DHSC director general: update on the ten-year health plan

MATTHEW: Hello, and welcome to Health on the Line from the NHS Confederation, the organisation that represents members from across the health and care sector. 

Well, listeners, as you all know, we are in the middle of an unprecedented engagement process in which the government is reaching out to health and care leaders, to patients, to the public, to anyone really who has a view on what the NHS needs to look like and how it needs to develop over the next ten years. 

With me, to give an update on where that plan is at and what its emerging themes are, there really could be no one better than the person who is the director general in the Department for Health and Social Care for that ten-year plan – Sally Warren. 

Welcome, Sally, to Health on the Line.

SALLY: Thanks, Matthew. Great to be with you today.

MATTHEW: So Sally, let's go back to the very beginning. Of course, you're a well-known figure in health policy. I'd enjoyed being in lots of meetings and conversations with you before your role was announced. But then a phone call must have come asking you to take this on. Just tell us what happened and why did you say yes?

SALLY: Great question, Matthew. I mean, why did I say yes? Because it just feels like this is such an amazing opportunity at this stage in the history of the NHS. So my career for people who don't know, I started off as a civil servant in the Department of Health as it was then, I've worked in public health policy, NHS policy, social care policy, and I've then most recently been out of the civil service at the King's Fund. 

When you then get asked, will you come and lead a process that is trying to determine a new future for the NHS, and you're asked not only can you help to find that new plan and that new future, but that they want to do this in a way that is completely different to how government has been doing policy; they want to do it in a way that is really, really connected to people, communities and staff. 

Both of those two things were just too exciting to say no to. So I absolutely jumped at the chance. And July now seems like a really long time ago. a lot of activity has happened since then.

MATTHEW: So, you said yes; you didn't even have to think about it.

SALLY: No, I didn't really, I think I did pretend I needed to think about it, but no, no.

MATTHEW: Always good, it's always good to pretend a little bit, isn't it? Just to make sure that they really want you.

SALLY: Yeah, precisely. I mean, it just felt like this really was an opportunity to bring together so many different parts of my career over the last 25 years, that I really want to do it. And the main thing I thought is if I say no to this, I'll be really jealous of the person who does do this job. Will I really regret having said no to it? So I just wanted to kind of leap at the opportunity with both hands and to lead the process. So yeah, it's been a really good decision so far.

MATTHEW: There's another thing, isn't there, Sally, which is that if you've been outside advocating policy, like you did in the King's Fund, and someone comes along and says, well, do you want to make it? And you go, oh, no, it rather reduces your credibility when you complain about policy in the future. So let's talk about the engagement process, huge engagement process.

We all remember the initial response to it. The suggestions about blowing Wes Streeting out of a cannon, which I thought Wes handled very well, actually, and used to kind of encourage more people to participate. 

Tell me what you've learned on that engagement journey, Sally, in particular. Just pick out a couple of things which you wouldn't necessarily have predicted at the outset that have come through that public engagement.

SALLY: The engagement has been really, really rich so far and when we were first asked to lead this process, the secretary of state, Wes, was really clear he, the process was as important as the output itself and he wanted the process to really reset a relationship between government and the public and the communities we serve and between government and the staff who work across our health and care system.

So that's the kind of ethos that's very much been in our minds as we've been designing and delivering the engagement process. 

In terms of what we've been hearing from the public, there's absolutely a huge sense of pride in the NHS, a huge commitment to the model, but a really, really strong sense that it just isn't working for people at the moment, that the NHS isn't getting the basics right.

Now, I don't think any of that would be hugely surprising to your listeners, Matthew, who are working throughout the NHS. But for me, what's been really interesting is the public really do want the NHS to work for them; they understand that that means there are choices and priorities to make and they're happy with that. They understand you can't have everything all at once. They actually want quite a lot of the small bits, which make their current experience really difficult. Like everybody's saying, once we get it through the front door, whatever that front door might be to the GP surgery, to A&E, to the mental health services, they're getting really good services.

But it's a real struggle. Their letters aren't coming till after the appointment. They're not able to get the phone answered. So a lot of the things which are really work well for us in the rest of our lives and not working for people who are trying to access the NHS. So that really strong sense was there.

I think the other bit for me that's been a really interesting part of the engagement – it's less, is it a real surprise that the public is saying the basics aren't working for us. It's more that by having a deeper conversation with the public. You better appreciate what they currently understand about the NHS, you better appreciate how they can be supported to understand and support change in a different way.

So I really remember sitting in a public deliberative event in Leicester, where there was a really strong sense of the public just not understanding the current range of services that we provide beyond a hospital or beyond a GP surgery. And that absolutely isn't the public's fault. That is that we as a system, nationally, regionally and locally are not doing enough to take our people and communities with us as we go.

MATTHEW: That's fascinating. Two thoughts there. One is your former organisation, King’s Fund, I think, produced a report, just a few days ago, about the kind of problems of administration in the health service and that we need to take it more seriously because it's very often the thing that is standing in the way of the public getting the care that it wants.

And things that feel quite trivial, like getting a letter in time or being told where you are in a process really do matter to people. So that obviously chimes from what you heard. 

But the other thing is that characteristic of forms of engagement, which is what the public say when you initially ask them a question is often quite different to what the public say when they've had a chance to hear the facts, talk to other people, to ruminate a little. And that's always a challenge, I think, because we kind of know what the public feel when they've had a chance to do that properly engage with it. But in many ways politicians have to respond to a shallower kind of level of public engagement. 

Is that particularly an issue for example with things like Wes' two shifts, prevention and the leftward shift that I'm sure if you were to say to you know, a standard member of the public walking down the street, do you think it's important to shift to prevention, to shift to the community? They wouldn't necessarily see it as important, but when you're in the groups of people and they have time to think about it, they absolutely recognise it.

SALLY: I think as we've been speaking to the public, they intuitively see all of those shifts as a good thing. So of course they think, yeah, prevention's a good thing. They can understand shifting from hospital to community is a good thing, but then you start to tease out with them, ok, what might that mean? And entirely legitimate concerns are raised there about we understand what you might want to achieve, but you need to make sure it works for us. 

As an example for the shift from hospital to community, there's a real sense from the public about at the moment, if I'm a what we might call a high-intensity user of health service, or I'm somebody that's using multiple services, I feel like I'm holding a huge amount of personal burden to coordinate that care. And there's an anxiety that if more carers move from hospital to community, will individuals have to have an even higher burden to navigate that care? So the public is saying, I understand a shift to community, and that could be really beneficial closer to home with clinical teams I know better and more regularly, but please don't do it in a way which actually makes the current burden I have to carry worse.

So that's a really good example where we can then design policy to mean that we're addressing that concern. And we can really think about how we're communicating this change in a way that's quite upfront about recognising that concern and addressing it head on. 

So, for me, the engagement has both helped us think about the content of policy, what we're trying to achieve, but also how do we talk to people and communities about what we're trying to achieve and why, and how can we allay any concerns they legitimately have about what it might mean for them.

MATTHEW: And there's sometimes, Sally, a distinction made between people who are generally healthy, whose need for the health service is kind of episodic, it might reflect they get a bug of some kind that doesn't go away, or they want a mole checked on their skin, or they're just a kind of standard health check or whatever, and their needs are quite different from those people and that ever-growing number of people who have long-term conditions, multiple conditions, often a combination of physical health, mental health, and even social challenges.

When you engaged with the public, was that kind of an element that you recognise that people's attitude to the health service depends quite a lot on the level of day-to day-engagement they have with it?

SALLY: Yes, absolutely. Definitely people's attitude is affected by their own personal interaction and whether they are a carer or if somebody with a greater interaction with health service. So that's definitely true. But it's also true that if you have a conversation with the public, They will be able to differentiate between for example, who should be a priority for a face-to-face appointment with a, GP, as opposed to another member of the clinical team in, in a primary care surgery. Who might be more comfortable with a video consultation and who might prefer face to face.

So when you start to talk to the public, they absolutely understand if I'm normally relatively healthy but I've got a specific issue that I want to talk to a clinician about in general practice, I might be quite comfortable with a phone consultation or a face-to-face consultation, and that would meet my needs adequately.

Somebody else who has multiple long-term conditions or other needs, it should be a priority for more face-to-face interaction. So actually the public can understand and appreciate that this shouldn't be a one size fits all in terms of what is the service delivery model for everybody, because we all have different needs and they really do understand and respect that.

So that's been a really interesting part of the conversation. I think seeing that the public have a much more sophisticated understanding of that different need than sometimes we might assume that they would do.

MATTHEW: Really interesting. So, Sally, what I'm going to do now is I'm going to channel, you know, imagine you're going to a dinner party. I'm sure, you know, you're a Londoner, aren't you? You go to dinner parties all the time. Now you're sitting next to somebody and you just know that's one of those people who knows what you do and they want to be a bit cynical.

They're going to ask you what they think are brilliant questions. They're going to floor you, but you've heard them all before. And I want to see if I get them right. Are these the questions you most often get from people who are trying to be clever and cynical about it? 

Question number one. How is this ten-year plan going to be different? Haven't there been hundreds of ten-year plans in the NHS? They only seem to last about three weeks.

SALLY: Yeah, get that one all the time. And my answer to that one is it's the process that’s going to make this different, actually. So if you invest all of this time and energy and commitment into saying we want the people and communities, we want staff, we want leaders to help shape the plan. you've got to have a plan that you're then committed to delivering.

So that to me is what will make it feel different. But I do absolutely understand the cynicism of that. And yes, I don't often go to dinner parties, but yes, other social gatherings, that is a question that is normally the first one that pops up.

MATTHEW: OK, I'm going to carry on with the kind of ten-year plan of cynicism bingo and see if I can get other ones as well. 

So here's the second one, which is: you've got your ten-year plan, but I keep hearing policy being announced. You know, there's a electives plan, and there's this stuff called planning, and there's all this stuff coming out, which seems to in some way kind of undercut what you're doing in the ten-year plan. I'm very confused. What's the ten-year plan about when there's all this other stuff being announced?

SALLY: Yeah, so that one I probably get slightly less and this might be a sign of the people I have dinner with Matthew don't you know, planning guidance and elective reform plan isn't the top conversation piece but no all joking aside I think this is an important area for us actually because when Labour went in opposition started talking about ten-year plan, there was a real sense of that's great because actually we've been in such a cycle of short-term decision-making that we now really do need to think about long term.

So there was a real support for that long-term thinking. But at the same time, recognising the current  delivery pressures, There was  also a real sense of, but we can't wait for the ten-year plan. We can't wait for this plan to be produced and we can't wait for ten years for it to be better. 

So people wanted to start to see action and that's exactly what's happening now with the elective reform plan, with the planning guidance, with the forthcoming urgent and emergency care plan. This is about us saying, we know we need to start making improvements now for the public we serve, for the staff who are working in the system. And all of those plans are leaning into the three shifts as part of their way of delivering improvement now.

So for me, they're ramping up to an, into the ten-year plan, they're not setting a separate path for us that we will then need to readjust when we get to the ten-year plan. 

So I think these are key the first steps, the early steps, the build up to continuing reform in the ten-year flat plan. 

MATTHEW: Ok, let's move on – I didn't do very well in the second wasn't clear that was in the bingo card, but I'm sure this one is: when Labour was last in government and it radically changed the health service, it was spending six or seven per cent a year extra for year after year, you haven't got that money. How can you achieve transformation without transformational funding? 

SALLY: Yeah, bingo, house, whatever we're saying. And that is of course a very legitimate point to raise, particularly if thinking about what was working in the 2000s and how do we need to learn from those approaches, but think about a set of approaches which is going to work for the position we find ourselves in now in terms of current performance, demographic pressures, that the potential of science and innovation to really transform healthcare.

So I think it is definitely something that leaders are concerned about. I think for me, what it really enforces for all of us, though, is a sense of we are going to have to really seriously think about everything we're doing in the health service. When you've got six or seven per cent growth a year, you can be focusing your transformation on the additional six or seven per cent a year. 

When you're not, when you're much closer to the longer-term historical averages that the NHS has been getting, we really need to be thinking about every single pound we're spending rather than just the additional amount. And that's the challenge and the opportunity for us is to really think through.

There is huge variation right across the NHS. How can we improve that? How can we really push productivity and how can we be thinking about how we can stop things which no longer have a really strong clinical evidence base? So I think there's a real challenge, but also an opportunity there. 

MATTHEW: I find it fascinating, Sally, that when I go around the health service, I hear two things, said over and over again, but in a way not really connected. One is it's very difficult to see how we can do the things we want to do when we're so short of money. And the other is there are so many things we do that aren't as effective as they should be, where we waste money, where we don't work effectively with each other.

And somehow we have to kind of bring the recognition that we aren't spending our money as effectively as we could. That the relationship between how we invest money in the health service and getting the best outcomes for people is far from straightforward. With that question of the overall kind of resource challenge that we've got in the health service, I think the good news is that what I've noticed in the ten-year plan is although people are extremely concerned about money, there isn't a leader who isn't under a lot of pressure, next year is going to be really, really tough. There is also a recognition that there is a lot of scope for us to do things differently.

Now, I just want to focus in as we draw to a close, Sally, on a couple of areas that are really particularly interesting to us at the Confed. 

The first is around systems, around ICSs. You will have read, I think you've probably participated in the development of the Patricia Hewitt report, some time ago.

And at the heart of that, what Patricia argued was that we created ICSs, but we didn't really create the conditions in which they could succeed. Do you see the ten-year plan as providing the context in which ICSs can actually start to deliver what they were supposed to deliver in the first place? 

SALLY: Yeah, absolutely. So ICSs have a huge opportunity to be able to transform healthcare and also change how they partner with other organisations, statutory, civic, charity, business to really be able to shift health as well. And I agree. We, focus, as is often the case in with health reform, we focus on a structural change without really thinking about how we can make sure those new organisations have the capacity, the capability to really be able to deliver what they're intended to do.

So I very much hope the ten-year plan is a plan which not only thinks about the structure of the system, but fundamentally thinks about how can we make sure though that structure delivers the outcomes we want it to. So whether that's about the culture and leadership of organisations, whether it's about what I increasingly think of the ‘wiring and plumbing’ – how the financial flow support ICSs to be able to carry out their roles. How does regulation and oversight work to do that? I think we need to make sure all of those things are aligning behind local leaders. So it's as easy as possible for them to make the best decisions for their people in their communities.

But this is fundamentally a big leadership challenge. And one of the key messages we're hearing time and time again in the consultation and the engagement is that the NHS isn't as good a partner to others as it can and should be. So the NHS and the leadership and management skills and community really need to be thinking, how can I partner in a very different way to mean that I'm bringing something to the table for others as well as expecting and hoping others will help contribute to the NHS and its, problems and challenges. And solutions as well. 

So absolutely, I want this to be, how can we help ICSs really thrive? How can we make sure every organisation in our structure is set up as well as possible to be able to deliver their purpose and really improve outcomes and experience.

MATTHEW: Such a great answer, Sally, and I really like the way you're bringing in questions of culture. But also I hear in what you're saying is, is a good recognition of something that, and I'm going to be very pompous and quote myself, I've said a few times, which is that we often what hear when we're out in the service is that the conversation between NHSE and the department is about what the centre can demand of the service, but we need to see in the ten-year plan and more broadly, a bit more of a conversation about what the centre can do to best support and enable the service to drive change. So hearing echoes of that in what you said is great. 

Now I've saved my most complex question for last, which isn't really fair, but you've kind of hinted at it in your previous, answer.

So, another area we're really interested in, in the Confed is around neighbourhoods. And when we think about neighbourhood policy and we think about the idea that the NHS might have quite a different model of care and a different model of kind of engaging the community. I mean, there are fantastic examples of this, as you know, but to make this more general, it does involve us thinking about how the health service works with our partners – with local government, with the voluntary sector.

If you want to think about health in a deprived area with people with many challenges, you need to be working with your partners – in schools, in police, etc. When you think about work, the role of DWP. 

Now I know because I've undertaken a government review that one of the challenges is that you're given quite strong guide rails as to what's in and what's not in the review, but then when you get into the subject, you realise that those guide rails often describe an area which is actually much more fuzzy.

How are you approaching that in the ten-year plan? How are you approaching the fact that when it comes to population health or when it comes to a new model of public services and neighbourhoods, we need to be working with our partners. I know you'll often be asked about the fact that you don't have social care as part of the ten-year plan, but we all know about that.

But there's a more general challenge about these edges of the health service and the importance of us working with our partners. How are you hoping to kind of deal with that in the ten-year plan?

SALLY: That's an absolutely great question, Matthew. And that the question of scope is always so important. I remember the first couple of months I was in the job people would be asking if, is the ten-year plan going to solve poverty? And you, we got to a point where the kind of ask and the expectations of the ten-year plan was pretty much, it was a government plan for the entirety of society, which would, I'm sure your listeners will recognise, be an impossible plan to try to navigate and create.

So you have to put some, some guardrails around. I think the key bit for me is then how do you think about delivering within those guardrails in a way that, that not only gives permission for the health and care service as we're looking at it to be able to look outside and partner, but also to actively make sure that your rules, your leadership, your approach to delivering policy. encourages that looking out to others as well. 

So you can create a new NHS plan, which has an awful lot of the centre determining the number of widgets we want and everybody just looking up to the centre to be told how many widgets to deliver when, and kind of jumping in that tune. 

Or you can create a ten-year plan, which is much more about outcomes and experience that we want to see our people and communities be able to have the NHS support them to and allow much greater freedom about how do you deliver that within your particular communities, how do you partner in a different way.

I think it's really important to say freedom doesn't mean a lack of accountability. It means clearly balancing national and local accountability a way that we've tended to draw more to national accountability in the past. So, freedom and expectation to partner differently but still really, really clear accountability. 

We do need to be honest with ourselves that we spend a huge amount of taxpayers money. It is absolutely right that we are accountable for that. We need to be accountable for in a way that actually means we're demonstrating how we're using those taxpayers funds to deliver the outcomes that our people and communities want and expect from the service, rather than just what's being determined from the centre.

MATTHEW: Yes, slightly less vertical accountability, slightly more horizontal and slightly more downward accountability, I think is the order of the day. 

So, Sally, we're about halfway through the process. Just to finish off, tell us what's going to happen over the next three or four months. I know the kind of broad consultation process is drawing to a close, but are there other landmarks between now and the great day when the report is published? 

SALLY: We're currently still doing a tour of the country for our staff deliberative events which have been really, really good conversations so far. So those will draw to an end at the beginning of March. We've got a whole host of round tables that we're still undertaking. And we're working with the health and wellbeing alliance to do some particularly targeted activity for communities, which are often underserved and under listened to in these kinds of processes, so we're making sure that we are really actively listening and actively reaching out to those communities. So a lot more activity to come. 

And then as you can expect, the kind of more classic Whitehall policy process where we then crunch all of that together. We will be having a national summit in April that will draw together the deliberative process we've been having with public and staff. So we're hoping that will again be a really rich conversation where we can bring together both of those different communities to really be thinking about the vision and the trade-offs. 

And then the plan will pop out of all of that process. And from the plan, obviously we'll then be shifting into planning guidance allocations for future years. 

So plan is very much a milestone along the way. It's neither the starting line nor the finishing line, if you see what I mean. So a real opportunity for us to publish the plan and then really make strides with implementation.

MATTHEW: Well, Sally, thank you so much for joining us on Health Online. It's been a fascinating conversation. I think the headline to come out of our talk is clearly that you sometimes go to dinner parties where people haven't heard of the planning guidance, which I have to say many of us will find deeply shocking. But otherwise, Sally, thanks so much. 

SALLY: Thank you. Great to be with you.

MATTHEW: And now it's time for the latest Leader in Six, where I ask NHS leaders a range of questions about the health service and about themselves. And for this edition of Health on the Line I'm delighted to have talked to Prem Singh, who is chair of University Hospitals of Derby and Burton Foundation Trust.

So, six questions in five minutes if we can, Prem. First one, how do things feel at the moment, what's the most pressing issue for you here? 

PREM: I think what keeps me awake at night at the moment is how do we keep both our patients and our communities who attend here at A&E and our hospital, how do we keep them safe?

And how do we keep our staff safe? Because we're really worried about not only the pressure that is at our front door on our services, and we're doing everything we can to improve that. It's not acceptable, people having to wait and wait in A&E. But also we're worried about the moral injury that our staff are going through. 

MATTHEW: you had to choose one bit of innovation, what within the trust that you're most excited by, Prem, what would it be? 

PREM: Two bits. I think you've seen one of those, which is SDEC.

I think that's incredible in terms of how it's grown and, and the impact that's having on A&E. There's still a huge amount of pressure on A&E; the more we can do, I think, on that front. 

The other is a cultural shift. The Compassionate Inclusive Leadership Programme. That wasn't something that I initiated. I've only been here six months, but it's something that I fully backed and ensured that the board gets fully behind it and undertaking the programme itself. It's a medium to long-term programme and while it's called Compassionate Inclusive Leadership, it has got the bits and elements about compassion and how we're kind towards each other and how we're inclusive as an organisation, but it's also got elements which have to do with accountability. If  you like, the harder edge. 

And then the final component, which is about continuous improvement in the organisation. 

MATTHEW: Third question, Prem, if you were king of the NHS for a day, what's the one thing you would do?

PREM: I think I'd really push Matthew for transformation of social care and more investment in social care because the impact of that on the health service and on society as a whole. As a society, we owe it to our children. and our adults and our older generation to look after them. We're not going to do that as things stand.

MATTHEW: Yeah, you'll know that although we're a health representative organisation, we've been arguing for a long time that social care is an absolute priority for investment. So we echo that. 

Who is the leader that you've worked with that you've most admired? 

PREM: Wow. I was hoping you weren't going to say that I've worked.

MATTHEW: It can be any leader. 

PREM: Ok, the leader I have admired over the years is Mahatma Gandhi, actually. And the reason for that is he had vision. He, without having legitimate power, so he wasn't an appointed politician, or elected politician, despite all of that, his vision and his energy and his ability to get mobility, if you like, across the nation and globally, actually in that impact of followership was just incredible. And I think that's what, for me, good leadership is about. You don't need a badge, you know, which is why our Compassionate Leadership Programme is so important in the organisation, because everyone's a leader and it's how we mobilise that in the organisation.

MATTHEW: Parim, tell us something about yourself. It's nothing to do with the health service that people would find interesting. 

PREM: Oh, I'm not that interesting, Matthew, basically. 

MATTHEW: You just had a gap year.  

PREM: Yeah, I toured India for the first time ever, despite having Indian and Sikh heritage. That was a fascinating experience. But one I would share is I've been inside Number 10, and I walked up the famous stairs with all the photographs from previous Prime Ministers.

And every year, when the kids and I watch Love Actually, our favourite Christmas film, I talk about I've been up those stairs. And then I get asked the question, Did you dance, Dad? Did you do a dad dance? The answer is no, I didn't. 

MATTHEW: Because I used to work there, and, every time up the street, I reminded myself of what a privilege it was to work there.

Last thing, Prem. Tell us something you've watched on TV, listened to as a podcast, read as a book, that you recommend to other people. 

PREM: I'm currently watching The Day of the Jackal. Which is fascinating, I think. Love it. 

MATTHEW: Prem, great to talk to you. 

Well, sadly, I'm afraid that's all we've got time for on this edition of Health on the Line.

We'll be back with our next episode very soon, but in the meantime, please do follow us and leave us a rating or review wherever you get your podcasts. It really does make a difference. Thank you.