Holding NHS leaders to account: how far should journalists go?

 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 in England, Northern Ireland and Wales. 

In a moment, I'll be speaking to long time editor of the Health Service Journal, Alastair McLellan. Alastair is an extremely important figure as we all know in agenda setting in the Health Service and reporting the good, the bad and, well, let's face it, sometimes the ugly of what happens in the service.

We'll be chatting about all of that and more in just a few minutes. 

But first, I'm joined now by the managing director of the Association of Ambulance Chief Executives, Anna Parry, and we're going to have a quick chat about, well, ambulance waiting times, handovers, the relentless pressure of patient demand as we move into the midst of winter.

So, Anna, thank you for joining us on Health on the Line. 

ANNA PARRY: Thank you for inviting me, Matthew. Good to be with you. 

MATTHEW TAYLOR: So this looks like it's going to be a really challenging winter. We had the first in the series of the NHS's England sit reps last week, and there was some pretty worrying stuff in there. What would you pick out, Anna, as the most concerning bits of information in that sit rep?

ANNA PARRY: So, I think from an ambulance service perspective, Matthew, the increase in handover delays is a real concern to us. So we're aware, as NHS England reported, that there's a multitude of reasons for increased pressures on the health service at the moment because of rises in flu cases, norovirus cases, covid, respiratory virus activity, and what we've seen is that the hours lost to handover delays is at 87 per cent from this time last year. 

So from an ambulance service perspective, we represent all UK NHS ambulance services. That's a particular concern. 

MATTHEW: Yes, absolutely. And, and I think we all recognise in the health service, although there are risks all across the system, that the biggest risk is that risk of delayed ambulance response times. And of course, we've modelled our work in emergency departments around that kind of insight. 

What, what do you think, Anna, that we can do at this late stage? Just earlier this week, I know that Wes Streeting and Amanda Pritchard briefed leaders about doing what they could to manage risk in winter. They talked about the things that we could still do at this late stage to try to reduce demand.

What do you think we should be prioritising? 

ANNA PARRY: So, lots of measures have been put in place and continue to be put in place with regard to handover delays and of course they're just symptomatic of the greater pressures that the whole NHS is feeling. So, steps that have been taken are kind of being enhanced around increasing the use of same-day emergency care provision, more fall services.

From an ambulance service perspective, specifically, we're continuing to increase the ‘see and treat’ that we can use, whereby we deliver clinical advice on the phone to those patients where that's an appropriate response and ‘hear and treat’ where we go and treat a patient, but then don't convey to the hospital if that's sufficient. So very much focusing on those two sort of alternative ambulance services pathways, with a kind of desire to convey fewer patients to hospital where hospital admission won't be beneficial in the context of the increased pressures that we're finding. 

From the September 23 to September 24, the growth in number of incidents handled through hearing treat processes increased by 27 per cent. So we've been doing a lot of work in that area. And we have seen, again, in that period from September 23 to September 24, an improved response, significantly improved response, on the previous year to our category 1 patients, so the most sort of life threatening category 2 patients and category three and category four. So although winter has come with a real punch over recent weeks, we in a stronger position as I think we could be in given decade of austerity, covid and so on, and we'll continue to make those risk assessments to ensure that we're delivering the best possible level of care to the patients that most need it in society, Matthew.

MATTHEW TAYLOR: And is there a message here to the public as well? And I know it's a very difficult balance. We don't want to stop people seeking help when they need it. We don't want to alarm people. But do you think we need stronger messaging to the public about only using 999 when they really need to, not walking into ED before they've tried other services?

ANNA PARRY: It's a difficult one that because of course when patients need help, we want them to seek help and we know that access to GP services in some parts of the country and in specific areas, it isn't as good as it has been previously. We were really pleased and welcome the Secretary of State's proposed refresh of the workforce plan yesterday and him speaking about more GPs, more community nurses and health visitors, which are kind of really important and we'd kind of advocate the use of paramedics in the kind of community setting as well and increased usage of paramedics.

From an ambulance service perspective, half of 111 services are provided by NHS ambulance services, which means that when people contact 999 or 111, we can ensure that they are getting the right service. So they're transferred over to either kind of urgent care provision or emergency care provision, and I kind of, sort of strongly feel this on us within the NHS to make sure that we navigate patients to the right place and the front door is kind of less relevant really. I think the owners should be on the NHS. 

That said, of course, given pressures that, that we are finding, I think if we can call up on, so patients, the public to go to their sort of GPs where there is a kind of urgent care requirement. 1 1 1 when their GP isn't it a work out of hours. And then of course, 999 in the case of emergencies.

And I think increasingly, Matthew, where we're kind of moving to with different kinds of response, so moving away from a kind of default conveyance to hospital, which is the best thing for the individual patient, for all patients and for the system. I think that there kind of needs to be this shift to the position where by people who shouldn't just expect to convey it to hospital if that's not deemed to be the right thing for them at any given time.

MATTHEW TAYLOR: Yes. And I visited a number of ambulance services, Anna, and I think LAS was the last one I went to. And the work they do there both on triaging, but also minimising unnecessary conveyancing to EDs is really powerful.

Now, One of the things that we've been hearing recently in terms of the kind of pressures that you've described. And by the way, what you described, I think is quite hard for the public and even sometimes politicians to understand, is that things look as though they're deteriorating because of the unprecedented levels of demand, even though actually they're improving in terms of how productive we are, but it's hard to kind of see because of that kind of tide of demand.

Now in the face of that, West Midlands Ambulance Service has said to people in categories 3 and 4, which can include people with abdominal pain, people who've fallen or vomiting, that given that the ambulance is likely to take several hours to get to them, that they should, if they can, make their own way to hospital.

Do you think that that is going to be something which we are generally going to have to see across winter, that when it comes to cat 3 and 4, people will be encouraged to make their own way to hospital if that's what they need? 

ANNA PARRY: Firstly, with regard to that one, Matthew, sort of on behalf of the ambulance sector, I'd like to sort of say sorry to patients that are waiting too long and where we're not able to provide the level of service we would want to be providing.

I think what's kind of key to reiterate is that we're seeking to be sort of as efficient and effective as we can in the context of the pressures we're facing. And less serious patients may have to wait longer because of that, because we will be prioritising the nearest sort of available resource to the sickest patients as quickly as we can.

Therefore, we've talked about sort of advice over the phone. We use community first responders in some instances, such as, with regards to West Midlands Ambulance Service recently, as well as other ambulance services, the advice has kind of been issued to some patients to make their own way to hospital to ensure that people can kind of make an informed decision based on the resourcing levels that we find ourselves faced with.

MATTHEW TAYLOR: Yeah, I fully understand that. So, Anna, a final question. This has been so helpful and for making the time to talk to us. But there's a general conversation at the moment around kind of NHS, targets. The government has absolutely doubled down on the 18 week target, but there's discussion of other targets. I think Wes Streeting has recognised, for example, that four hour waits in ED will be a longer-term objective.

Now, you have got your targets, and one that's been a particular focus is the 30 minute response time for category 2. I know London Ambulance Service has actually already agreed to change that to 36-minute target. What's your view and what's the view of the service around the value of that 30-minute target?

ANNA PARRY: Thank you, Matthew. So I could speak for a long time about this. Really, really good questions. So of course, category 2, 30-minute response time target, the clinical standard that we're seeking to adhere to that it's 18 minutes. So there's already a sort of 12 minute increase on what that was kind of clinically originally determined to do and the response that was originally intended for those category 2 patients.

Something that we published last week. So we, we know that the ambulance service hasn't delivered against that 18-minute target or that 30-minute target for some time now. What we called for the week before last was a national approach to commissioning of ambulance services. So we know that in some regional areas there's been commissioning decisions being made on the basis of finance, whereas in others, they'd be made on the basis of achieving that target.

So you talked about London ambulance services agreement to 36 minutes. We know that that varies across the country and we don't think that that's right as a sector, as an association. So we published a call for a national standardised national approach the week before last with regard to that as a first thing there.

More broadly to answer your question, what we would welcome kind of as we move forward and in the context of the ten-year plan is a much greater focus on clinical outcomes and ensuring that patients get the care that they need at the right time and through the right means, whether that's here in treat c and treat a conveyance to ED by ambulance, whether it's referral to some other sort of primary care or community facility. 

And what we would welcome is a more sophisticated, nuanced approach to targets really, so that we don't end up chasing the target and missing the point, essentially. So we laid out in the context of the government's ten-year plan, which we've kind of really, really welcomed as we have welcomed the government's desire for honesty, speaking up and collective rebuilding of the NHS with the provision of high-quality, equitable care back at its heart.

Where we're at, what we would sort of like to focus on as a sector and work with partners to deliver is providing life-saving response to patients needing emergency care and seriously urgent out-of-hospital care. We would really welcome the ambulance service stepping right into the heart of coordinating and navigating unscheduled urgent emergency care demand via 999 and 111 and then providing community paramedicine models on a much greater scale to help support and bolster the move from hospital to home, sickness to prevention, that underlines the government's mission in this space.

MATTHEW TAYLOR: Well, I know that's a very comprehensive and clear answer. Thank you so much for joining us and good luck for what I know is going to be a challenging winter. 

ANNA PARRY: Thank you, Matthew.

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MATTHEW TAYLOR: Before we get into the next part of Health on the Line, I've got a bit of a favour to ask. If you're a regular listener, in which case, thank you. Or if you're tuning in for the first time, in which case, well done. I'm really keen to hear what you think about this podcast. In a way, I'm turning the microphone on to you so you can have your say.

If you could spare just five minutes, it really is just five minutes to complete a short survey, You can help me, you can help us at the Confed, make health on the Line better, more relevant, more useful to you. You'll find the link in the show notes. I really look forward to hearing from you.

And now, as promised, it's on to my chat with the HSJ's Alistair McLellan. Just a quick note though, before we hear that, you may notice Alistair and I reference a couple of articles and events from a few weeks back. That's because we originally planned to release this as the short opening chat for our last episode in November.

But you know, the conversation ended up being so interesting that there was just no way we could cut it down that much. So, we're bringing it to you as the main event this week instead, and here it is. 

Alistair, welcome to Health on the Line. 

ALASTAIR McLELLAN: Thank you for having me. 

MATTHEW TAYLOR: So, look, it's been a busy few weeks in the land of health policy, with some notable speeches and announcements from the Secretary of State and from Amanda Pritchard, the chief executive of NHSE, and with some healthcare leaders caught in the crossfire.

Earlier this month, Alistair, you wrote a piece in HSJ advising Wes Streeting that there were better things he could do than, in your words, ‘picking rows with NHS managers’. Can you, can you kind of talk through that advice that you gave to the Secretary of State? 

ALASTAIR McLELLAN: So, people listening to the podcast will have seen the coverage that the Secretary of State got for his speech at the NHS Providers Conference.

The sort of setting of these speeches are always significant. Speech was happening on Wednesday, I think. That's right. There was an embargo press release on Monday, embargoed for Tuesday morning saying we're gonna stop pay rises for failing managers. Then another press release Tuesday embargoed for Wednesday morning say and we're gonna sack them too.

We're going to cut their pay. We're going to sack them. So, you know, this wasn't just a speech. This was a concerted campaign to get a big row about failing NHS managers in the national press. And I thought about this. I thought, well, HSJ readers will expect HSJ to respond to this. 

And then I thought, well, Is that the best approach? Because, actually, I thought, and we saw this from Wes Streeting beforehand, It's a well-established strategy. Lots of other politicians do it. Which is, if you don't want to answer a question about difficult things, you choose to have a row on something that you want to have a row about. Something that is usually safer ground. 

And we saw a row about, for example, the future of GP practices, the practice model. We did a big row about it and then he sort of rode back on it. And I thought, well, he's doing this again. You know, I'm saying my piece that it's a tactic that Alan Milburn well used.

And I thought, well, I'm not going to fall for that, I'm not going to join in the row over failing managers. I'm just going to point out all the things that he's trying to distract us from and there is a very, very long list of decisions that need to be made either very quickly or quite soon, stretching from the fate of the elective recovery fund to the future of the mental health investment standard, to the, uh, review of the forty hospitals - new hospitals programme, etc. 

I had a long list. And I thought, as I say, rather than joining in the row, which is a silly row, we all know that. I see this is for the distraction technique it is. Here are the things that you should focus on. Please focus on them. 

MATTHEW TAYLOR: Yes, I mean, I hear that.

I guess, We kind of understand, you and I, because we've existed in the worlds of politics and policy for a long time, the kind of pressures that the Secretary of State is under. And there was a kind of narrative building in the mainstream media, and I suspect also amongst some of his cabinet colleagues, after the kind of budget, which was, well, look, you've got the money, but where's the reform?

And that in some senses, the reason that the West Streeting had kind of turned to this kind of rhetoric, was he needed to double down on the fact that he wasn't You know, subject to producer capture, that he was going to carry on being somebody who focused on reform. Do you agree that that's in a sense, you know, whatever or whether or not we think the individual things he announced were a good idea, that that politically, there continues to be a strong sense that he has to constantly demonstrate his commitment to kind of red in tooth and claw reform?

ALASTAIR McLELLAN: I think that's part of his pitch. He's always said the lessons from the noughties was that money accompanied by reform and it was the combination of the two that was a success and I think that is broadly a correct view of the world. So absolutely he wasn't really talking about reform though, was he? He was having an old-fashioned row about failing managers.

So there was not really anything reformy about what he said, as people in the health service will know. In fact, he didn't actually announce anything new at all. Even the things that he was saying, was sort of putting forward new, either already were planned or already exist. And any changes he's proposing were like little tweaks on the ladder.

So yes, I absolutely understand his need to keep signalling to the broader political world that he is committed to reform. And I believe he is committed to reform. But this wasn't reform, this was just a distraction technique. 

MATTHEW TAYLOR: So let's talk about management more broadly. I mean, one of the things, I've been in this job now for three and a half years, and one of the things I had to get my head around quite early on was the kind of incredible influence that the HSJ has in the kind of health debate.

Now, it's kind of interesting. And obviously, these two ideas that I'm about to share with you are kind of reconcilable intellectually, but sometimes not so much in practice, which is on the one hand, the HSJ has written pieces that go with analysis the NHS Confed has done about the fact that the NHS is under-managed, that we have a high turnover of leaders, that in many ways, being an NHS leader is a bloody tough job to do.

On the other hand, arguably, your news coverage, highlighting things that trusts have got wrong, highlighting internal conflicts, makes the life of these leaders even more difficult. What do you personally feel we need to be doing in terms of the conversation about leadership and management in NHS?

ALASTAIR McLELLAN: I'm afraid, Matthew, I'm going to bring you a bit of a counsel of despair. And I'll come to HSJ's coverage in a minute. But if I just talk a bit about the debate around managers

As you rightly said, I've been around, you know, my career plateaued very early, I've been HSJ editor pretty much since April 2002. So one of the things that I've concluded that period is that there is nothing you can do about the narrative that there are too many managers and they get in the way of clinicians and blah blah blah.

It's like the weather. It's always going to be there. Evidence isn't shifting it. There's so much evidence, as you have rightly said, done by everybody, even right-wing think tankers and commentators in the election process, were saying actually the NHS is under-managed and if we want to reform it, in the way they vote, we need people to do it.

So, in some ways, there is no reasons for existence, other than it's sort of deep in the psyche of British politics, and indeed, British culture, you could say, given the NHS is such a strong cultural thing. So, it's just one of those many difficult things that NHS leaders, including yourself and others, have to manage within.

It's never going to go away. What the hope is, is that people like yourselves, with significant influence on the centre, are able to point out to leaders that it is these managers who will deliver their reforms. It won't be the doctors or nurses, outstanding at what they do, et cetera, et cetera, all the other cliches and apple pie motherhood, when it comes down to it, it's actually the managers that are actually going to deliver it. 

So, you can win some political good coverage if you want to have a go at managers. But let me tell you that, when it comes to delivery, it's going to make it more difficult for you. So, you, Mr. Politician, Mrs. Politician, you have to make that calculation. 

So, I'm sorry it's a bit of a council of despair, and I realise that, you know, that's a hard line for somewhere like the NHS Confederation to sort of put forward, but I'm afraid it's my view of the world that I have learnt over the last couple of decades.

Very briefly on coverage, what we believe at HSJ, we believe that NHS management leadership is largely about risk management because there are lots of penalties for failure and very few awards for success. You can say that about the public sector. So if we can give people as much information on how people are handling risks, and sometimes that is they're handling it badly, we're giving them the best possible chance of success. So, up to people, whether they agree or not, but that is our approach. 

Our approach is we don't benefit the NHS leadership community by hiding anything away. because they're going to be dealing with the consequences of it anyway. So rather, let's get it up front so that people are very clear on what's happening and they can make their own decisions about how they should manage in the real world.

MATTHEW TAYLOR: Yeah, I get that. I would have to say that I think that the wellbeing of managers and leaders in the NHS is not enhanced by the fear of their failings or divisions of their board or whatever being highlighted. But you know, that's a peril that comes with the pay and with the job. 

Let me ask you about NHS England. We have our lively conversations with NHS England, as we did recently over the issue of the operating framework. Ninety per cent of the time we work cooperatively and collaboratively with them. There is a perception that the HSJ was much more positively inclined to NHS England when Simon Stevens was in charge and you had a good relationship with Simon Stevens and you’ve become much more kind of sceptical, much more willing to be quite kind of aggressively dismissive of NHS England and some of the things it does since the change of leadership.

Is that unfair? 

ALASTAIR McLELLAN: Do I think that's unfair? I think it's a little unfair, yes. I don't think I have written anything aggressively dismissive of what NHS England have done – ever. Under either Simon Stevens, Amanda Pritchard, or indeed David Nicholson. I think in some ways HSJ just performs a relatively simple fact which is we simply report what's going on.

It's up to others to interpret whether they think that coverage shows any organisation or individual in a good or a bad light. I mean, really, people often ask me about HSJ's agenda and I really say we really, really don't have one. And anybody who doesn't believe me is welcome to come and spend some time in the HSJ newsroom to see it's just not how we make decisions.

We report on the things that are happening, but a lot of that reporting is driven by what very senior leaders tell us. So if people are telling it, ringing us up and saying, have you noticed this? What about this? I'm unhappy about that. That tends to be guide our coverage. Now, I don't believe that we are any more negative about NHS England than we were beforehand.

I do recognise that if you discount the pandemic, which was sort of a strange period, that the period in which Simon Stevens was operating was, though very challenging in its own way -  if I think back there, we thought, wow, that was challenging - but it's nowhere near as challenging as the environment in which the current NHS England is operating, in which, Amanda Pritchard is leading, they're dealing with the aftereffects of the pandemic, there's a big productivity issue, etc, etc.

There are a lot more problems and a lot more things are going wrong because it's so difficult. And because we report what's going on, we're tending to write more negative things than we did. Because those are the facts on the ground. So, Matthew, you'll know, because you've been in this world, that there's always a tendency to shoot the messenger. And I'm very happy to be shot. But it's not really how we see the world. 

MATTHEW TAYLOR: No, and Alistair, you're being a great sport in letting me dig into this, but, you hold us all to account and this is a rare opportunity for me to kind of give you a taste of your own medicine. 

ALASTAIR McLELLAN: You're being very gentle, Matthew. Don't worry about it. You're being very gentle. 

MATTHEW TAYLOR: Thanks so much for taking time to talk to us on Health on the Line. 

ALASTAIR McLELLAN: Thank you. 

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MATTHEW TAYLOR: Now, it's time to wrap things up with another edition of Leader in Six, where we get to know prominent leaders from across health and care. Joining us this week for six quickfire questions is Patricia Miller, chief executive of Dorset ICS.

So, Patricia, first question, what's the most pressing issue you're dealing with right now? 

PATRICIA MILLER: Finances. But not just finances, I think the most pressing issue other than that is trying to work in an environment where the transaction of finances and operational targets takes primacy, when what we want to and need to be doing is getting the balance right between the delivery of that, because it's in the operating standard for the NHS, as well as the transforming for the future in terms of the leftward shift, the focus on prevention and making sure strategically we're moving in the right direction in concert with partners around that broader agenda.

MATTHEW TAYLOR: Thank you. It's an answer I recognise from other leaders. 

Second question. Give us an example. I know there are lots, but one example of the innovation in your system you're most proud of right now. 

PATRICIA MILLER: So the innovation that I'm most proud of at the moment is the work we're doing on integrated neighbourhood teams.

I'm proud because the fact that we have made this commitment to some of the bigger, more fundamental decisions we make being community driven has meant that we've moved in the principle of how integrated neighbourhood teams should be developed and implemented from something that started off as being quite prescriptive as a model to now evolving into broader, deeper conversations with our communities that say, what do you recognise as a neighbourhood? Where do you see the geographical boundary? Because that's important because that's where you recognise where all your assets are going to come from that we need to build on. 

And that now evolving into a work of core production with the 30 to 40 neighbourhoods across a million population because that's where they recognise the boundary to be and it's focused on the needs of those populations in those areas which even means that our PCN boundaries become quite fluid and also an agreement that when we stand all 40 up by the end of this financial year, that really important next step is how do we then at place level wrap around that wider determinant work around those teams so we're really starting to see a really well deeply embedded population health approach.

And I'm really pleased with that development because I've seen the growth in our teams, the recognition of how important the community voice is, and we’re really starting to gain pace underneath that work. 

MATTHEW TAYLOR: Thank you. 

Tell us, Patricia, something about yourself, which is nothing to do with your job as a health service leader.

Something about you that is just interesting but nothing to do with your job. 

PATRICIA MILLER: I've got a degree in French.

MATTHEW TAYLOR: No. 

PATRICIA MILLER: Yeah.

MATTHEW TAYLOR: Do you ever use it? 

PATRICIA MILLER: Occasionally, yeah. Yeah. Yeah. 

MATTHEW TAYLOR: That's fascinating. I would, of course, I should be able to chat to you in French, but I'm afraid I can't do that. 

So, um, next question. If you were king or queen of the NHS for a day, what is the one thing you would do?

PATRICIA MILLER: I'd completely change the model of delivery. Because I think the current model is not affordable. If we don't make some significant changes to that leftward shift, I don't think the NHS is financially sustainable going forward. And I think as part of changing that model of delivery, we need to get into the habit of having a regular discussion with the public about what the NHS not be afraid of doing that.

MATTHEW TAYLOR: Great. 

Who is the leader? And it could be a health service leader, it could be someone completely different. Who is the leader you most admire, Patricia? 

PATRICIA MILLER: If we're talking about in the NHS, I admire someone like Owen Williams, who has made the leap from local government into the NHS, which is not an easy leap, because we do operate in a very different way in a very different environment, but has taken the learning from one sector, and then gone into a completely different sector where the two are connected, but not the same, made some substantial changes to organisations in Yorkshire, and then come to a very complex organisation in the Northern Care Alliance and not being afraid to try and tackle some of the really deep-rooted challenges that you've got there, with a backdrop of all the usual things that we have to deal with in terms of being leaders from global majority communities. So yeah, I really admire Owen. 

MATTHEW TAYLOR: Great. 

And then last but not least, tell us what you're watching or listening, podcasts, box sets, what are you consuming when you finally get home and you sit on  your sofa, you're in your car and you're listening to a podcast.

What could you recommend to people? 

PATRICIA MILLER: If you're asking me what I'm actually watching at the moment and not my podcast, I'm not sure that you want me to say this, but it's Rivals by Julie Cooper. A lot of escapism is what's needed when you get home. 

I am watching that and I'm a great fan of Maya Angelou's book, so I read quite a lot of those and I read them more than once, so over a period of five years, 'cause I enjoy them so much.

MATTHEW TAYLOR: Very good. Great way to get your credibility back after Julie Cooper going to Maya Angelou. 

Patricia, it only remains for me to say ‘merci beaucoup’. 

PATRICIA MILLER: You're welcome. 

MATTHEW TAYLOR: And 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 in a couple of weeks.

But in the meantime, please do follow us and leave a rating on your review or wherever podcast. It really does make a difference. Thank you.