do it virtually or somewhere else, what you've actually done is free up GP time to see all their very complicated, complex patients who really need them.

In an ideal world everyone would get to see their own GP. But for the moment I think you have to use the primary care resource to focus on the people it's essential they see. And I think you could implement something like that in the next few months and I think it would be totally transformational because what you'd actually be saying to primary care is not that you can't do it and we don't want you to do it. What we would be what we'd be saying is the rest of the NHS is going to come and support you to do lots more primary care locally.

And if we get that right, I think that most of the rest of the urgent and emergency care pathway will work. And when the urgent emergency care pathway works, you can do more planned care.

Matthew

Well, that's a really compelling vision, Daniel.

You've been in the service of 27 years. One thing you must have noticed is that often there are barriers to change that seem sensible. What do you think are the barriers to such a vision? And I'll just give you one as a starter.

What I find really interesting about what you've described, is it's partly elements of the UEC recovery strategy, but it also reminds me of the Fuller Review, Claire Fuller's stocktake. Now that stocktake seems to have been almost knocked into the long grass. Now we've been waiting some time to see what NHSE's response is going to be to that. We've got a primary recovery plan promised by, I don't know, the end of March.

One of the challenges, isn't it, is that we have all these strategies, they're actually interdependent and overlapping, but they can sometimes feel like they're barging into each other and making life more complex than it needs to be.

Daniel

I totally agree. So, Sarah-Jane Marsh hosted a UEC recovery day yesterday for the whole NHS leadership community. And it was very good that it focused on a huge part of the NHS system working together as a system. But it was conspicuous by its absence that it didn't include primary care and they said it didn't include primary care because there's a primary care recovery plan coming.

But the biggest barrier we've got is we still think of things in silos, so patients don't think of things in silos. The patient doesn't think my GP service is totally separate from the hospital service. The patient thinks this is the care I need. The NHS should provide the care.

The most powerful slide Sarah Jane put up yesterday was a slide that says we're doing UEC recovery because we have to focus on patients. And then she listed some patient groups that are the most important in the UEC - old people, children, people with mental health and learning disabilities. And you think if we can just get back to thinking about patients and people and the needs of particular population groups, that is how you galvanise lots of clinical engagement and activity and alignment.

I just remember when I was at Epsom and St Helier and we were trying to work out how did we not admit so many old people to hospital. And so, we got a group of clinicians together that included the GPs, the community nurses, social care and the hospital tribes and said: What would you do? Just imagine you are one team, how would you do it? And they said: Well, we'd form a team and we'd work together.

And that's where all the integrated care stuff came from. Because if you say to clinicians, think about your patient, what would you do? They intuitively know what to do. So, we've got to stop the NHS organising itself into the silos of management and into how do you organise it in the interests of patients?

Matthew

I completely agree with that. And my observation as someone coming into the NHS from the outside is, well, before I got into this job, I developed a kind of way of thinking about change, which was based upon understanding why change often fails and those examples when it succeeds. And my observation was that when change happens and happens in a way that is sustainable and continuous, it's often because you've got an alignment of three different types of kind of driver for change.

So, you've got top-down drivers, you know, strategy, expertise, resourcing, accountability to an extent. Then you've got those lateral drivers, which is what, when you talk about teamwork, that's your shared values, your loyalty to the people you work with, your sense of professionalism. And then you've got the bottom-up drivers, which is responding to patients, thinking about what patients want, listening to what patients want.

The problem with the health service, it seems to me, is that people do still spend far too much time looking up, and that consumes energy that could be spent looking, as it were, sideways across the team and into others and working with others and creating shared purpose and responding kind of downwards, as it were, or to the pressure coming upwards in terms of what the public wants.

Now, you just mentioned systems, ICS, but also places. You're in London and most of the ICSs in London devolve a lot to places. That’s supposed to be in some ways the organisational solution to the problem of how do we devolve more, how do we have better integration, but, how can I put this? I have heard it said that you are ambivalent about ICSs or about them at the moment. Why is it that you don't think yet that systems are living up to their potential and what do they need to do to grasp that opportunity?

Daniel

I'm a complete advocate of clinicians from all the different tribes from the different organisations working together in a place to deliver really good care for particular parts of the population. So, if we said, for example, that the point of the ICSs was to come up with the most seamless, best joined-up care for older people, for children, for people with mental health, then I think you would realise the potential of what the ICS was created for. And I don't think we've quite got there - yet.

And you also have to realise that, so if you're something like an ambulance trust, it feels to me really odd that I have five 111 contracts with five different ICSs, with different service specifications. And yet, I can answer the phone in London and I could be talking to a patient from anywhere in London. And you end up thinking, this isn't quite right. We have got to get the plumbing right for the services where ICS is actually need to work together to get it right for groups of patients too.

It's like the specialist end of health care we still haven't found an operating model that works. So, we need that bit of improvement.

And then for me in the ambulance trust, I need to find a way of working at a regional scale for the 999 part of the service. But I’ve also got to get to work out how do I get to be hyperlocal? Because I think my paramedic workforce could massively help GPs at PCN level, but I haven't yet found a way of engaging with 210 PCNs in London. But that is the unit, the neighbourhood level where I really think we could have a big input. So, I'm also wanting to have the conversations with the ICSs about how can they help me help primary care.

Matthew

There is no solution to the complex geography of the NHS. We have a variable geography. We have to recognise that systems may be the kind of big new unit, but they should devolve to places and they should also devolve to collaboratives where they can.

And I completely agree with you, Daniel, but the game changer could be integrated neighbourhood teams, which takes me to a final question, which is, I think one critique of the urgent emergency care recovery plan, which isn't really a critique of what it is, it's more a critique of what it isn't, is that it is, in the end, still around how do we respond to demand? There still isn't much in terms of how do we try to reduce demand. Now with greater data available, and I'm thinking here of your kind of reforming zeal, presumably you have quite strong insights now into the kind of people who end up calling ambulances and therefore information that could be used to start to think about how to build support around those people so that, well, not only do they not end up calling ambulances, but their health does not end up deteriorating so much that they feel the need to.

Daniel

I think that's very true. We're working on our new five-year strategy. And one element of it is how can we use all the information that we have as an ambulance service to help improve the health of Londoners so we can map where do we. Get calls from, what kinds of patients are calling us?

And there's a very clear correlation, as you would expect, between areas of London with deprivation, areas of London with not the best primary care, areas of London with the older population, those areas of London that have the biggest mental health needs, are the people who use our services the most? None of that is surprising. The question is what do we do about it?

And this is where I think Claire Fuller's review is so important because. She said essentially GPs do three things: they do preventative care; they do care for people with chronic long-term conditions; and they do episodic on-the-day urgent care. And my hypothesis would be if we can help GPs to spend a lot less time doing urgent on the day episodic care because we find ways to support them, then they can use their expertise where we most need it, which is in prevention and continuity. Because only if we put our effort into those two parts of the NHS will we actually make an indent in improving the health of people. Because for lots of people it is, as we all know, are very complicated intermesh of their health, their work environment, their home environment, and it requires a joined-up, thoughtful, and a lot of time, spent with those people.

So, we need to release primary care to be able to do the thing that in the past it's been able to do so brilliantly. By giving it support in the place where I think it's the easiest part for us to give it support, which is in urgent care.

Matthew

I completely agree, Daniel, and I think that you talked earlier about vision, and I think in a way what is slightly missing from the NHS discourse at the moment is that kind of compelling vision. You've described a vision for how it would be that people access emergency services. I think there's a vision for the future of primary care that's compelling. I think there's a vision for how citizens engage with the health service in a world of a kind of diagnostic revolution of wearables, home diagnosis, remote monitoring, and then through to virtual care hospital at home.

You know, there's going to be an overall shift in the way that people access the health service, but also the relationship they have with their care. And I think it's a pity in a way that we weren't more ready to have that conversation with the public as we came out of covid, because, of course, what happened during covid was people got used to home diagnosis. They got used to doing the things you needed to do when you'd undertaken that diagnosis. And that's got to be part of the future, don't you think?

Daniel

Two things have happened recently, and one is because of covid.

I think because of covid people have got a whole heap less sure about being able to look after themselves because they've got scared, they've got uncertain, they don't they don't know what to do, which is why demand has gone up in part hugely, which is why answering the phone is so very important, because in the Internet age, people expect an instant response. And when they don't get an instant response, they don't do nothing they're going do something else.

And so, the two things together mean that we are massively missing public expectation of what the NHS should be doing in the urgent and emergency care space. And I don't think it is beyond us to get to a place where we can answer the phone and we can give them a good healthcare response in in a timescale that people will think was acceptable.

And if we did that, we would completely transform, I think, the public satisfaction with the NHS, because if we're not careful people are going to think the NHS isn't the answer because it isn't meeting their needs. And I think you've got a million or so people who work for the NHS who desperately want it to be the answer, because we think we have an amazing institution that is the bedrock of what it's like to be British. And we want it to be successful.

So, I think it's really time for us to say this is this is what we can do to get the NHS back to being the thing that the public would like it to be.

Matthew

What a splendid way to end our conversation. Daniel, I'm going to ask you to commit to come back onto Health on the Line next spring and see how much progress we have indeed made. Thanks so much for giving us this time.

Daniel

Thank you very much, Matthew.